Closing Velocity And Injury Severity

Trauma professionals, both prehospital and in trauma centers, make a big deal about “closing velocity” when describing motor vehicle crashes.  How important is this?

So let me give you a little quiz to illustrate the concept:

Two cars, of the same make and model, are both traveling on a two lane highway at 60 mph in opposite directions. Car A crosses the midline and strikes Car B head-on. This is the same as:

  1. Car A striking a wall at 120 mph
  2. Car B striking a wall at 60 mph
  3. Car A striking a wall at 30 mph

2010-saab-9-5-head-on-crash-test_100313384_m1

The closing velocity is calculated by adding the head-on components of both vehicles. Since the cars struck each other exactly head-on, this would be 60+60 = 120 mph. If the impact is angled there is a little trigonometry involved, which I will avoid in this example. And if there is a large difference in mass between the vehicles, there are some other calculation nuances as well.

So a closing velocity of 120 mph means that the injuries are worse than what you would expect from a car traveling at 60 mph, right?

Wrong!

In this example, since the masses are the same, each vehicle would come to a stop on impact because the masses are equal. This is equivalent to each vehicle striking a solid wall and decelerating from 60 mph to zero immediately. Hence, answer #2 is correct. If you remember your physics, momentum must be conserved, so both of these cars can’t have struck each other at the equivalent of 120 mph. The injuries sustained by any passengers will be those expected in a 60 mph crash.

If you change the scenario a little so that a car and a freight train are traveling toward each other at 60 mph each, the closing velocity is still 120 mph. However, due the the fact that the car’s mass is negligible compared to the train, it will strike the train, decelerate to 0, then accelerate to -60 mph in mere moments. The train will not slow down a bit. For occupants of the car, this would be equivalent to striking an immovable wall at 120 mph. The injuries will probably be immediately fatal for all.

Bottom line: Closing velocity has little relationship to the injuries sustained for most passenger vehicle crashes. Those injuries will be consistent with the speed of the vehicle the occupants were riding, and not the sum of the velocities of the vehicles. 

Source: http://thetraumapro.com/2016/11/30/closing-velocity-and-injury-severity/

Why you should care about billing for your scans

hand abdo probe dollar sign

An uncomfortable subject for physicians but billing for our services is not just about compensation it is also recognition of the training, expertise, and time involved in providing a service.  But most importantly, compensation for POCUS is necessary for its long term viability.

Join the dark side, but watch your gain!

Join the dark side, but watch your gain!

The initial battle was all about fighting for our right to perform bedside ultrasound.  Most of the early adopters put remuneration on the back burner while they overcame political, legal, and logistical obstacles.  They did it because they saw the immediate benefits to their patients.

As I have told numerous  students, in my two decades of practice, new skills I learned through CME would result in something I might apply once a week, once a month, maybe once in a career.  When I picked up my first probe, I was learning a skill I would use every single shift, on the majority of my patients.  A real career game-changer.  Payment was of a far lesser priority than mastering a skill that made such a difference.

As POCUS matures, we have a growing body of literature demonstrating its efficacy in care, but also significant cost savings to the system.  Yet most of us are not remunerated anywhere close to what this service is worth.  Even more insulting, some specialities are eligible to receive a greater payment for the performing the exact same scan.

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The American College of Emergency Physicians released a statement this summer summarizing their stance:

“Emergency physician use of ultrasonography provides timely and cost-efficient means to accurately diagnose ED presenting illness and injury to provide higher-quality lower-cost care. ED ultrasonography use can often reduce the need for more expensive studies such as computed tomography or magnetic resonance imaging and reduce unnecessary admissions for more comprehensive diagnostic evaluations. Ultrasonography use in the ED should be appropriately recognized and fairly compensated.”

Approved by the ACEP Board of Directors June 2016

In Canada, like most medical care, emergency physician compensation is primarily based on a single-payer government system.  However the method of payment differs by province.

In Ontario, payment for POCUS is either provided at 100% of the provincial fee schedule for departments that work entirely on a fee for service plan, and for the others around 37%  in the form of shadow billings where income is based on an hourly rate.

Before you say that doesn’t sound too bad, it should be noted that the fee schedule was modified several years ago to disallow emergency physicians to bill almost all ultrasound codes in schedule.  Instead a new diagnostic code was established that pays either $20 or $7 for shadow billers (before current across the board cutbacks).  However this code can only be billed on basic scans such as AAA, pericardial effusion, FAST, and detection of 1st TM pregnancy.

Unlike radiology fees, this billing code does not provide any funding for equipment or archiving costs.  Many emergency departments have funded some or all of the ultrasound equipment and QA out of their own pockets or through charitable donations.  Our physician group pooled its own money to help buy our last three ultrasound machines and obtained donors to help pay the difference.  That is no way to fund a sustainable medical service.

Out of plane

Procedure or scan but not both!

The code fails to recognize all the other diagnostic POCUS scans used in shock, abdominal pain, chest pain, etc.  In fact, the only other official code that can be used by EP’s is a procedural code that cannot be billed along with the procedure.  Thus, performing an ultrasound guided abscess drainage or pleurocentesis means an Ontario physician may only bill for the procedure or the scan.  In most cases the procedure pays slightly more, so once again, no remuneration is provided for POCUS.

In Quebec, there is a $20 billing code with several more eligible types of scans. There is a fear this code may be discontinued in the near future as part of cost-cutting measures.

In Saskatchewan and British Columbia, there is no billing for complex skills such as POCUS at all.

The effects of this billing restriction is insidious and potentially catastrophic.

POCUS is under-utilized in fee-for-service departments in all provinces without billing codes as it is perceived to slow the physician down with no remuneration to compensate them for their time.   Although experienced POCUS providers find that a greater use of POCUS saves time, the perception is real.  This is the biggest danger of our inadequate payment system.  The time and cost for practicing physicians to become competent is an even greater barrier when there is no subsequent compensation to apply POCUS.  A modality that saves lives, reduces patient hospital stays, and saves the system money, is not being performed because of the inadequate upfront monetary support.

Without funding for physicians or hospitals, administrative aspects of POCUS programs, including quality assurance, are threatened.

There are an insufficient number of machines in most ED’s because of this funding deficit.  POCUS cannot be effectively practiced if three physicians on shift are sharing a single system.  How often would you use a stethoscope if there was only one to share amongst three or four caregivers?

As more clinicians in various practice settings embrace POCUS, there will be a growing pressure to support providing this service.  A remote rural physician who can detect an aortic aneurysm or early heart failure at their clinic and arrange followup before rupture or fulminant pulmonary edema is saving lives and money.  This is worth supporting.

There didn’t exist billing codes to support laparoscopic surgery when it took off many years ago, as I was beginning my career.  However, recognition of this new procedure and its costs resulted in new fees that make it sustainable.  POCUS is a tectonic shift of the same magnitude and deserves more than a token fee code that fails to acknowledge the required training, skills, cost savings, and improved patient care.

We need to advocate for proper funding if we want POCUS to evolve, be performed safely with adequate oversight, and allow the acquisition and maintenance of equipment.  It is time for organizations like the Canadian Association of Emergency Physicians to produce a statement of support like ACEP has done.

I would love to hear what current compensation is available where you practice and your thoughts on appropriate remuneration and its effects on POCUS.

Addendum:

For non-Ontario physicians I have attached an excerpt of our POCUS billing code.  Note that it can’t be billed if a radiologist is available to perform the scan, despite the fact the cost of their scan is greater.  They have also included the bizarre requirement that the ultrasound machine have M-mode, which isn’t even required for any of the billable ED scans.

Emergency department investigative ultrasound

An Emergency Department investigative ultrasound is only eligible for payment when:

  1. the procedure is personally rendered by an Emergency Department Physician who meets standards for training and experience to render the service;
  2. a specialist in Diagnostic Radiology is not available to render an urgent interpretation; and
  3. the procedure is rendered for a patient that is clinically suspected of having at least one of the following life-threatening conditions: pericardial tamponade, cardiac standstill, intraperitoneal hemorrhage associated with trauma, ruptured abdominal aortic aneurysm, ruptured ectopic pregnancy

Payment rules:
1. H100 is limited to two (2) services per patient per day where the second service is rendered as a follow-up to the first service for the same condition(s).
2. Services listed in the Diagnostic Ultrasound section of the Schedule, both technical and professional components are not eligible for payment to any physician when ultrasound images described by H100 are eligible for payment.

Note:

H100 is only eligible for payment when it is rendered using equipment that meets the following minimum technical requirements:

1. Images must be of a quality acceptable to allow a different physician who meets standards for training and experience to render the service to arrive at the same interpretation;

2. Scanning capabilities must include B- and M-mode; and
3. The trans-abdominal probe must be at least 3.5MHz or greater.

Medical record requirements:

The service is only eligible for payment when the Emergency Department investigative ultrasound includes both a permanent record of the image(s) and an interpretative report.

Claims submission instructions:

Claims in excess of two (2) services of H100 per day by the same physician for the same patient should be submitted using the manual review indicator and accompanied by supporting documentation.

[Commentary:
1. See page GP34 for the definition of an “Emergency Department Physician”.

2. Current standards and minimum requirements for training and experience for Emergency Department investigative ultrasound may be found at the Canadian Emergency Ultrasound Society website at the following internet link: http:// www.ceus.ca.]

 

Live and let die

lald

Everyone dies. It’s a sad fact of life and a tough part of any healthcare professional’s day. Some deaths are unexpected, and hit us hard. Thankfully, there are those that we know are coming, and this gives us the opportunity to try to give that person a peaceful and comfortable end of their life, and for their family to be present and informed when it happens, or at the very least to have that choice.

If something acutely changes, or the person deteriorates suddenly, it can sometimes be very difficult for carers or families. Despite plans for end-of-life care to take place at a nursing home, it’s not uncommon for an ambulance to be called to attend. Transferring the patient to the emergency department can be inappropriate, and have negative consequences on both care of the patient, and the experiences of them and their family in the last few hours of life. In a busy emergency department, it can be difficult to provide the dedicated medical care and emotional support that is often needed. Often we try to get the patient back home or to a ward, where the atmosphere is a bit more relaxed, but with bed pressures and if death is imminent, this can all be very difficult to achieve, though I’d like to think we try our utmost.

In October’s EMJ, Georgina Murphy-Jones from the London Ambulance Service, and Stephen Timmons from the University of Nottingham have explored how paramedics make decisions regarding transfer to hospital for nursing home residents nearing the end of their lives. As they highlight in their paper, it’s difficult to know exactly how often this occurs, but these calls are complex, and there are often multiple factors in play to consider. Face-to-face interviews were conducted with six paramedics, which were recorded, transcribed and analysed to identify themes.

It’s a fantastic paper, and really gives a good insight into how paramedics think in these situations. It can be all too easy to blame our pre-hospital colleagues for bringing patients into hospital when they have an end-of-life plan to avoid hospital admission, and die at home or another preferred place. However, it’s important to remember that whilst emergency physicians operate in an information-light, time-critical environment, paramedics and ambulance technicians often have less facts than we do, and have to make decisions more quickly.

There are some really good take home messages here from the identified themes, and food for thought for your next end-of-life encounter.

  • Paramedics find it difficult to understand patients’ wishes – in the experience of those studied, these wishes were inadequately documented or limited in content, sometimes just confined to a DNACPR decision. When nursing home staff were asked about their patients, they often did not know them or their wishes well. This made it difficult in an end-of-life situation to make a decision, as quite often the patient themselves was too unwell to express their desires verbally.
  • Evaluating best interests is difficult – when patients lack capacity to make a decision, paramedics have to make it for them. It’s difficult to do this, particularly if this is the first time you’ve met someone and have limited information. Paramedics have to weigh up the risks versus the benefits of leaving the patient at home, or bringing them into hospital, and this can be even more difficult taking into account the next point.
  • Everyone wants to have an input – decision to convey or leave at home is influenced by nursing home staff, relatives, and other pre-hospital professionals. There can be a lot of pressure from nursing home staff to transport the patient, even if alternate decisions have already been made and documented around end-of-life care. Paramedics who took part in the study described situations of conflict between staff, relatives, and patients, and the difficulties they face in trying to keep the patient at home when other parties disagree, even if the patient themselves does not wish to go to hospital.

It’s obviously hugely difficult for paramedics to make these decisions, but the overriding theme here is communication. So what can we do to help?

Document everything

In order to understand patients’ wishes, make a best interests decision, and weigh up input from all parties, paramedics need to know the facts. Information about the patient, their condition, their decisions about end-of-life care, discussions with their family, and communication with other professionals involved in their care should be documented and easily accessible. It should be easy to see what the patient wants to happen towards the end of their life, and in what cases the patient should return to hospital.

Talk to the family

Dying relatives are hard. As a family, you want to do everything you can to help your relative. Sometimes, it’s hard to feel like you’re doing everything possible unless you call an ambulance, even if your family member is already in a nursing home, being cared for. Talking to families, not just about the decision to send the patient home to die, but also about what will happen later on once the patient is actually in the nursing home, is crucial.

Empower the nursing staff

From the paper, it seems that there were instances of nursing staff not feeling able or qualified enough to nurse patients who are dying. If we send patients to a nursing home to spend the rest of their life being cared for there, we need to be sure that the nursing home have the capability and experience to do so. This ties into the first two action points also. If we document clearly the plan, and inform the family as well, the nursing home staff will have a much easier time looking after our patient, with less ambiguity. If your patient is being discharged, phone the nursing home, speak to the manager, and let them know what’s going on. The GP needs to know as well!

Support your paramedics

Not only to help them make decisions in the nursing home, but also when these patients do arrive in our ED. They’ve had to make some tough choices, usually under pressure from staff or family members, and some that they might be disappointed with because they feel it’s not the best thing for the patient. But, they’ve done what they can, in the time they had, with the information they had. We need to support them through these difficult decisions, not criticise them.

 

Much to think about regarding end-of-life care, and hopefully from reading the paper, and assessing needs in our own practice, we can try to ensure more people can achieve the death they want, in the place they want to die.

vb

Chris
@cgraydoc