Wednesday, January 25, 2006

Goodbye to the Finger Wave...
The latest burning controversy in trauma surgery: perform the SMA-1 or not? From the Journal of Trauma: Reasons to Omit Digital Rectal Exam in Trauma Patients: No Fingers, No Rectum, No Useful Additional Information. From the abstract:
Background: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted.

Methods: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males.

Results: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%.

Conclusion: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.
For a year trauma patients underwent DRE's and a data collection tool was used and the diagnostic acumen of both were compared. Here is the data sheet:

Snippets from the discussion:
This study demonstrates that DRE is equivalent to OCI for confirming or excluding the presence of index injuries, and is of limited value in the initial assessment of trauma patients. DRE rarely provided additional accurate or useful information that changed patient management. Clinical acumen based on other information, short of DRE results, appears to be a safe and accurate method of ruling in, or ruling out, an index injury thereby avoiding this unpleasant encounter.

In this study, when all cases are considered, the NPV, PPV, and efficiency (which is essentially a measure of accuracy) of DRE and OCI are no different, potentially making one or the other expendable. Furthermore, in cases with confirmed index injury, the more accurate tool proved to be OCI. In all index injury cases where OCI were falsely negative, DRE was falsely negative as well. Therefore, no index injury would have been missed by omitting DRE that would also not be missed by relying on OCI alone. However, omission of DRE would have avoided acquisition of false-negative or false-positive information in 31 patients or 6% of the entire sample versus 21 or 4% for OCI. Of greater note, and perhaps clinical importance, is the significantly higher false-negative examination rate (63%) for DRE compared with OCI (22%) in patients with confirmed index injury.
The fact that it rolls downhill can affect the diagnostic utility of the DRE:
One factor that may contribute to the propensity of DRE to yield less than useful or accurate information is that it is generally relegated to the least experienced member of the trauma team (at least in academic centers), which is often a medical student. This may stem from the perceived menial nature of the task or a genuine effort to provide a complete educational experience. The issue of poor interrater reliability in determining normal and abnormal DRE has been raised. Further, other investigators have found difficulty even among experienced examiners in determining normal and abnormal rectal tone as confirmed by manometry.
There is also the concern of violence or litigation associated with rectal exams:
The occurrence of violence in the emergency department setting, despite being under reported, is well described. In one study, 36% of surgical staff and 30% of emergency department staff were assaulted. Verbal assaults are more common than physical assaults. The profile of both perpetrator and victim of violence fit well with the trauma patient and the physician relegated to the task of DRE, at least in academic centers. The perpetrator is usually young, male, intoxicated, or a substance abuser. Doctors are less likely to be victims than nurses, but those physicians who are victims tend to be younger and less experienced. Circumstances precipitating assault are not well described. Although DRE is never specifically implicated, one study does describe a significant correlation with averse stimulation of the patient. It would be reasonable to assume that DRE falls into that category. Although there were no documented episodes of physical assault on the examiner related to DRE in this current study, anecdotally, instances of animated protest and verbal abuse were not uncommon. This is consistent with the cited literature.

DRE, if misunderstood or poorly performed can lead to litigation, or other administrative actions initiated as a result of complaints. A noteworthy level of emotional and physical discomfort associated with DRE has also been described,which may precipitate a less than optimal doctor, patient encounter, and heightened potential for the above mentioned occurrences. There are also small but not insignificant or inconsequential risks of adverse patient events associated with DRE related to rectal injury or other conditions. Again, although such actual or potential occurrences are rare, avoidance of even the smallest of risks seems sensible from a number of standpoints if an equivalent screening process that is less provocative can be substituted for DRE.

Good study and good points are made. Certainly goes against the old "no finger or no rectum" being the only exceptions to performing a rectal exam. It will be interesting to see how much this takes off. But for now, join in the chorus of Moon River.
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