Arbitrary Physician Protocols

My mother broke her hip last week.  When she fell, she bumped her head, so the trauma team that collected her put a cervical collar around her neck, “just in case”.

The protocol at Yale New Haven Hospital is that a patient in this situation must be evaluated within 72 hours to determine whether ligament damage occurred.  Damaged ligaments, if not allowed to heal, or repaired, can lead to neck instability and the possibility of paralysis. The evaluation can be done either by asking the patient to move their head, and determining whether symptoms arise (pain, numbness, tingling), or an MRI can be performed.  If the evaluation is not done within 72 hours, I was told that my mother would  “have to” wear the collar for another six weeks.

My mother has dementia, and also was receiving pain medication, so the former style of evaluation was not successful.  She could neither obey orders/requests reliably, nor report her observed feelings reliably.  It took 24 hours to arrange for hip joint replacement surgery, and then another 24 hours for her to recover a bit.  And then she was in pain.  Moving her for the MRI seemed to be quite an imposition.  We were repeatedly told, in urgent terms, that we were running out of time.

This all seemed out of proportion to the evidence, since my mother seemed to be quite comfortable, hip and surgical pain aside.  I began to push back.  It seemed to me that one could remove the collar and simply observe my mother for 10 or 15 minutes.  Visitors could enter the room to cause her to turn her head in curiosity.  People could see whether she winced or seemed comfortable.

Then I was told that there was no evidence at all that any aspect of this protocol was correct or useful to the patient.  Useful to the Hospital?  Yes.  It might reduce the chance of a law suit.  But necessary, or even reasonable?  Fears, yes.  Concerns, yes.  But no evidence, no studies.

I also pointed out that while they could recommend that my mother wear the collar for six weeks, and explain the possible consequences of not doing that, they could not require that she do so.  Their use of the phrase “have to” was really inappropriate.

Lessons learned?  When a doctor tells you that something must be done, often they are over-stating the case, either to cover their ass, or their attorney’s asses.  And while they often use words like “must” they almost never mean what they say.  They should be offering information and making recommendations.

Ask questions.  Push back.  Do not let the creators of protocols push you thoughtlessly in an uncomfortable or expensive direction.

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