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New Brain Injury Treatment at VGH Improving Outcomes

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Autoregulation monitoring, a new procedure for treating patients who have suffered traumatic brain injury, is now being used at Vancouver General Hospital.

In a healthy brain, autoregulation is an intrinsic control mechanism that maintains constant cerebral blood flow and oxygenation. When a person suffers a traumatic brain injury, their autoregulation mechanisms are impaired, and the brain may not receive enough oxygen in order for it to properly heal and recover.

Blood pressure plays a key role in determining how much oxygen the brain is receiving. In autoregulation monitoring the medical team inserts a catheter into the patient’s brain. The catheter is then attached to a monitor. The patient’s blood pressure is manipulated with medications to make the heart pump harder, which causes the patient’s blood pressure to increase dramatically. As a result, the patient’s brain receives the correct amount of oxygen within hours.

Dr. Donald Griesdale and Dr. Mypinder Sekhon studied autoregulation monitoring at the University of Cambridge in the United Kingdom, and were instrumental in bringing the treatment to Vancouver.

Competitive freestyle skier, Jamie Crane-Mauzy, was the first patient in British Columbia to undergo this treatment. On April 11, 2015, she crashed while competing in the World Ski and Snowboard Festival in Whistler, suffering a severe traumatic brain injury that resulted in microbleeds throughout her brain and brain stem. Through autoregulation monitoring, Crane-Mauzy’s doctors learned that her oxygen levels were critically low. They were able to raise her blood pressure with medications to allow her oxygen levels to normalize within hours. Crane-Mauzy had to learn to walk and talk all over again, but she credits autoregulation monitoring with helping to save her life and get her back on her skis again.

Since then, 36 other patients have been treated with autoregulation monitoring at VGH. The doctors involved in the treatment report that 60% of patients have had favorable outcomes with autoregulation monitoring, compared to 37% of patients previously. According to Dr. Griesdale, “This technique is giving severe brain injury trauma patients a better shot at recovering to the point where they are able to live independently.”

Medico-legal review suggests that physicians miss the signs of stroke

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A recent review of cases conducted by the Canadian Medical Protective Association, an organization that defends physicians in Canada, has found that most medical malpractice cases involving stroke had issues with the diagnosis. This means that sometimes doctors are missing the signs of stroke at initial presentation thereby depriving patients of necessary prompt treatment. In the cases reviewed, more than 25% of patients died and another 40% were left with a significant disability.

In the reviewed cases, the common stroke symptoms were headache, dizziness, nausea and vomiting. Delayed presentation with longer symptom duration spanning days and sometimes weeks was also seen. We can take it from the CMPA synopsis that cases where there was atypical presentation of stroke were generally easier to defend, especially where there was adequate neurological assessment and where appropriate discharge instructions were provided to a patient.

  • Malpractice cases that were more successful included situations where physicians
  • Failed to recognize the seriousness of the patient’s condition with red flags such as a new or severe headache, or focal neurological signs,
  • Did not perform a full physical examination including full vital signs, orientation, gait, speech, finger-to-nose testing, and visual field assessment, examination of the cranial nerves and motor and sensory function in all four extremities,
  • Developed an inadequate differential diagnosis,
  • Failed to consider the possibility of stroke in patients who have obvious risk factors such as smoking, obesity and hypertension,
  • Anchored on a specific diagnosis such as migraine or psychiatric disorder without considering the possibility of stroke.

Research suggests that up to 10% of strokes are not recognized at initial presentation. Research also shows that earlier diagnosis and treatment of stroke can improve outcomes. If you or your loved one suffered an injury as a result of a stroke and you were seen at the hospital or at a medical clinic and you believe that the diagnosis was potentially missed or delayed, you may be entitled to compensation for the injuries. At Pacific Medical Law we often hear from patients who have experienced a misdiagnosis or delayed diagnosis of stroke that left them with a permanent disability. Although it is not possible to identify negligence in every case we review, we have been successful at helping clients obtain much-needed compensation for the injuries that they suffered as a result of a missed or delayed diagnosis of stroke.

You can read more about the CMPA case review findings here: https://www.cmpa-acpm.ca/-/stroke-can-you-recognize-the-signs-

Why is it so hard for doctors to apologize?

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Research suggests that about 70,000 Canadian patients experience serious, preventable injury as a result of medical treatments each year. Further, as many as 23,000 adults in Canada die annually due to preventable errors in acute-care hospitals alone.

Disclosure of medical mistakes to patients is an integral part of patient care, and doctors have an ethical and legal duty to disclose errors to patients. While the duty to disclose is clear, many patients do not discover that their injury or poor outcome is due to medical error until litigation is started. Most provinces have legislation that allows a physician to offer an apology without admitting fault or liability, and a 2006 commentary from the New England Journal of Medicine reported that in systems where medical providers were encouraged to apologize for mistakes causing harm and make reasonable settlement offers, the number of lawsuits fell by more than half. So why is it so hard for doctors to apologize?

Part of the problem is the structure of the modern medical system. Increasing specialization has also depersonalized modern medicine, so that when a mistake is suspected, it might be unclear who from the medical team involved must step up and take responsibility. However, a bigger part may be that our health care culture is focused on denial and punishment rather than learning from mistakes.

In Dr. Brian Goldman’s TED Talk, Doctors Make Mistakes. Can we talk about that? he states that medicine’s culture of shame and denial prevents doctors from talking about mistakes and using them to learn and improve. All doctors make mistakes, he says, but they are taught to “be perfect.” When a mistake is made, doctors and other health care professionals are left alone, ashamed, and unsupported – unable to share their experience with colleagues so that the mistake is not repeated. Health care experts have suggested that releasing descriptions of incidents and lessons learned from them would be the most effective way to educate those in the medical field, yet doing so remains an anomaly in Canada.

As our health care system is run by human beings, human error is inevitable. While some physicians and other health-care professionals communicate with compassion after an error has been made, many simply try to sweep the error under the rug. Dr. Goldman is one of a growing number of physicians looking to redefine the culture of medicine by changing the landscape to one where doctors are able to tell their stories of mistakes, to learn from mistakes, and pass this knowledge on to someone else. These physicians do not see lawsuits and complaints as nuisances to be stamped out, but as the starting point to improving sub-standard care. Mistakes made by others should be pointed out in a supportive way so that everyone can benefit. In this way, it can be better understood why errors happen, what can be learned from them, and how they can be prevented in the future.

Disclosure of medical errors is an integral part of patient care, and can decrease blame, increase trust, and improve relationships. There is no harm in a doctor offering an apology, and much to be gained for health care professionals and patients alike.

Cauda Equina – when timing is everything in diagnosis and treatment of low back pain

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Low back pain affects millions of people and is quite common. Most often, it resolves on its own. In rare occasions, severe back pain can be a symptom of cauda equina syndrome, a serious neurologic condition in which damage to the cauda equina network of nerves causes loss of function of the spinal cord. Cauda equina syndrome can be caused by a variety of medical conditions including herniated disks, tumors, fractures or infections. The most common cause, however, is a prolapsed or herniated disk.

Symptoms of cauda equina include low back pain, bilateral leg pain, “saddle” anesthesia, weakness in the legs, loss of sensation around perineal and/or perianal areas, and bladder or bowel incontinence/retention. This syndrome is considered a true surgical emergency meaning any patient who exhibits the signs and symptoms of cauda equina should be taken to the OR as soon as possible for surgical decompression of the nerves involved. Cauda equina syndrome occurs relatively rarely, but a missed or delayed diagnosis of the condition often becomes the cause of action in medico-legal lawsuits.

Some of the more common examples of medical negligence involving the delayed diagnosis of cauda equina syndrome include the following medical mistakes:

  • failing to complete a thorough medical exam, including checking the rectal tone,
  • failing to diagnose saddle anesthesia by eliciting proper history from a patient,
  • failing to obtain emergency imaging,
  • failing to refer a patient for an urgent consultation with a qualified spine surgeon,
  • failing to recognize bladder/bowel incontinence as absolute emergency symptoms,
  • failing to provide a patient with appropriate instructions as to when to seek emergency help,
  • failing to organize and perform the surgery right away.

Prompt surgical decompression of cauda equina syndrome results in improved patient outcomes. Care providers must view cauda equina syndrome as an absolute emergency that requires prompt diagnosis, consultation and treatment.

Induction of Labour: what you should know

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Induction of labour is the artificial initiation of labour before its spontaneous onset. Induction rates vary widely across British Columbia but roughly 15-30% of all mothers have their labour induced. Across Canada, induction rates average approximately 20%. The most common reason for inducing labour is post-dates pregnancy (pregnancy extending beyond 41 weeks).

Given the high rate of induction in Canada, it is important for expectant mothers to have an understanding of the risks and benefits of induction. Before inducing labour, physicians have a legal obligation to discuss its risks and benefits and to allow their patient to make an informed choice. Whether induction is offered as an option, its relative risks and benefits will depend on each individual woman’s circumstances. However, there are some general principles that the Society of Obstetricians and Gynaecologists of Canada (SOGC) have outlined.

Indications and Contraindications

First and foremost, induction carries risks; as a result, it should only be done when there is a convincing and compelling reason. There are many compelling reasons for a care provider to offer induction. Some examples include suspected fetal compromise, significant maternal disease not responding to treatment, and pregnancy extending beyond 41 weeks. Convenience (for the patient or the care provider) is not considered by the SOGC to be a convincing reason for inducing labour. A large baby (unless the mother is diabetic) is also not considered to be an acceptable reason to induce labour.

There are also clinical situations where induction should be specifically avoided. These situations include abnormal fetal presentation, significant prior uterine surgery, active genital herpes, and pelvic structural deformities. For women who have had a prior caesarean section, the type of incision will affect whether induction of labour is appropriate. In this situation, the SOGC recommends that the prior surgical report should be obtained to confirm that the previous incision will not create undue risk for the patient.

Benefits and Risks of Induction

The primary benefit, and goal, of induction of labour is to allow a mother to give birth as naturally as possible.

This benefit must be balanced against the known risks of induction. Induction of labour can increase the risk of caesarean section, as well as the risk of the use of forceps or vacuum, and can also increase the risk of failure to achieve labour. There is an increased risk of chorioamnionitis (a bacterial infection that can occur before or during labour), excessively frequent uterine contractions (which can affect the baby’s heart rate), and rupture of the uterus (a very serious obstetrical emergency). When the mother’s membranes are artificially ruptured, induction is associated with an increased risk of umbilical cord compression during labour, which cuts off the baby’s oxygen supply. Induction also increases the risk of inadvertently delivering a premature infant when fetal age has not been accurately dated.

Conclusion

Induction of labour may be the right choice for an expectant mother. However, since it is associated with some serious risks, expectant mothers should ensure that they have a thorough discussion with their physician to ensure they understand the reasons why induction is being recommended in their unique circumstances, as well as the specific risks and benefits that apply to the mother and her baby.

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