JM & Associates Legal Nursing Consultants PC, Yucaipa, CA (2026)

$In one of our recent cases, an elderly patient with mild dementia suffered a hip fracture and passed away 6 months later...$

12/03/2022

In one of our recent cases, an elderly patient with mild dementia suffered a hip fracture and passed away 6 months later.

Did the patient’s hip fracture cause her death?

Many authoritative sources show strong evidence that hip fractures in the elderly cause a notable spike in 6 month and 1 year mortality rates. Roche et al (2005) prospectively evaluated 2448 patients with hip fracture over a four-year period. Mortality was 33% at one year.

Patients with dementia have additional challenges in their recovery from a hip fracture which further increases the risk of mortality. A 2018 study published in the Journal of Orthopaedic Surgery and Research looked at mortality rates among dementia patients after hip fracture surgery. They found that dementia patients had a 39% 1-year mortality rate following hip fracture surgery. It was noted that “Patients with dementia usually have less activity and poor self-care ability, which increased postoperative complications, such as surgical site infection, urinary tract infection, and respiratory complications.” (Bai et al, 2018).

A more recent, 2022 study was presented to the Congress of the European Academy of Neurology by Swedish researchers. The study included 122,614 participants and it was found that patients with dementia are six times more likely to die after sustaining a hip fracture than are those without dementia. (Medscape, 2022).

The patient in our case manifested a pattern of decline after her injury. She suffered multiple UTIs and experienced a nose-dive in her physical and cognitive function after each infection. She was very weak and her responsiveness to physical therapy became greatly limited.

This wasn’t the first case we’ve reviewed where an elderly patient died months after a hip fracture. Hip fractures are often catastrophic in the elderly.

Sources:
https://pubmed.ncbi.nlm.nih.gov/16299013/
https://josr-online.biomedcentral.com/articles/10.1186/s13018-018-0988-6
https://www.medscape.com/viewarticle/976645

JM & Associates Legal Nursing Consultants PC
909-836-9119
[email protected]
www.jmlegalnurse.com

11/10/2022

Over the past several months, my team and I have been asked to review multiple cases involving pressure injuries. We analyze events surrounding pressure injuries occurring in both long-term care and hospital settings and help attorneys determine whether the injuries were avoidable or unavoidable.

For our hospital cases, we frequently refer to a landmark, 2019 study by Pittman et al which studied hospital-acquired pressure injuries (HAPIs) in critical and progressive care.

Pittman et al found that close to 60% of HAPIs are avoidable and 41% are unavoidable. They identified several risk factors that help differentiate avoidable from unavoidable. These include:

· A congestive heart failure diagnosis (CHF)
· Multi-organ failure
· Mechanical ventilation
· Chemical sedation
· Systolic blood pressure less than 90 mm Hg
· Malnourishment
· Incontinence
· Prolonged hospitalization
· Vasopressors (medication to support blood pressure).
· Old age

So, what if a patient with many or all risk factors develops a pressure injury? That is an unavoidable injury, correct?

Not necessarily.

Pittman et al writes, “Unavoidable pressure injuries may occur when the magnitude and severity of the risk factors are extremely high AND preventive measures are either contraindicated or inadequate given the risk. In this study, unavoidable HAPIs were defined as those that developed in spite of consistent documentation of evidence-based preventive interventions.”

In other words, ultimate determination rests heavily on whether preventive interventions were documented and implemented appropriately.

For example, 90-year-old Ed has CHF and is sedated and intubated in the ICU. His blood pressure is very unstable, and he is on high doses of pressors. In fact, Ed’s hemodynamic status is so unstable that even turning and repositioning will precipitate a drop in blood pressure.

Even in Ed’s precarious situation, best practice would require that efforts are made to safely shift his position periodically.
Pittman et al notes that “the critical care unit’s culture and clinicians’ perceptions about hemodynamic instability may lead to staff members’ not repositioning patients.” However,
best practice recommends that slow, gradual turning allows sufficient time for stabilization of blood pressure and oxygen saturation and should be attempted.

The path to determining avoidable vs. unavoidable pressure injuries always involves careful and comprehensive review.

Source: https://lnkd.in/gXAWF2nz

11/07/2022

83-year-old Lillian presents to urgent care with a cough and cold symptoms. After a thorough workup, she is diagnosed with an upper respiratory infection. Lillian is given a prescription for a 10-day course of penicillin and advised to follow up with her primary physician within the next week. Lillian is stable for discharge. Good to go, right?

Maybe not so fast.

Lillian is part of a high-risk population that has unique physiologic and psychosocial needs. Geriatric patients over 65 years of age require close attention when it comes to both medical and nonmedical elements of their health.

A 2014 study by Stevens et al looked at the prevalence of nonmedical problems impacting geriatric healthcare. Among older adults presenting to the ER, they found that:

60% had pain
47% had difficulty walking
32% had a lack of money
14% were isolated and lonely
12% had a lack of transportation
10% had hazardous drinking habits
4% had difficulty scheduling a doctor’s appointment
4% had difficulty getting prescriptions filled

If we were to pry a bit, we would find that Lillian does not have transportation available on most days. Her finances are tight, and she doesn’t think she can afford the copayment for Penicillin. Lillian feels confused about calling to schedule a follow-up appointment. When and where exactly?

If these issues are not addressed, Lillian will likely not fill her prescription or follow up with her primary physician. Her condition may deteriorate as a result, leading to pneumonia or worse.

There are multiple screening tools available for geriatric-specific risk factors. One example is the Identification of Seniors at Risk (ISAR) tool, which identifies geriatric patients at increased risk of 6-month adverse health outcomes. It is important to implement routine screening on every geriatric patient.

It is essential to facilitate referrals to community resources to ensure needs are met (medical transportation, home health, meals-on-wheels, etc.). Consult case management or social services as indicated to help out with this. A follow-up phone call is never a bad idea. Involve family members or other caregivers if available and appropriate.

Source: https://lnkd.in/gNr9b5AC

11/05/2022

Which sounds better?

· “The patient has a substance use disorder” or “The patient is an IV drug abuser”
· “The patient is not tolerating treatment” or “The patient refused treatment”
· “Patient with complex health issues” or “Frequent flier”
· “Difficulty taking meds due to...” or “Noncompliant”
· “Patient has been incarcerated” or “inmate, felon, convict”

I think we would all agree that the first statements have a better tone, a more neutral tone, than the second statements.

My last two posts looked at studies that investigated the characteristics of stigmatizing language used to describe patients in the medical record and revealed the potentially damaging effects of such language.

How can we practically address this issue?

Various medical literature and patient advocacy groups have suggested guidelines on how to promote humanization of a patient’s medical record, but it has been difficult to find a source that consolidates the recommendations until recently. The Temple University Hospital in Philadelphia, PA, embraced this task and pulled these guidelines together into nine core principles (check out their website below!). Here they are:

1. Use person-first language (a person with diabetes, not a “diabetic”). This is an easy change to make!

2. Avoid stereotypes and generalizations (“non-compliant, “poor historian” – I had difficulty taking a history because the caregiver wasn’t at the bedside, or an interpreter wasn’t available. This approach suggests ways to improve the situation)

3. Assign blame to the system, not the individual (What are the broader structures at play? Be attentive to verb selection describing choice. Pt chooses one treatment over another or patient declines. This moves away from individual blame)

4. Eliminate pejorative terms (convict, alien – there are neutral alternatives: patient who has been incarcerated, immigrant)

5. Think critically and be intentional about using social identifiers (race and socioeconomic status don’t belong in the one-liner. They easily transmit biases.)

6. State the facts – avoid interpretations (“patient alleges/claims 10/10 pain” rather than “has 10/10 pain”)

7. Use inclusive language (“patient uses a wheelchair” rather than “wheelchair bound”. Describe the tool and avoid describing the patient with a tool)

8. Use the active voice (“I prescribed antibiotics” rather than “antibiotics were prescribed”. This helps with taking ownership)

9. Don’t weaponize quotes (don’t quote patients in a way that is humorous or belittling. “Patient is having ‘horrendous’ pain”)

Perhaps all these principles can be summarized into one golden rule: when in doubt, ask yourself, “If I were the patient reading/hearing this, how would I feel?”

Source: https://lnkd.in/gks3dpSP

11/03/2022

We recently reviewed a case where the patient was portrayed negatively in documentation. There were multiple notes that described the patient as “manipulative”, “drug-seeking”, and “non-compliant”. However, while reviewing the patient’s medical record objectively, we were unable to find any real evidence to support these descriptors. Even if there was, is it helpful to use these terms in a patient’s medical record?

My last post focused on a study by Goddu that revealed how stigmatizing language evokes judgment and may influence medical outcomes. This language can perpetuate stigma and stereotyping. It can reinforce our own implicit and explicit biases and transmit bias to other providers. A sobering thought is to realize that patients themselves may see negative descriptors in their record and avoid seeking care if they perceive high levels of stigma.

How is stigmatizing language most frequently expressed in a medical record?

Park et al, published a qualitative study in 2021 that looked at 600 encounter notes from 138 physicians in an ambulatory internal medicine setting.

Park analyzed the notes for themes of stigma and bias and identified five categories of negative language:

1. Questioning patient credibility (ex. ‘supposedly’, “claims”, or “insists”)
2. Disapproval (ex. “Despite repeated counseling”)
3. Racial or class stereotyping (ex. Surgical bandage got “a li’l wet”)
4. Difficult patient (ex. “the patient was adamant” or “this seems to pacify him”)
5. Unilateral decision-making (ex. “I impressed upon her the importance of”)

Our words matter. Guidelines for documentation standards have been suggested in medical literature, but also by many patient advocacy groups. My next post will highlight some of these guidelines, which provide some interesting food for thought. Check back soon!

Source: https://lnkd.in/gxw-ebUF

10/28/2022

“Sticks and stones may break my bones, but words will never harm me.”

We all know from experience that the old idiom isn’t true. But what about when it comes to language used in patients’ medical records? Do we need to be extra cautious about the terminology and patient descriptors being used? Can language impact quality of care?

One excellent study performed by Goddu et al in 2018 presented emergency medicine and internal medicine trainees with two different versions of a medical record note. The patient was the same for both versions: an individual with sickle cell disease who needed treatment for pain. All clinically relevant information was the same, but one version had stigmatizing language planted in it, and the other had neutral language.

Check out the stigmatizing version pictured at the bottom of this post. What parts can you identify as being stereotyping or stigmatizing?

Here are a few:

· “all up in my arms and legs”
· Narcotic dependent
· In our ED frequently
· Housing authority moved him to a new neighborhood
· Hanging out with friends outside McDonald’s
· He refuses to wear his oxygen mask and is insisting that his pain is “still a 10”

At first glance, some of these statements might seem harmless. Yet each one falls into one of three categories that give subtle, unhelpful (at best) messages about the patient:

1. Casting doubt on the patient’s pain (e.g. insisting that his pain is “still a 10” vs. still has 10/10 pain).
2. Implying patient responsibility with references to uncooperativeness (e.g. he refuses his oxygen mask vs. he is not tolerating the oxygen mask).
3. Portraying the patient negatively (irrelevant and unnecessary indicators of socioeconomic status are used, such as the reference to housing authority and McDonald’s).

Goddu’s study found that trainees’ exposure to the stigmatizing language was associated with:

· More negative attitudes towards the patient (20.6 stigmatizing vs. 25.6 neutral. P < 0.001)
· Less aggressive management of the patient’s pain (5.56 stigmatizing vs. 6.22 neutral. P – 0.003).

Interestingly, the trainees could also identify the planted, stigmatizing language following the study.

Goddu concluded that stigmatizing language used in medical records to describe patients can influence subsequent physicians-in-training in terms of their attitudes towards the patient and their medication prescribing behavior.

Have you encountered EHR documentation that is stigmatizing? Have you noticed an impact on the patient’s care?

Source: https://lnkd.in/gUBjYgPC

10/26/2022

2-year-old Luna fell off her bunk bed and thankfully landed on her feet. In fact, it was a great landing. She stuck it perfectly. Luna only cried briefly, but now she will not bear any weight. She is crawling around and refuses to walk.

An exam reveals that there is no tenderness to palpation or limitations to range of motion in Luna’s hip, ankle, and knee. There are no external findings.

We get an x-ray. What do you see in the picture below on the far left? Not a thing. What about the x-ray image in the middle? Kind of. If we zoom in? Yes! There is an obvious oblique/spiral fracture of the tibial shaft.

Luna has a classic toddler’s fracture or spiral fracture of the tibia. In contrast to a couple of fracture-types we recently discussed, this fracture can happen very easily. Between the ages of 9 months and 4 years, any type of twisting of the tibia can cause a spiral fracture. The classic mechanism is a child jumping and then rotating his/her body on landing while the foot is planted.

The presentation is often subtle with minimal or no trauma. But there are some clues. If the child refuses to bear weight, this sign has 82% sensitivity and 30% specificity. If there is localized tenderness to palpation, this exam finding has 71% sensitivity and 67% specificity.

Spiral fractures of the tibia can be difficult to see on x-ray (13-43% of fractures are initially missed), but an internal oblique projection (type of x-ray view) can assist with detecting one.

If the clinical suspicion is high, providers should go ahead and treat! Management ranges from long leg cast to short leg cast to splint or CAM boot. A follow-up x-ray in 10-14 days will help confirm the diagnosis. A fracture will show up a lot more clearly by that point. Consult an orthopedist if the diagnosis is confirmed.

This is part V and the final post in our “missed fractures” series. I will be posting soon on a very interesting topic in healthcare: stigmatizing language. Stay tuned!

Source: 2022 EM lecture by Ilene Claudius, MD
https://lnkd.in/gN7NweVz

$How do you rip off the lateral process of your talus? This post is part IV in our “missed fractures” series. Welcome bac...$

10/24/2022

How do you rip off the lateral process of your talus?

This post is part IV in our “missed fractures” series. Welcome back!

To use non-medical terms, the talar process is a wedge-shaped prominence on the talar bone, which makes up part of the ankle joint. This is the area of concern with 15-year-old Luke, who was snowboarding yesterday at Vail Mountain Resort in Colorado.

Luke is now complaining of pain with range of motion in his left ankle, and he reports tenderness with palpation about 1 cm below his lateral malleolus (ankle bone). Luke’s mom tells you that she thinks his complaints of pain and limping are dramatic because he has a test at school tomorrow and there was no fall or trauma event at the ski resort yesterday.

However, there is some bruising and swelling around Luke’s ankle, so an x-ray is ordered. (See photo below on the left.) Anything there?

No, there are no visible fractures. But what is the pretest probability in this case? Very high! High enough to get a CT. The CT image on the right vividly shows that the lateral process of Luke’s talus has been torn off.

Talar process fractures are frequently missed: 33-41% of them are overlooked initially. They are difficult to diagnose because they mimic sprain injuries. However, if they are missed on the initial exam, chronic inflammation and pain may develop, along with non-union of the bone and arthritis of the ankle joint.

If there is < 2 mm displacement of the talar process from the talus bone, patients need 6 weeks of immobilization and no weight-bearing on the affected extremity. If there is > 2 mm of displacement, surgical intervention is needed.

In conclusion, let’s answer our initial question. There must be high suspicion for a talar process fracture when tenderness is present just below the lateral ankle bone, an x-ray is negative, and the patient was recently snowboarding. This is a classic snowboarder’s fracture. You really only get it snowboarding or some other mechanism where you land a significantly high jump with your feet immobilized in very slight internal rotation (can you think of how this would occur other than with snowboarding?). That is how you rip off the lateral process of your talus. When the mechanism is there, don’t stop with an x-ray. Get a CT!

Source: 2022 EM lecture by Ilene Claudius, MD
https://lnkd.in/gicAn-dx

$Take a look at the x-ray below. What stands out to you?Yes, the arrows help. There are teeny tiny fractures at the ends ...$

10/18/2022

Take a look at the x-ray below. What stands out to you?

Yes, the arrows help. There are teeny tiny fractures at the ends of the bones. These fractures are called metaphyseal fractures – breaks on the metaphysis, which is the growing plate at each end of a long bone.

Let’s pretend that these are 6-year-old Bobby’s x-rays. At first glance, the injuries don’t seem significant. We are told that Bobby was running, then tripped and fell. But there is a problem with this story. The mechanism simply doesn’t match the injuries.

The size of these fractures is deceptive because they require a very high level of force: a twisting and yanking type of force. This mechanism can rip the periosteum (membrane of blood vessels and nerves that wraps around most bones) and take off a little bit of bone with it. Even though the bone fractures are small, there is actually a big tear in the periosteum and huge implications of abuse.

The story would make sense if Bobby’s extremity was caught in a washing machine, yanked very hard, and twisted. But that’s not what we are told, so this is another example where the suspicion of abuse must be investigated.

This post is part III in our “missed fractures” series. As mentioned last time, the stakes are high if abuse is missed because 30-50% of children will experience repeat abuse and 5-10% will die at the hands of their abuser. It is critical that these hallmarks of child abuse are detected in a timely manner.

Source: 2022 EM lecture by Ilene Claudius, MD
https://lnkd.in/gbKpBxGZ

$Why learn about missed fractures on x-ray?Three big reasons! · The second-highest malpractice payouts involve misse...$

10/15/2022

Why learn about missed fractures on x-ray?

Three big reasons!

· The second-highest malpractice payouts involve missed fractures

· 80% of missed radiographs are fractures

· The top 3 missed fractures are the foot, knee, and elbow. Rib fractures are also frequently missed, especially when lung and cardiac pathology are the main reasons for obtaining an x-ray.

With that in mind, let’s do part II in our “missed fractures” series…

2-year-old Mandy is brought to her P*P with a cough and fever. A chest x-ray is done, and the results look like the picture below. The provider immediately sees that Mandy’s lungs are a lot denser on one side, which may indicate aspiration pneumonia. But there’s something else… A close look reveals three rib fractures that are an unexpected finding, as there was no reported history of trauma.

Most rib fractures heal on their own without treatment. So why is it so important that Mandy’s rib fractures are detected?

Because rib fractures in a small child (0–2-year-olds) have a 66% positive predictor value for abuse. They are key to diagnosing abuse. A small child’s ribs are very pliable, which makes them difficult to break. Fractures may be found on the anterior, lateral, or posterior chest. The location is not significant, but the presence of any rib fractures in an infant/toddler is very alarming.

If this warning sign for abuse is missed, there is a 30-50% chance of repeat abuse and a 5-10% chance of death. A provider cannot afford to miss rib fractures in small children.

Source: 2022 Ilene Claudius, MD

10/12/2022

6-year-old Evan fell from monkey bars at the park. He is seen in urgent care with complaints of left elbow pain. He doesn’t want to move his arm. There is some swelling around his left elbow and it is very tender to palpation. His left arm is neurovascularly intact and there are no other obvious injuries.

On the first x-ray obtained, the provider was unable to visualize an anterior fat pad (see photo) due to Evan’s elbow being bent at a sharp angle during the x-ray. Evan was sent back for another lateral elbow x-ray to improve visualization of the anterior fat pad. Why was this important?

The provider knew that a poorly done lateral elbow x-ray could obscure a fracture injury. A large anterior fat pad or any posterior fat pad on an elbow x-ray means that there is swelling in the joint. With this sign, a fracture is present in 70% of anterior fat pad cases and in 90% of posterior fat pad cases.

Evan had a type 1 supracondylar fracture (upper arm bone). His arm was immobilized in a long arm posterior splint. The physician ordered follow-up in 10 days with his P*P or ortho for repeat imaging to confirm the diagnosis and get him the appropriate referral.

Making the effort to obtain high-quality imaging is usually always a good idea when it comes to ruling out fractures!

Source: 2022 EM lecture by Ilene Claudias, MD

05/04/2022

Spinal epidural abscess (quiz)

A spinal epidural abscess (SEA) is an infection and accumulation of pus in the epidural space near the spine or inside the skull. Treatment needs to be initiated as soon as possible or serious and life-threatening complications, including paralysis and meningitis, may result.

The incidence of SEA has doubled in the last two decades. 60% of cases are missed on the first dr.’s visit due to the presentation often being subtle.

Let’s take a quiz on this need-to-know illness:

1. Which is not a risk factor for SEA?

A. Intravenous drug use
B. Trauma/falls
C. Cancer
D. Heart disease

2. Which is considered a high-risk procedure for SEA?

A. Dental work
B. Appendectomy
C. Liposuction
D. Hernia repair surgery

3. Which statement is true?

A. 5% of cases are idiopathic – etiology is unclear
B. The triad of back pain, fever, and neurological deficit is rarely seen in the presentation
C. Focal spinal tenderness is present more than diffuse spinal tenderness.
D. Abnormal reflexes are not a sign of SEA

4. Which test should always be ordered for a patient presenting with back pain, fever, and abnormal reflexes?

A. Back CT w/ angiography
B. Abdominal ultrasound
C. EKG
D. Head CT

5. True or false?

It is important to obtain imaging at the spinal level above where the complaint is, if not the entire spine because there are often skipped lesions
A. True
B. False

Answers

1. D
2. A
3. B; 20% of cases are idiopathic. Diffuse spinal tenderness more common than focal.
4. A
5. A

(Source: https://lnkd.in/gwvRCE2n)

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