Background This case series report discusses patients presenting with hemorrhage and hemodymanic compromise due to severe pelvic fractures and undergoing intraoperative angioembolization (IAE) with other resuscitative procedures. Methods We used portable digital subtraction fluoroscopy units for IAE in patients with severe pelvic hemorrhage and hemodynamic instability (5/03-4/09). Data was collected on demographics, injury severity, resource utilization, and outcomes at our Level 1 trauma center. Results There were 6,538 adult admissions with 912 having pelvic fractures and 65 of these undergoing pelvic angioembolization. Twelve hemodynamically compromised patients (10 males, 2 females) had intraoperative pelvic angiography (age: 22-79 years; mean 51.3 ± 17.4). Injury severity score (ISS) was 37.5 ± 8.4 (22-50). Mean emergency department (ED) length of stay (LOS) was 57.4 min ± 47.9 with 10 patients transported directly to the OR and 2 to the SICU prior to OR. Ten of 12 patients underwent exploratory laparotomy followed by angioembolization. Mortality was 50%. Among the 6 survivors (ISS 22 - 50), all had a pre-op CT scan, five had an initial base deficit <13, and four were transfused ≤ 6 units pre-incision/pre-procedure. Four of the 6 survivors had unilateral embolization. In contrast, all 6 non-survivors (ISS 29-41) required massive transfusion prior to OR (>6 units PRBCs) with 4 having a based deficit >13. Three of these patients bypassed CT and five underwent bilateral internal iliac embolization (BIIE). Conclusions IAE for severe pelvic hemorrhage can be successfully performed concurrently with exploratory laparotomy, pelvic packing or other resuscitative procedures. Patients most likely to benefit have a base deficit <13, and do not require massive transfusion prior to IAE or suffer from a vertically unstable pelvis fracture.

Explore the challenges in making performance improvement data publicly available on hospital websites, and consider some practical tips and suggestions for aligning organizational goals with community and consumer needs.

Locked-in syndrome is an extremely rare neurological state caused by injury of the ventral pons. The syndrome is characterized by quadriplegia and anarthria with concomitant preservation of cortical function. When a reversible underlying pathological abnormality is identified and managed aggressively, meaningful recovery is possible. Because patients retain consciousness throughout their illness, a dependable method for titrating sedation may improve their quality of life. The case presented suggests that bispectral index monitoring may be a cost-effective and reliable method for managing sedation in patients with locked-in syndrome.

Background This study assesses the impact that a resident oversight and credentialing policy for central venous catheter (CVC) placement had on institution-wide central line associated bloodstream infections (CLABSI). We therefore investigated the rate of CLABSI per 1,000 line days during the 12 months before and after implementation of the policy. Methods This is a retrospective analysis of prospectively collected data at an academic medical center with four adult ICUs and a pediatric ICU. All patients undergoing non-tunneled CVC placement were included in the study. Data was collected on CLABSI, line days, and serious adverse events in the year prior to and following policy implementation on 9/01/08. Results A total of 813 supervised central lines were self-reported by residents in four departments. Statistical analysis was performed using paired Wilcoxon signed rank tests. There were reductions in median CLABSI rate (3.52 vs. 2.26; p = 0.015), number of CLBSI per month (16.0 to 10.0; p = 0.012), and line days (4495 vs. 4193; p = 0.019). No serious adverse events reported to the Pennsylvania Patient Safety Authority. Conclusions Implementation of a new CVC resident oversight and credentialing policy has been significantly associated with an institution-wide reduction in the rate of CLABSI per 1,000 central line days and total central line days. No serious adverse events were reported. Similar resident oversight policies may benefit other teaching institutions, and support concurrent organizational efforts to reduce hospital acquired infections.

I have carefully read the comments made by the reviewers and have attached to this letter the suggested changes made to the manuscript. The authors wish to thank you and the reviewers for the time and effort made to evaluate this manuscript. Reviewer's report: While this work presents some interesting results, the draft in its current form does not support the authors' final conclusions. The supporting data would be fine for a descriptive paper; however, in an effort to lend credence to their hypotheses, the manuscript is overreaching with the data they provide. To adequately support findings of significant difference between two groups, logistic regression analysis should be performed at a minimum. From the manner in which these data is presented, it appears that this was not done. There are two solutions; (1) perform logistic regression culling additional variables from the database for which to meaningfully compare the two groups, or (2) simply report that this is retrospective descriptive study. However, option (1) would probably more readily result in publication. The feedback regarding the statistical analysis and interpretation of the manuscript is greatly appreciated. Multivariable logistic regression analysis was not performed in this study. The culling of additional numerical or categorical predictor variables to determine the probability of occurrence is certainly credible. Practically speaking, we believe that this would best be performed as a prospective study because of the limitations inherent in a retrospective, registry-based study. The prospective collection of variables such as vehicle speed and type, daytime vs. nighttime vehicle operation, seat belt use, airbag deployment, driver experience, and distractions (ex. number of occupants) would also be valuable. For these reasons, we concur that the study should be categorized as a retrospective descriptive study. (See abstract and p. 4, highlighted copy) We have also made revisions to the limitations of the study. (See p.9, highlighted copy) In addition, we agree that any associations linked to differences between groups must be interpreted with caution and should not be " overreaching " or appear to be definitive. We have therefore made revisions to the language used in the interpretation of the results. We have avoided the use of conclusive terms such as " significant " , " results " , and " findings ". Instead, we are using words such as " observed " , " described " , and " apparent " in the context of " supporting data. " …

The high risk behavior of intoxicated drivers, impaired reaction time, lack of seat belt use, and increased incidence of head injury raises questions of whether pre-hospital use of alcohol leads to a higher injury severity score and worse clinical outcomes. We therefore compared intoxicated and non-intoxicated drivers of motor vehicle crashes with respect to outcome measurements and also describe the resources utilized to achieve those outcomes at our Level 1 trauma center.

BACKGROUND:In June of 2003 the Commonwealth of Pennsylvania passed S. 259 which repealed the state's 35-year old motorcycle helmet safety law. Motorcycle helmets are now only required for riders who are under the age of 21 and for those who are 21 years or older who have had a motorcycle operator's license for less than two years, or who have not completed an approved motorcycle safety course.DISCUSSION:Prior to the repeal, and in the years that have followed, there has been intense debate and controversy regarding Pennsylvania's decision to repeal the law that required universal and mandatory use of motorcycle helmets for all riders. Proponents of the helmet repeal have argued in favor of individual rights and freedom, whereas advocates for mandatory helmet laws have voiced concerns over public health and safety based on available data.SUMMARY:This commentary will discuss the policy-making process that led to Pennsylvania's repeal of the motorcycle helmet safety law from an ethical, political, and economic perspective.

Background We investigated the outcomes of injured patients who were undertriaged and compared them with those meeting full trauma team activation (TTA) criteriaMethods. Blunt trauma patients (July 2002 January 2008) meeting full TEA criteria and had a partial TTA were in. the undertriage group ((UTG). Data was collected on. demographics, injury severity, OR delays, resource utilization, and outcomes Excluded penetrating trauma, transfers, burns, age <18 years Statistics. Chi square, P < 05, mean +/- SDResults. One thousand finer hundred and twenty-four patients with 318 (22.3%) in the UTG and 1,106 in the correctly triaged group (CTG). The CTG was 70.4% male (vs 67 1%, P = 26), 41 5 +/- 19 8 years old (vs 45.8 +/- 205. P < 01), and had an injury severity score (ISS) of 24.7 (vs 17 0; P < .0001). The CTG was more likely to require ED intubation (34.9% vs 8.2%; P < .0001), ICU admission (49.0% vs 37.1%, P < .0001), longer ICU/hospital LOS, and more ventilator days (P < 0001) with no differences in. OR delays. The UTG had a lower mortality (6.0% vs 16 7%; P < 0001) and were discharged home more often (65 3% vs 52.2%; P = 02)Conclusion. The UTG had a lower IS'S and improved outcomes compared to the CTG with no differences in. OR delays. Despite inherent challenges in. TTA protocols, patients who were undertriaged at our institution appear to have satisfactory outcomes (Surgery 2010;148 239-45)

We present a case of a migrated biliary stent that resulted in a distal small bowel perforation, abscess formation and high grade partial small bowel obstruction in a medically stable patient without signs of sepsis or diffuse peritonitis. We performed a percutaneous drainage of the abscess followed by percutaneous retrieval of the stent. The entero-peritoneal fistula closed spontaneously with a drain in place. We conclude, migrated biliary stents associated with perforation distal to the Ligament of Trietz (LOT), may be treated by percutaneous drainage of the abscess and retrieval of the stent from the peritoneal cavity, even when associated with a large intra-abdominal abscess.

BACKGROUND:We have previously demonstrated improved medical student performance using standardized live patient models in the Trauma Evaluation and Management (TEAM) program. The trauma manikin has also been offered as an option for teaching trauma skills in this program. In this study, we compare performance using both models.METHODS:Final year medical students were randomly assigned to three groups: group I (n = 22) with neither model, group II (n = 24) with patient model, and group III (n = 24) with mechanical model using the same clinical scenario. All students completed pre-TEAM and post-TEAM multiple choice question (MCQ) exams and an evaluation questionnaire scoring five items on a scale of 1 to 5 with 5 being the highest. The items were objectives were met, knowledge improved, skills improved, overall satisfaction, and course should be mandatory. Students (groups II and III) then switched models, rating preferences in six categories: more challenging, more interesting, more dynamic, more enjoyable learning, more realistic, and overall better model. Scores were analyzed by ANOVA with p < 0.05 being considered statistically significant.RESULTS:All groups had similar scores (means % +/- SD)in the pretest (group I - 50.8 +/- 7.4, group II - 51.3 +/- 6.4, group III - 51.1 +/- 6.6). All groups improved their post-test scores but groups II and III scored higher than group I with no difference in scores between groups II and III (group I - 77.5 +/- 3.8, group II - 84.8 +/- 3.6, group III - 86.3 +/- 3.2). The percent of students scoring 5 in the questionnaire are as follows: objectives met - 100% for all groups; knowledge improved: group I - 91%, group II - 96%, group III - 92%; skills improved: group I - 9%, group II - 83%, group III - 96%; overall satisfaction: group I - 91%, group II - 92%, group III - 92%; should be mandatory: group I - 32%, group II - 96%, group III - 100%. Student preferences (48 students) are as follows: the mechanical model was more challenging (44 of 48); more interesting (40 of 48); more dynamic (46 of 48); more enjoyable (48 of 48); more realistic (32/48), and better overall model (42 of 48).CONCLUSIONS:Using the TEAM program, we have demonstrated that improvement in knowledge and skills are equally enhanced by using mechanical or patient models in trauma teaching. However, students overwhelmingly preferred the mechanical model.

Background: A number of conflicting studies have been conducted to analyze the relationship between the timing of tracheostomy and mortality, intensive care unit (ICU) length of stay (LOS), hospital LOS, and the incidence of pneumonia. In contrast to previous studies, this relationship was investigated in the context of expected survival based on probability of survival (Ps) greater than 25%. Methods: Trauma patients were screened using a statewide registry during a 5-year period (January 2001 to December 2005). Burn patients, transfer patients, permanent tracheostomies, and patients who underwent multiple surgical airways were excluded from the study. Data were collected on patient demographics, Trauma and Injury Severity Score, days to tracheostomy, mortality, ICU LOS, total ventilator days, pneumonia, and hospital LOS. Statistical analyses: log-linear modeling, chi(2), p < 0.05. Results: A total of 125,533 trauma patients were analyzed. Out of these, 82,148 patients met inclusion criteria and had complete data for analysis. There were 6,880 patients intubated at the scene, during transport, or at admission to the emergency department, with 685 receiving a temporary tracheostomy. There was a significantly higher mortality rate (48.9%) associated with patients with low Ps (<0.25) receiving early tracheostomy (ET), <4 days. Among high-Ps patients, the ET group demonstrated reduced ICU LOS, total ventilator days, pneumonia, and hospital LOS (p < 0.05). Conclusion: ET in patients with low Ps may not be beneficial given the substantially high mortality rate before post injury day 4. However, ET in high-Ps patients reduces ICU and hospital LOS, total ventilator days, and the incidence of pneumonia. This suggests an increased benefit in ET to trauma patients with high Ps.

BACKGROUND:The Homeland Security Act (HSA) of 2002 provided for the designation of a critical infrastructure protection program. This ultimately led to the designation of emergency services as a targeted critical infrastructure. In the context of an evolving crisis in hospital-based emergency care, the extent to which federal funding has addressed disaster preparedness will be examined.DISCUSSION:After 9/11, federal plans, procedures and benchmarks were mandated to assure a unified, comprehensive disaster response, ranging from local to federal activation of resources. Nevertheless, insufficient federal funding has contributed to a long-standing counter-trend which has eroded emergency medical care. The causes are complex and multifactorial, but they have converged to present a severely overburdened system that regularly exceeds emergency capacity and capabilities. This constant acute overcrowding, felt in communities all across the country, indicates a nation at risk. Federal funding has not sufficiently prioritized the improvements necessary for an emergency care infrastructure that is critical for an all hazards response to disaster and terrorist emergencies.SUMMARY:Currently, the nation is unable to meet presidential preparedness mandates for emergency and disaster care. Federal funding strategies must therefore be re-prioritized and targeted in a way that reasonably and consistently follows need.

The use of simulation-based technology in trauma education has focused on providing a safe and effective alternative to the more traditional methods that are used to teach technical skills and critical concepts in trauma resuscitation. Trauma team training using simulation-based technology is also being used to develop skills in leadership, team-information sharing, communication, and decision-making. The integration of simulators into medical student curriculum, residency training, and continuing medical education has been strongly recommended by the American College of Surgeons as an innovative means of enhancing patient safety, reducing medical errors, and performing a systematic evaluation of various competencies. Advanced human patient simulators are increasingly being used in trauma as an evaluation tool to assess clinical performance and to teach and reinforce essential knowledge, skills, and abilities. A number of specialty simulators in trauma and critical care have also been designed to meet these educational objectives. Ongoing educational research is still needed to validate long-term retention of knowledge and skills, provide reliable methods to evaluate teaching effectiveness and performance, and to demonstrate improvement in patient safety and overall quality of care.

BACKGROUND:Inferior vena cava filters (IVCF) are used in trauma patients to reduce the incidence of pulmonary embolism (PE). This study investigates the efficacy of prophylactic IVCF (PIVCF) placement from implantation through outpatient follow-up.METHODS:Data were prospectively collected on PIVCF placed in trauma patients > or =18-years old from 2004 to 2006. Exclusion criteria include therapeutic IVCF, major burns, deviated from a modified EAST protocol, and deaths. Data were collected on age, gender, Injury Severity Score (ISS), filter type, total implant days, PE, deep venous thrombosis (DVT), and filter-related complications.STATISTICAL ANALYSIS:p < 0.05*, chi square test, mean +/- SD.RESULTS:Of 4,936 patients, 280 had an IVCF with 244 meeting inclusion criteria. Study group demographics: 63.5% men; 98.8% blunt; mean age 43.8 +/- 20.3; ISS 26.7 +/- 12.8. There were 176 of 244 (72.1%) patients who met traditional EAST guidelines for PIVCF. PIVCF increased significantly from 29 in 2004 to 127 in 2006 with no difference in the PE rate (0.7% to 0.4%). There were 4 PEs (1.6%) on postprocedure days 7, 14, 18, and 23. Five technical complications occurred: two filter fractures, two caudal migrations, and one filter tilt. A total of 140 retrievable filters had the opportunity for outpatient follow-up for 18 months with 58.6% removed, 15.7% declared permanent, 12.1% lost to follow-up, and 13.6% still considered potential removal candidates. Days to implant: 0 to 32; 3.89 +/- 4.79. Implant days: 15 to 838; mean 231 +/- 162.CONCLUSIONS:PIVCF increased significantly without impacting the overall PE rate. There was a 1.6% PE rate among PIVCF, high retrieval rate (59%), low complication rate (0.1%), and satisfactory compliance with traditional EAST guidelines.

Background. The use of simulation as a teaching adjunct in Advanced Trauma Life Support (ATLS) has not undergone rigorous psychometric testing. We hypothesized that an advanced, computer-controlled human patient simulator (HPS) would be a useful adjunct to the ATLS shock skills station.Materials and methods. Forty-four PGY-1 residents enrolled in ATLS courses were randomized into control (CTL) and experimental (EXP) groups. All students took a shock-specific pre- and post-test multiple choice question examination (MCQE). The EXP group used the HPS in the shock skills station; the CTL group was taught in a traditional manner. All students participated in an experimental, shock-specific objective structured clinical examination (OSCE) session at the end and had their performance evaluated. The EXP group was asked to evaluate the teaching effectiveness of the shock skills station.Results. There were no statistically significant differences between the EXP and CTL groups with respect to the pre- and post-test MCQE or the change in scores. The groups were similar in their overall performance during the shock-specific OSCE. The EXP and CTL groups were equivalent with respect to shock recognition, identification of the type of shock, and ability to select the correct treatment plan. The shock skills station was rated from very good to excellent in 91% of the EXP group versus 63% in the CTL group. The EXP group rated the simulator most helpful in learning to analyze data from the monitors.Conclusions. Use of an advanced HPS during the ATLS shock skills station was equivalent to traditional teaching scenarios based on psychometric testing. Students subjectively preferred the simulator as a teaching tool and found it most useful in learning how to integrate data from hemodynamic monitors into clinical decision making. (C) 2007 Elsevier Inc. All rights reserved.