FLUFF Flashcards
Give 8 steps in the WHO preop checklist to enhance the safety of surgery. (2011, 2012, 2013, 2014)
“<img></img><br></br><div><ul> <li>confirm identity, consent, and procedure</li> <li>Side/site marked</li> <li>Anesthesia equipment check completed</li> <li>Pulse ox check</li> <li>Check allergies</li> <li>Assess airway risk</li> <li>Confirm expected blood loss and availability of blood products</li> <li>Confirm antibiotic prophylaxis administered</li></ul></div>”
4 components of WOMAC
<div>Western Ontario and McMaster Universities Osteoarthritis Index<br></br></div>
<ul> <li>Pain (5 items)</li> <li>Stiffness (2 items)</li> <li>Physical Function (17 items)</li> <li>Index/Global Score (summary of 3 subscales)</li></ul>
<div>4 principles for establishing causality (2012)</div>
“<ul> <li>Consistency</li> <li>Strength of relationship</li> <li>Excluding alternative (no plausible alternatives)</li> <li>Dose Response</li></ul><div><ul> <li>Bradford Hill’s Criteria for Causality</li> </ul><ol> <li>Strength of association: a strong association supports causality</li> <li>Consistency: causality is more likely if multiple studies show a consistent relationship </li> <li>Temporal Relationship: there must be a temporal relationship between exposure and outcome in order for there to be causality</li> <li>Dose Response Relationship (aka biological gradient): If there is a relationship between the degree of exposure and the magnitude of effect then there is more likely to be causality</li> <li>Specificity: if there is a specific outcome related to a specific exposure, causality is more likely</li> <li>Plausibility: whether or not the association is plausible</li> <li>Coherence: the cause and effect relationship should not contradict current substantive knowledge</li> <li>Analogy: existing similar associations would support causality</li> <li>Experiment: causation is more likely if evidence is based on randomized experiments</li> </ol></div>”
<ul><li>Surgeon is conducting an RCT on olecranon fractures. Patient comes into emergency with a fracture that could likely be included. The surgeon is scrubbed in but the OR says they could call for that patient next. Surgeon sends med student to discuss the study and obtain consent. Give 3 problems with this scenario. (2014)</li></ul>
“<ul><ul><li>Med student is not a ““qualified representative”” who is trained in proper procedures to obtain informed consent</li> <li>Medical student is not familiar with the details of the study protocol including required follow up, nor is he/she likely aware of treatment alternatives, risks and benefits to participating, etc</li> <li>This is a rushed consent if they are going to be called for next case. ““For consent to be informed, prospective participants shall be given adequate time and opportunity to assimilate the information provided, pose any questions they ma have, and discuss and consider whether they will participate.””</li> </ul> </ul> <div></div> <div>Government of Canada Research Ethics website (<a>http://www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/chapter3-chapitre3/#toc03-1</a>)</div> <div>"”For consent to be informed, prospective participants shall be given adequate time and opportunity to assimilate the information provided, pose any questions they may have, and discuss and consider whether they will participate. The time required for this initial phase of the consent process will depend on such factors as the magnitude and probability of harms, the complexity of the information conveyed, and the setting where the information is given.””</div> <div>””</div> <div>The information generally required for informed consent includes:</div> <ul> <li>information that the individual is being invited to participate in a research project;</li> <li>a statement of the research purpose in plain language, the identity of the researcher, the identity of the funder or sponsor, the expected duration and nature of participation, a description of research procedures, and an explanation of the responsibilities of the participant;””</li> </ul> <div>"”The approach to recruitment is an important element in assuring voluntariness. In particular, how, when and where participants are approached, and who recruits them are important elements in assuring (or undermining) voluntariness. In considering the voluntariness of consent, REBs and researchers should be cognizant of situations where undue influence, coercion or the offer of incentives may undermine the voluntariness of a participant’s consent to participate in research.””</div>”
<div>List 5 components of determining capacity to provide consent.</div>
“<div>vowels: UEEIOD</div><ul> <li>Does the person <u>understand</u> the conditions for which the specific treatment is being proposed</li> <li>Is the person able to <u>explain</u> the nature of treatment and understand relevant information</li> <li>Is the person <u>aware of possible outcomes </u>of treatment, alternatives or lack of treatment</li> <li>Are the persons’ <u>expectations reasonable</u></li> <li>Is the person able to make a <u>decision</u> and communicate a choice</li> <li>Is the person able to <u>manipulate the information</u> rationally</li></ul>”
<div>List 5 steps in management of a medical error</div>
<div>DDDDP</div>
<div>detect</div>
<div>disclose</div>
<div>document</div>
<div>display empathy</div>
<div>prevent recurrence</div>
<ul> <li>CMPA Website - Disclosing harm from healthcare</li> <ul> <li>Detect the error and address the error</li> <li>Full Disclosure to patients</li> <li>Show empathy and apologize</li> <li>Full Documentation</li> <li>Identify cause and prevent recurrence</li> </ul></ul>
<div>List 5 methods to help eliminate bias in constructing a randomized control trial.</div>
<ul> <li>Centralized random allocation (non tamperable way, aka not envelopes)</li> <li>Blinding of assessors at minimum (triple blinding is best)</li> <li>Predetermined, objective, valid outcome measures</li> <li>Intention to treat analysis</li> <li>Appropriate sample size/power</li> <li>Adequate follow up period to capture outcome (minimum 80% need to reach for high quality study)</li></ul>
<div>RC 2015 - Name 6 risk factors for non-therapeutic opioid abuse</div>
<ul> <li>Personal or family history of substance abuse</li> <li>Nicotine dependency</li> <li>Age < 45 years</li> <li>History of depression or psychiatric diagnosis</li> <li>Lower level of education</li> <li>Pre-injury/Pre-operative opioid use</li></ul>
Canmeds roles?
“<ul> <li>PALS CC</li><li>Professional</li> <li>Advocate</li> <li>Scholar</li> <li>Medical Expert</li> <li>Communicator</li> <li>Leader</li> <li>Collaborator</li> </ul> <div></div> <ul> <li><img></img></li></ul>”
RC 2010 - principles of medial ethics
<ol> <li>Non-maleficence - do no harm</li> <li>Respect for Autonomy</li> <li>Beneficence (benefit the patient)</li> <li>Justice (fairness)</li></ol>
RC 2011 - 16 y/o F Jehovah witness trauma patient who has lost enough blood to require a blood transfusion. You explain her that she needs blood. She gets agitated when you say this and refuses. Although she is in shock, she seems competent. What ethical principles are in conflict with each other when dealing with this situation?
“<ul> <li>respect for autonomy (pt’s desire as a competent minor to make her own decisions about her body)</li> <li>Beneficence (desire to save her life with blood products)</li> <li>Non-maleficence (concern about ostracizing her from her family/religious community, and potentially affecting her eternal soul, according to her beliefs, if you provide blood products against her will.)</li></ul>”
RC 2013 - Which of the following are not important when evaluating an outcome instrument? <ol> <li>Content</li> <li>Cost effectiveness</li> <li>Methodology</li> <li>Clinical utility</li></ol>
“B<div><br></br><div><div>Outcome Instruments: Rationale for Their Use (JBJS 2009) Schemitsh is a co-author</div><div><br></br></div> <div>"”Terwee et al. proposed a checklist of quality criteria to evaluate the methodological soundness of patient reported outcome instruments. These criteria include: content validity, internal consistency, criterion validity, construct validity, reproducibility (agreement and reliability), responsiveness, floor and ceiling effects, and interpretability.””</div> <div></div> <div>"”The most important feature of outcome instruments is their ability to test whether treatment is effective in improving symptoms or function from a patient’s point of view””</div></div></div>”
<ul> <li>RC 2008 - What is ethical principle of “do no harm”</li> </ul>
<ol> <li>nonmalefecince</li> <li>beneficence</li> <li>autonomy</li> <li>justice</li></ol>
A<div><ul> <li>Non-maleficence –> first, do not harm</li> <li>Beneficence - actions that promote wellbeing of others, serves best interest of patient</li> <li>Autonomy - right of individuals to self-determine, make informed choices about personal matters</li> <li>Justice - moral obligation to act on basis of fair adjudication</li></ul></div>
RC 2008 - A patient’s right to know his diagnosis is grounded in the principle of: <ol> <li>Beneficence</li> <li>Justice</li> <li>Truthfulness</li> <li>Autonomy</li></ol>
D<div><ul> <li>Non-maleficence –> first, do not harm</li> <li>Beneficence - actions that promote wellbeing of others, serves best interest of patient</li> <li>Autonomy - right of individuals to self-determine, make informed choices about personal matters</li> <li>Justice - moral obligation to act on basis of fair adjudication</li></ul></div>
RC 2016, 2013 - When plotting a survivorship curve using the Kaplan Meier survivorship analysis, the number of failed is divided by: <ol> <li>Initial number of procedures</li> <li>Total number still being followed</li> <li>Number that have already failed</li> <li>Number that were lost of follow</li></ol>
B
RC 2013 - Very serious question. Patient has been “Malingering” and “making unreasonable requests”. In regard to ending this relationship the physician should do all the following except: <ol> <li>talk with the patient and explain the situation</li> <li>Provide written notice to the patient</li> <li>Stop seeing the patient once they receive written notice</li> <li>Make alternative recommendations for another physician to treat the patient.</li></ol>
“C.<div><ul> <li>Consider the circumstances, and if you think it is appropriate, inform the patient in person of the decision to terminate. There may be circumstances, such as when you are concerned for your safety, where such a meeting would not be advisable. If you do have a discussion with the patient, you should clearly document it in the patient’s medical record and send a confirming letter, if your College requires it.</li> <li>If you do not think a face-to-face meeting is advisable, send a letter (your College may require that it be registered) to the patient. Keep a copy of the letter in the patient’s medical record.</li> <li>Whether you meet with the patient in person and/or send a letter, you will want to:</li> <li>Notify the patient clearly of your decision to end the doctor-patient relationship. You also need to decide what, if anything, you will tell the patient about the reasons for the termination. The Colleges appear to differ on the best course of action. When making this decision, you should take into consideration issues such as your personal safety and the patient’s particular circumstances.</li> <li>Provide the patient with reasonable notice of the date on which medical services will terminate. Tailor the notice period to each situation taking into consideration such things as the patient’s circumstances, the availability of alternative physician resources in the community, and whether the patient poses any threat.</li> <li>Advise the patient to obtain a new physician and, if possible, provide advice to the patient on possible steps to do so.</li> <li>Advise the patient of the need to transfer copies of medical records to the new physician. You should also request the necessary consent to make the transfer. Consider any Privacy Commission or College guidelines that might apply to the transfer of patient records.</li> <li>Inform the patient you will provide only urgent or emergent care in the interim.</li> <li>Provide any specific information or instructions concerning the patient’s particular medical condition (e.g., information about outstanding laboratory results and where they will be sent, information about renewal of prescriptions, or other specific medical advice) to ensure the continuity of care in the circumstances.</li> <li>Inform your staff members about the termination and instruct them on how to transfer copies of the medical records. You should be as helpful as possible in ensuring the transfer to the new treating physician is done promptly.</li></ul></div>”
RC 2012 -You are designing an RCT. You want to analyze patients based on allocation and not the treatment they received. What is the name of this principle? <ol> <li>block randomization</li> <li>intention-to-treat analysis</li> <li>some other shit</li> <li>as-treated analysis</li></ol>
“B.<div><br></br></div><div><ul> <li>Intention-to-treat analysis and accounting for missing data in orthopaedic randomized clinical trials JBJS Am 2009</li> <li>"”The intention-to-treat principle implies that all patients who are randomized in a clinical trial should be analyzed according to their original allocation. This means that patients crossing over to another treatment group and patients lost to follow-up should be included in the analysis as a part of their original group.””</li></ul></div>”
RC 2012 - What is the best study design to capture prevalence <ol> <li>RCT</li> <li>Cohort</li> <li>Retrospective</li> <li>Cross sectional</li></ol>
D.<div><br></br></div><div><div>Cross-sectional studies, otherwise known as cross-sectional analyses, transversal studies, prevalence study</div></div>
RC 2014 - All are true regarding observational studies EXCEPT? <ol> <li>May involve observing patients over time</li> <li>May involve observing patients at a certain point in time</li> <li>Can allow researchers to identify association but not causation</li> <li>Interventions are under control of the researchers</li></ol>
“D.<div><br></br></div><div> <div> <div> <div>Observational study designs include case series, case- control studies, cross-sectional surveys, and cohort studies.</div> <ul> <li>Researchers observe patient groups <b><u>without</u></b> allocation or intervention</li> <li>May be either prospective or retrospective</li> <li>May be descriptive or analytic</li> <li>Descriptive - useful for obtaining background information for more advance studies</li> <ul> <li>Examples: case reports, case series, cross-sectional studies</li> </ul> <li>Analytic - explores the association between a given outcome and a potentially related variable</li> <ul> <li>Examples: case-control, cohort, meta-analysis</li> </ul></ul><div></div> </div> </div></div>”
RC 2014 -<div>Which of the following study designs will convey level IV evidence? <ol> <li>Prospective double-blind RCT</li> <li>Case control study</li> <li>Case series</li> <li>Prospective cohort study</li></ol></div>
“<div>C</div><div><img></img></div> <div></div> <div><img></img></div>”
<ul> <li>RC 2012 - In a resource shortage environment, what is not an appropriate way to distribute resources?</li> </ul>
<ol> <li>Give preferential treatment to patients you know and have developed a relationship with</li> <li>Treat patients on a first come first serve bases</li> <li>Prioritize patients in a sense of urgency</li> <li>Try to find the cheapest, most cost effective treatment</li></ol>
A<div><br></br></div><div><br></br></div>
RC 2016 - Hawthorne effect - how to minimize it? <ol> <li>Randomization of patients using random numbers</li> <li>Blinding subjects to treatments being compared</li> <li>Using constant correction in statistical analysis</li> <li>Modifying inferences concerning external validity</li></ol>
B.<div><br></br></div><div><div>Hawthorne effect is a type of reactivity in which individuals modify an aspect of their behavior to their awareness of being observed.</div> <div>Not as random as it seems….only principle mentioned in AAOS Comp Review 2</div></div>
RC 2011 - What is the definition of incidence? <ol> <li>number of patients that developed disease over a set period of time</li> <li>rate of people with disease at set time</li> <li># of new people with disease</li></ol>
A<div><br></br></div><div>incidence: frequency of NEW cases (incidents)</div><div>prevalence: frequency of ALL cases</div>
RC 2011 - When using human subjects in a study. The following ethical principles are followed, <b><u>except</u></b>? <ol> <li>Benficience</li> <li>treated patients with respect </li> <li>justice </li> <li>allocation of research</li> </ol> <div></div>
D.<div><br></br></div>
- Beat (type II) error
- 1- beta and (type II)
- alpha error (type 1)
- a- alpha (type 1)
- Power: Probability of finding a significant association when one truly exists (1 − probability of type-II [B] error). By convention, a power of ≥80% is considered sufficient.
- Beta (type-II) error: Error in hypothesis testing where no significant association is found when there is a true significant association (rejecting a true alternative hypothesis).
- Alpha (type-I) error: Error in hypothesis testing where a sig- nificant association is found when there is no true sig- nificant association (rejecting a true null hypothesis). The alpha level is the threshold of statistical significance established by the researcher (p < 0.05 by convention).
- 0.05
- 1
- 7
- 0.7
- Further away from 1 is more predictive
- So if 1 is neutral, 0.05 is 4 notches away and 7 would be 2.5 notches away.
- When the patient has been told all the information that would be desired by a reasonable person in similar circumstances, including the risk and benefits of the treatment, treatment alternatives, and the likely outcome without treatment
- When the treatment and risks have been described in accordance of the standard of care in Canada
- When all the risks of the procedure have been described
- Cannot remember the last option
- When possible inform the patient of the diagnosis. If some uncertainty exists about the diagnosis mention this uncertainty, the reason for it, and what other possibilities are being considered.
- Explain the proposed investigations or treatments.
- Indicate the chances of success.
- Inform the patient about available alternative treatments and their risks. There is no obligation to discuss what might be clearly regarded as unconventional therapy, but patients should know there are other accepted alternatives and why the recommended therapy has been chosen.
- Inform the patient about the consequences of leaving the medical condition untreated.
- The physician is always responsible
- When the physician has explained the treatment as well as the consequences of noncompliance
- When the physician has determined that the noncompliance is not due to socioeconomic factors
- When the physician has determined that the noncompliance is not due to depression or denial
- Identify the non-compliance. Know what test or treatment was recommended and verify and document that the patient obtained notice of the recommendation. In a non-judgmental manner, ask the patient what they understand about the recommendation and whether they are following it
- Clarify the reason for non-compliance. These reasons may include but are not limited to financial difficulties, social problems, fear, confusion, or side effects.
- Educate the patient about his or her medical condition and the risks and benefits of non-compliance dealing specifically with the identified reasons for non-compliance. This may involve social services who can help access resources such as financial assistance, transportation, or counseling. Verify patient understanding by asking the patient to explain in his or her own words what was communicated to them.
- Decide how to proceed with patient care. If the patient still decides to refuse the plan, there are several options the physician may take:
- Open door policy: The physician is allowing the possibility of continued treatment and dialogue. To protect oneself in this situation, perform a careful history and exam at each visit and note any disease progression, follow the ICEDD process at every visit and document what was discussed.
- Termination of patient-physician relationship: this option is exercised when the ophthalmologist feels that the patient cannot be persuaded to accept treatment, feels uncomfortable with patient safety and the liability risks of treatment refusal, or feels that the patient is disruptive, hostile or violent. Be sure to give sufficient notice in advance that the patient can obtain other care and get written consent for transfer of records.
- Document. Consider asking the patient to sign and informed refusal document. [ Refusal for Surgery sample letter at OMIC site]
- 1 in 50 women will present to orthopedic clinic as a direct result of intimate partner violence
- Orthopedic surgeons are adept at assessing for intimate partner violence
- Orthopedic surgeons have access to a wide variety of resources and referral services for intimate partner violence
- The emergency physician is primarily responsible for reporting intimate partner violence
- ""PRAISE is the largest prevalence study done so far in orthopaedics. Orthopaedic surgeons should be confident in the assumption that one in six women have a history of physical abuse, and that one in 50 injured women will present to the clinic as a direct result of IPV. Our findings warrant serious consideration for fracture clinics to improve identification of, respond to, and provide referral services for, victims of IPV.""
- Education sessions required to improve surgeon awareness
- Most patients (male and female) feel that the cast clinic is an appropriate place to talk about IPV
- People in a long-term relationship are more likely to experience IPV
- Country of origin affects the risk of IPV
- 2016
- PRAISE trial, Lancet 2013
- The discussion goes into detail about the importance of improving orthopedic surgery buy in for this issue. ""…orthopedic guidelines for management of IPV victims are new and are not implemented widely in orthopaedic practices. Consequently, an intervention programme in orthopaedic and trauma clinics is needed.""
- Although 2/3 of the people surveyed said that they believe orthopedic surgeons were appropriate health care people to ask about IPV, this study ONLY asked women, not men, so B is wrong.
- B is about cast clinic, not men and women. Cast clinic is a difficult setting for these discussions
- C is definitely wrong: Women in short-term relationships (OR 0·584, 99% CI 0·396-0·860, p=0·0001) were at increased risk of IPV and physical abuse in the past 12 months in this study.
- D is true, but maybe they don't mean it in a racist way? The study says, ""compared with women in Canada and the USA, those in the Netherlands and Denmark were at reduced risk of any abuse in the past 12 months, physical abuse in lifetime, and any abuse in lifetime ""
- Based on WHO IPV Fact sheet ""country"" makes a difference, but I am not sure that ""country of origin"" is the same thing for IPV within Canada
- ""Women are particularly vulnerable to abuse by their partners in societies where there are marked inequalities between men and women, rigid gender roles, cultural norms that support a man’s right to inflict violence on his intimate partner, and weak sanctions against such behaviour""
- Although I think C is reasonable, B seems like the safest option for the exam. If the real stem makes the situation seem immediately time sensitive, I would pick C.
- The CPSO website does not mention need for a second surgeon's opinion.
- From CMPA best practices website:
- In urgent situations, it may be necessary or appropriate to initiate emergency treatment while steps are taken to obtain the informed consent of the patient or the substitute decision-maker, or to determine the availability of advance directions. However, the instructions as to whether to proceed or not must be obtained as quickly as practicably possible.
- When an emergency dictates the need to proceed without valid consent from the patient or the substitute decision-maker, a contemporaneous record (at the time) should be made explaining the circumstances which forced the physician's hand. If the circumstances are such that the urgency might be questioned at a later date, arranging a second medical opinion would be prudent if possible.
- Surgeon attitude towards these patients
- Management of medical comorbidities
- Anaesthetic complications
- Increased risk of implant failure in TJA
- amputate as per parent’s wishes
- Do not amputate as per patient’s wishes
- Do intralesional curettage to decrease tumor load
- Do IM nail to prevent impending pathologic fracture
- From CMPA:
- The determinant of capacity in a minor has become the extent to which the young person's physical, mental, and emotional development will allow for a full appreciation of the nature and consequences of the proposed treatment, including the refusal of such treatments.
- Refer her back to original surgeon
- Educated her on what CRPS is and provide treatment
- Tell her to call her lawyer
- ?
