Delayed diagnosis in a rural trauma center

The rapid and accurate diagnosis of all injuries is critical in trauma surgery. Injuries not diagnosed after the secondary survey are not without serious consequences. Therefore, in an effort to decrease this problem a policy was initiated to perform an ongoing serial exam during the entire course of each patient's involvement with the trauma team at Saint Francis Medical Center.

Prospective identification and evaluation of patients admitted to a single trauma service with delayed diagnosis was done from July 1, 1993, to October 31, 1995.

Sixty-eight delayed diagnoses were identified in 56 patients, for an incidence of 3% of the total 1876 patients evaluated. The vast majority were nonspinal orthopedic injuries (63%). Of seven missed spinal fractures, only one resulted in permanent paralysis. The remaining injuries missed were 11 injuries located in the head and neck area, 3 arterial injuries, 3 pneumothoraces, and 2 small bowel injuries. Thirty-four percent of the patients required surgical intervention for these injuries and one patient died because of the delay. There was a high association of delayed diagnosis in victims with altered mental status, victims intubated in the field, and individuals requiring immediate operation. Twenty percent of our total missed injuries could have been avoided if a thorough evaluation of initial films had been done.

Delayed diagnosis remains a problem in all trauma centers. This study demonstrates that to keep this problem at a reasonable rate, we must: (1) carefully review initial x rays; (2) repeat any study that is not clear; and (3) continue serial examinations of each patient for the entire clinical course. Objective and thoughtful discussion of missed injuries on a routine basis will also keep this problem minimal.