Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient

This study investigated the effect on observer responses of the presence/absence of information about medical evidence for pain and psychosocial influences on the patient’s pain experience. Additionally, the moderating role of the patient’s pain expressions and the mediating role of the observer’s belief in deception and evaluation of the patient was examined. Sixty-two participants were presented with videos of 4 patients, each accompanied by a vignette describing the presence or absence of both medical evidence for the pain and psychosocial influences on the patient’s pain. Participants estimated patients’ pain and rated their own sympathy and inclination to help; they re-estimated patients’ pain when the patient’s self-report of pain was provided. Finally, participants evaluated each patient as positive or negative and the likelihood that the patient was feigning pain. Participants gave lower ratings on pain, sympathy, and help when medical evidence was absent. Further, in the presence of psychosocial influences, participants took patients’ self-reported pain less into account. Next, only for patients expressing high-intensity pain, information about both medical evidence and psychosocial influences was taken into account. Finally, the observer’s evaluation of the patient and his/her belief in deception fully, respectively partially, explained the effect of medical evidence. The results indicate that discounting pain in the absence of medical evidence may involve negative evaluation of the patient. Further, the patient’s pain expression is a moderating variable, and psychosocial influences negatively impact the degree to which patients’ self-reports are taken into account. The results indicate that contextual information impacts observer responses to pain.     

Use of Double Gloving to Reduce Surgical Personnel’s Risk of Exposure to Bloodborne Pathogens: An Integrative Review

Surgical team members are known to have a higher incidence of percutaneous injuries compared with other health care workers, which increases surgical personnel’s risk both of exposure to bloodborne pathogens and acquiring bloodborne illnesses. The purpose of this integrative review was to determine whether double gloving reduces the surgical team member’s risk of percutaneous injury when compared with single gloving. Factors addressed are double gloving versus single gloving, use of an indicator glove system, optimum levels of protection, and policies and procedures to facilitate compliance with double gloving. Evidence supports the use of double gloving and double gloving with an indicator glove system to decrease the risk of percutaneous injury and therefore is an effective barrier to bloodborne pathogen exposure. Perioperative managers and educators should develop educational methods to support double-gloving compliance; monitor and conduct periodic audits to evaluate compliance; and review and revise quality improvement strategies as necessary to protect surgical employees from percutaneous injuries.     

Surgical Scheduling: A Lean Approach to Process Improvement

A large teaching hospital in the northeast United States had an inefficient, paper-based process for scheduling orthopedic surgery that caused delays and contributed to site/side discrepancies. The hospital’s leaders formed a team with the goals of developing a safe, effective, patient-centered, timely, efficient, and accurate orthopedic scheduling process; smoothing the schedule so that block time was allocated more evenly; and ensuring correct site/side. Under the resulting process, real-time patient information is entered into a database during the patient’s preoperative visit in the surgeon’s office. The team found the new process reduced the occurrence of site/side discrepancies to zero, reduced instances of changing the sequence of orthopedic procedures by 70%, and increased patient satisfaction.     

Caring assessment in the Swedish ambulance services relieves suffering and enables safe decisions

This study has a health care science approach and explores pre-hospital emergency care with emphasis on assessment. Health care science is focused on the patient with the general aim to describe care that strengthens and supports health. Assessment in the ambulance services has not been explored earlier from this perspective, despite the emphasis on ‘coming close’ to the acute suffering patient. The aim of the study is to describe and analyse assessment in caring situations. Data was collected by participant observations. The major findings point out the importance of professional carers’ recognition of the patient’s lifeworld as an essential part of assessment. The carers’ openness to the situation and to the patient’s suffering and needs vary from being of minor interest to complete focus of the assessment. It seems that assessments that focus solely on a patient’s medical condition can be an obstacle to a full understanding of the individual, and thereby the illness per se. A caring assessment based on an encounter and a dialogue between patient and carer, characterised by inviting the patient to participate, adds further dimensions to the objective data. Therefore, the inclusion of the patient perspective relieves suffering and enables more safe decisions.     

Couple perceptions of fibromyalgia symptoms: The role of communication

The objectives of the current study were to describe fibromyalgia patient–spouse incongruence regarding patient pain, fatigue, and physical function; and to examine the associations of individual and interpersonal factors with patient–spouse incongruence. Two hundred four fibromyalgia patients and their coresiding partners rated the patient’s symptoms and function. Multilevel modeling revealed that spouses, on average, rated patient fatigue significantly lower than patients. Couple incongruence was not significantly different from zero, on average, for pain severity, interference, or physical function. However, there was significant variability across couples in how they rated the severity of symptoms and function, and how much incongruence existed within couples. Controlling for individual factors, patient and spouse reports of communication problems were significantly associated with levels of couple incongruence regarding patient fatigue and physical function, albeit in opposing directions. Across couples, incongruence was high when patients rated communication problems as high; incongruence was low when spouses rated communication problems as high. An important within-couple interaction was found for pain interference, suggesting that couples who are similar on level of communication problems experience low incongruence; those with disparate ratings of communication problems experience high incongruence. Findings suggest the important roles of spouse response and the patient’s perception of how well the couple is communicating. Couple-level interventions targeting communication or other interpersonal factors may help to decrease incongruence and lead to better patient outcomes.     

Responding to surrogate requests that seem inconsistent with a patient's living will

Clinicians may feel conflicted when a patient’s legal decision maker is making decisions that seem inconsistent with a patient’s living will. We provide evidence-based information to help clinicians consider whether a surrogate’s inconsistent decisions are ethically appropriate. Surrogates are not flawless translators of their loved one’s preferences; they are influenced by their own hopes and the current clinical context. Patients may be aware of this, are often concerned about burdening their loved ones, and often grant their surrogates leeway in interpreting their wishes. When appropriate, clinicians should respect surrogates’ interpretations of patient values and take steps to decrease surrogate stress during the decision-making process. Finally, if clinicians are cognizant of their own values and preferences, they may recognize how these may affect their responses to certain clinical cases.     

Electromagnetic Navigational Bronchoscopy and Robotic-Assisted Thoracic Surgery

With the use of electromagnetic navigational bronchoscopy and robotics, lung lesions can be diagnosed and resected during one surgical procedure. Global positioning system technology allows surgeons to identify and mark a thoracic tumor, and then robotics technology allows them to perform minimally invasive resection and cancer staging procedures. Nurses on the perioperative robotics team must consider the logistics of providing safe and competent care when performing combined procedures during one surgical encounter. Instrumentation, OR organization and room setup, and patient positioning are important factors to consider to complete the procedure systematically and efficiently. This revolutionary concept of combining navigational bronchoscopy with robotics requires a team of dedicated nurses to facilitate the sequence of events essential for providing optimal patient outcomes in highly advanced surgical procedures.     

An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report

Smuck M, Christensen S, Lee SS, Sagher O. An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report.Recent epidemiologic studies have shown back pain to be a significant cause of pain in lower-limb amputees, but only a handful of cases have reported sciatica in amputees. The symptoms are usually described as a phantom pain or neuropathic pain in the residual limb that is often refractory to conventional treatments. These symptoms typically occur with back pain and are distinct from the patient’s usual symptoms. Interestingly, back pain is not a universal finding. We present a patient with presumed phantom limb pain subsequently discovered to be caused by an S1 radiculopathy. This patient’s supposed phantom pain persisted despite multiple medication trials. Initial work-up revealed a sciatic neuroma at the stump. Treatments targeting this neuroma were unsuccessful. Further evaluation found that a sacroiliac joint screw placed to stabilize a pelvic fracture had intruded into the S1 neuroforamen. A diagnostic S1 nerve block temporarily relieved the patient’s pain, and the screw was removed. Pain persisted and a spinal cord stimulator was placed resulting in improvement of his pain. Because conventional diagnostic tests are limited, including physical exam and electromyography, a fluoroscopically guided selective spinal nerve block proved to be a useful diagnostic tool in this patient.     

A Hospital-Wide Initiative to Eliminate Preventable Causes of Immediate Use Steam Sterilization

Instruments and implants sterilized by immediate use steam sterilization (IUSS), formerly called flash sterilization, can increase the patient’s risk for acquiring a surgical site infection. We implemented a hospital-wide initiative to determine the reasons that perioperative personnel use IUSS to sterilize items and then designed a program to reduce the hospital’s rates. Program initiatives included educating perioperative personnel, improving scheduling processes, holding vendor discussions, purchasing additional instrument sets, and transitioning from paper wrap to metal containers for instrument sets. In addition, we instituted a policy whereby nursing leaders are required to approve IUSS before it can be used and developed guidelines for immediate and rapid processing in the sterile processing department, and we monitor compliance daily and communicate results regularly to all team members. These efforts decreased our facility use of IUSS for implants from 10.22% in January 2008 to 0.09% in August 2012, and we decreased our use of IUSS for instruments from 79% in May 2010 to 7.5% in February 2012. We simultaneously implemented a process to reduce surgical site infection rates and saw an improvement in surgical site infection from 5.4% in the first quarter of 2010 to 1.4% in the fourth quarter of 2012.     

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: a case report and literature review

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy (PCNL) is extremely rare, and little information is available about this complication. Because the patient’s prognosis may be poor, sufficient attention should be paid to early identification and treatment of this complication. We present an uncommon case of a patient with intravenous nephrostomy catheter misplacement after PCNL at our hospital. In our patient, the tip of the nephrostomy catheter was located in the inferior vena cava. It was successfully managed using two-step catheter withdrawal under fluoroscopy, and the percutaneous nephrostomy catheter was able to be withdrawn 7 to 8 cm back into the collecting system in stages with the surgical team on standby. There were no severe complications such as deep vein thrombosis that developed during or after the catheter withdrawal. Patients could be managed conservatively using intravenous antibiotics, strict bed rest, and tube withdrawal using computed tomography (CT) or fluoroscopy guide in most cases combined with information in the literature. Additionally, open surgery could be used as an alternative treatment.     

Surgical Management of Traumatic L2-L3 Spondyloptosis

Subluxation of a vertebra secondary to an injury (ie, traumatic spondyloptosis) is most commonly seen in the lumbosacral joint. This extremely rare spinal destabilization is caused by congenital defects, degeneration, tumors, infection, or trauma and is accompanied by severe neurologic debilitation.The patient's neurological function can be preserved when surgical team members have knowledge of spinal injuries, surgical interventions, positioning and its implications, and an awareness of the risks to the patient.Appropriate interventions can decrease complications, operative revisions, length of stay, morbidity and mortality, and hospital costs. AORN J 89 (April 2009) 657-672. © AORN, Inc, 2009.     

Transient reversal of anoxic brain injury-related minimally conscious state after zolpidem administration: a case report

Shames JL, Ring H. Transient reversal of anoxic brain injury-related minimally conscious state after zolpidem administration: a case report.Zolpidem is a unique nonbenzodiazepine sedative hypnotic drug that selectively binds to omega-1 γ-aminobutyric acid receptors in the brain. Although used for years in Israel and abroad for insomnia, there have been periodic reports of unusual or remarkable neurologic effects in patients with various brain pathologies. Here, we report on a 50-year-old woman 18 months after severe anoxic brain injury in a minimally conscious state. Residual deficits included mutism, athetoid movements of the extremities, and complete dependence for all personal care. After the administration of 5 to 10mg of zolpidem, within 45 minutes, the patient’s condition improved markedly, including the cessation of athetoid movements, regained speaking ability, and ability to perform various tasks including self-feeding. These effects lasted 3 to 4 hours, after which the patient returned to her former state. This effect was repeatable on a daily basis. Existing evidence and possible mechanisms to explain zolpidem’s effects in brain injury are described.     

Charcot spine in a person with congenital insensitivity to pain with anhydrosis: a case report of re-diagnosis

Sliwa JA, Rippe D, Do V. Charcot spine in a person with congenital insensitivity to pain with anhydrosis: a case report of re-diagnosis.We report the case of a 43-year-old woman referred for evaluation of worsening gait. Her initial evaluation led to a diagnosis of a Charcot spine and 2 spinal stabilization surgeries. Because no clear cause for the Charcot spine could be determined from the patient’s history or initial evaluation, an extensive diagnostic work-up was undertaken, which ultimately led to a diagnosis of congenital insensitivity to pain with anhydrosis (CIPA). This diagnosis was known and confirmed by the patient’s parents but was unknown to the patient and her treating physicians. Unique to this case is not only the significant medical implications and the value of the re-diagnosis and confirmation of this rare condition, but also the rarer occurrence of a Charcot spine in a person with CIPA.     

Patient Blood Management: Use of Topical Hemostatic and Sealant Agents

Patient blood management is the scientific use of safe, effective medical and surgical techniques designed to conserve blood, prevent anemia, decrease bleeding, and optimize coagulation in an effort to improve patient outcomes. Perioperative and primary care nurses play a vital role in promoting and making the best use of patient blood management and can play a key role in implementing effective strategies that decrease or eliminate patient exposure to allogeneic blood. The fast and effective minimization of intraoperative bleeding is integral in an effective blood management program. Topical hemostatic and sealant agents can be used to improve blood conservation, reduce overall procedure time, and contribute to faster patient recovery based on specific clinical situations. The proper selection of hemostatic agents can greatly influence the patient’s clinical outcomes.     

A Quality Improvement Project for Safe and Effective Patient Positioning During Robot-Assisted Surgery

During the initiation of a new robotic surgery program, a quality improvement team explored different techniques for positioning patients in the lithotomy and steep Trendelenburg position during robot-assisted procedures. Concerns associated with placing patients in the steep Trendelenburg position include the patient slipping toward the head of the bed and experiencing hemodynamic changes that may result in a rise in blood pressure, increased intraocular and intracranial pressures, and difficulty with ventilation, particularly in patients with a high body mass index. Skin integrity is also of concern because perioperative personnel are responsible for protecting the patient's skin from excessive sheer, friction, and injury. The quality improvement team evaluated and compared two positioning devices: an air-inflated positioning device and high-density foam padding. Both methods allowed personnel to position the patient without compromise; the surgeons performing the robot-assisted procedures preferred the high-density foam padding.     

Current state of computer-assisted trauma surgery

Computer assisted surgery (CAS) was first used in neurosurgery. Currently, CAS has gained popularity in several surgical disciplines including urology and abdominal surgery. In trauma and orthopaedic surgery, computer assisted systems are used for fracture reduction, planning and positioning of implants as well as the accurate implantation of hip and knee prostheses. The patient’s anatomy is virtualized and the surgical instruments integrated into the digitized image background, thus allowing the surgeon to navigate the surgical instruments and the bone in an improved, virtual visual environment. CAS improves overall accuracy, reducing intraoperative radiation exposure and minimizing unnecessary surgical dissection combined with increased patient and surgeon safety. However, limitations include prolonged surgical time, technical errors and cost implications. This article will outline the current state of computer assisted trauma surgery including its implications and specific challenges in orthopaedic trauma surgery.     

Patient Positioning for Proximal Femur Fracture Fixation: a Review of Best Practices

Purpose of ReviewProximal femur fractures are common traumatic injuries treated by orthopedic surgeons. Preparation and positioning for surgical intervention are critical in the proper management of proximal femur fractures. The purpose of this study was to review the current evidence on the various positioning options for patients and to highlight the principles and emerging techniques to help orthopedic surgeons treat this common injury.Recent FindingsStrategic patient positioning is key to the reduction and fixation of proximal femur fractures without complications. The use of intramedullary devices for the fixation of proximal femur fractures has led to an increased use of the modern fracture table. The fracture table should be used when surgeons are facile with its use to avoid significant complications. Recent best available evidence has suggested increased risk of malrotation associated with the use of the fracture table. The use of the radiolucent table offers the most flexibility, but limits surgeons as multiple assistants are needed to maintain reduction during fixation.SummaryPositioning for proximal femur fractures is an important technique for general and trauma orthopedic surgeons. Surgeons need to be aware of the various techniques for positioning of proximal femur fractures due to the diversity of injury patterns and patient characteristics. Each positioning technique has it benefits and potential complications that every orthopaedic surgeon should be familiar with while treating these injuries.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12178-021-09710-x.     

Streptococcal Necrotizing Myositis: A Case Report and Clinical Review

Background

Streptococcal necrotizing myositis, also known as gangrenous myositis, is a very rare and severe soft tissue infection that predominately involves skeletal muscle and, eventually, superficial fascia and surrounding tissues. The presentation is often nonspecific until the rapidly progressing clinical course becomes apparent. A high morbidity and mortality rate has been reported in the small number of cases since 1900. Despite several attempts to better define the different entities causing necrotizing myositis, no single definitive causal relationship has been defined.

Objectives

A review of the literature is presented here to help clinicians distinguish those with necrotizing myositis from those with nonnecrotizing myositis when the clinician is at all confronted with the suspicion for such an infection.

Case Report

The case presented is that of a 48-year-old woman who had streptococcal necrotizing myositis. She died roughly 72 h after admission. After the patient’s death, the clinical team sought consent for autopsy. Hospital staff made contact with family, and information was obtained from the family that the onset of the patient’s symptoms was allegedly temporally related to her acquisition of a new tattoo on the right back, where the tattoo process allegedly included injection of cremated ashes of a pet dog.

Conclusion

A high level of suspicion for necrotizing myositis must be maintained for a patient with unexplained severe muscle pain and soft tissue swelling accompanied by systemic inflammatory response syndrome.     

Leading Change

Teamwork remains a big part of a rehabilitation unit's success. What do you do when there is dissension within the ranks and each shift becomes segregated, is resentful of the other, and spends a good part of each day complaining about the inadequacies of the current system? At one facility, patient falls, staff injuries, and workers' compensation cases were on the rise. Work became a chore that few looked forward to. Staff call‐out rates increased, which added to the workload of the remaining staff A program was developed that provided a “tag‐team” approach to care delivery for rehabilitation patients. Nurses and clinical assistants worked in pairs as they provided care. No single‐person positioning and transfers were done when there was a clear need for two people. One staff member was not assigned to complete total care for patients when two staff members could complete the task more safely and efficiently. This “tag‐team” approach produced positive outcomes with regard to patient and staff satisfaction.