The decline and fall of the rectal exam

For almost 20 years, the value of the digital rectal exam (DRE), a long time staple of the complete examination of the trauma patient, has been questioned. Performing a rectal examination on all trauma patients is no longer advocated except for a few specific indications.

As recently as two months ago, trauma surgeon Michael McGonigal blogging at The Trauma Pro reinforced the message. Because a rectal examination is so uncomfortable for patients already traumatized and its yield is so minimal, he advocates doing it in only patients with spinal cord injury, pelvic fracture, and penetrating abdominal trauma. For a more extensive discussion of the topic, see Life in the Fastlane, an emergency medicine blog.

Can a cop’s baton accidentally slip into a man’s anus?

I doubt it.

A French police officer has been charged with rape after a black man who was being arrested suffered severe anal injuries.

After witnessing an officer slap someone, the 22-year-old had allegedly approached a group of policemen. The victim claims he was handcuffed, called names, and beaten. He says his pants were lowered and he felt pain in his buttocks.

At the police station another officer noted that he was covered with blood. He was taken to a hospital and diagnosed with the anal trauma which required “major surgery” including a colostomy. The family was told incontinence may result.

Doctors said the injury had been caused by a police baton which had been forced into his anus.

The Washington Post quoted the findings of a police investigation: “The violent sodomy was accidental and occurred when the officer’s expandable baton happened to slip into the victim’s anus.”

According to another story, “a French police union spokesman said there was no evidence so far that ‘the truncheon was actually introduced’ into the victim's rectum. And if that actually happened, it was likely done ‘accidentally.’”

A third story said, “a lawyer for the officer charged with rape said ‘the blow had been carried out in a totally involuntary manner, without his being aware of any injury.’” The word “his” must be referring to the officer because I have no doubt the victim was quite aware.

Based on my 40+ years of experience as a surgeon, I can assure you the police version of the incident is highly implausible. A patient who does not wish to undergo a rectal examination by a physician with a gloved and lubricated index finger can easily prevent it from occurring by voluntarily contracting his anal sphincter and gluteus muscles.

I would imagine a healthy 22-year-old man would react in exactly the same way if a policeman’s baton “happened to slip” with the end anywhere near his anus.

The incident has sparked many protests in France and has been widely reported by news media. Of the several accounts I have read, not one has asked a surgeon to comment on the nature or possible cause of the injuries.

Bottom line: A police baton slipping into a man’s anus is about as likely as a man accidentally falling on a woman and penetrating her.

From International Business Times

Thanks to @Tosk59 for the tip on the International Business Times story.

Health Care and the $20,000 Bruise: A different take

Twitter is buzzing about yet another medical billing horror story. This one appeared in the Wall Street Journal and was written by Eric Michael David who is an MD PhD JD and an officer at a biotech company.

He saw a large, swollen bruise on his three-year-old son's head several days after falling off his scooter. Other than the bruise, no other abnormalities were mentioned. He took the boy to "one of the top pediatric emergency rooms in the country" to have a CT scan done. It showed "a small, 11-day-old bleed inside his head, which was healing, and insignificant."

Dr. David received a bill for $20,000, $17,000 of which had been paid by his insurance company. He was responsible for the remaining $3000.

He noted a $10,000 charge for a trauma team activation which he said never happened. After a lengthy series of exchanges with the hospital's billing department and Dr. David having to prove that a trauma team activation was unwarranted and not permitted by certain regulations, he was able to have the charge rescinded.

The essay went on for some 1200 words listing the steps that he went through. He correctly described what a mess American healthcare delivery is and why as long as overuse and upcoding are rewarded, the Affordable Care Act will not fix it.

Dr. David was right to contest the $10,000 charge for a trauma team activation that wasn't indicated and didn't even occur.

What he didn't address was this.

Why would a doctor who said that he had "served on trauma teams in two of the busiest hospitals in New York City" feel the need to take his apparently asymptomatic son with an 11-day-old injury to an emergency room for a CT scan?

Doesn't this imply overuse of a different type?

Secondary questions:

Did anyone bring up the issue of radiation from the CT scan?
Did the docs in the ED think a CT scan was necessary?
"Inside his head" is a rather odd phrase. Does it mean intracranial? Intracerebral?
Was "one of the top pediatric emergency rooms in the country" the only option or could this asymptomatic boy have been seen in a doctor's office?
Why is the charge for a trauma team activation $10,000?

Helicopters & trauma patients: JAMA paper deconstructed

Twitter and the media were abuzz with reports of the paper in this week’s JAMA that found a 1.5% survival advantage if trauma patients were transported by helicopters rather than ground ambulances. The headlines were sensational and misleading.

LA Times: Trauma patients more likely to survive if rescued by helicopter
MSNBC: Helicopter beats ambulance for trauma patients
US News: Helicopter Beats Ground Transport for Trauma Victims: Study
Scientific American: Helicopters Save Lives for Serious Trauma Victims

What I am going to do is point out the many flaws in the paper and give you some information about the other side of the story. As is true of nearly all papers, you should read the full text, not just the abstract.

The paper looked at outcomes for 61,909 trauma patients transported by helicopter and 161,566 patients were transported by ground ambulances. Although the unadjusted results showed a higher mortality rate for those transported by helicopter, they were also more seriously injured. The adjusted mortality rates favored the helicopter by a statistically significant but small 1.5%. The number needed to treat was 65 to save 1 life and the cost for saving 1 life was estimated at $325,000, the same figure as heart surgery.

The authors used the National Trauma Data Bank [NTDB] as their source. More than 900 of the 6000 or so hospitals in the US voluntarily contribute data. Although the NTDB is said to contain more complete data than in prior years, some issues remain.

For example, the paper started with records of more than 1.8 million patients. Various appropriate exclusions, such as restricting the analysis to seriously injured patients, whittled the number down to 978,000. Over 115,000 records were then excluded because information about their method of transportation was not reported. More than 102,000 patients not treated at Level I or II trauma centers were omitted too. Of the patients included, some 38% were missing more than 40% of the data that was supposed to have been submitted. Remember, this is the so-called “improved quality” NTDB data.

This was a retrospective study and the authors point out that no accepted nationwide guidelines for first responders on the ground to call in a helicopter exist.

The cost analysis was done using information from the state of Maryland, which uses state police helicopters. At $5000 per flight, it is one of the least expensive medical helicopter services in the nation. Other cost estimates range from $5000 to well over $15,000 per flight. And some studies have shown that nearly half of all patients transported by helicopter are not even admitted to the hospital. The costs of those flights, had they to be included in the calculation, would certainly increase the cost per life saved.


There is also the issue of medical helicopter safety. Many crashes occur every year with several resulting in the deaths of patients and crew. [National Transportation Safety Board Report, page 32].

Should the safety record and the number of patients unnecessarily transported by helicopter be considered in the number needed to treat?

The authors mentioned several limitations of their study including the following:

They imputed [translation: made up] data for variables where data was missing in no more than 20% of the records. There is selection bias because hospitals submitting data to the NTDB are likely doing better than those which do not submit data. It is unknown whether the modest survival improvement is due to the helicopter or the fact that helicopters are usually staffed with MDs, nurses and advanced paramedics as opposed to paramedics and EMTs on ground ambulances.

The literature is replete with papers stating that helicopters do not increase survival rates. In fact one that was presented at the American Association for the Surgery of Trauma just appeared last month in the Journal of Trauma. Other than prehospital time which is significant longer for helicopter patients, there were no differences in any parameters including survival.

In the discussion of this paper, a well-known trauma thought leader, Dr. Ken Mattox, said, “So my question is, is it time for the ROC [Resuscitation Outcome Consortium] or this organization [AAST] or organized medicine to take the power of our convictions and our evidence and make a policy statement on this very expensive advertising mode that does not really alter outcomes?

Bottom line. The study left out almost as many patients [mode of transport unknown and those not taken to a level I or II trauma center] as it included. Many of the patient records include in the study had missing data. The cost per life saved was calculated to be as favorable as possible and did not include the substantial costs of unnecessary flights. The abysmal safety record of medical helicopters was not mentioned. The helicopter may not be the factor leading to the modest [1.5%] increase in survival rate, but rather it may be the way they are staffed.

How do the headlines look now?