The vast majority of hospitals in the United States today are led by nonphysicians. This is in sharp contrast to the turn of the 20th century, when over a third of the hospitals in the United States were physician led. As the pendulum swings back from lay leader to clinician leader, there is a strong and appropriate opportunity for physicians to reinsert themselves into a leadership role. In fact, the time has perhaps never been more appropriate than today. In a health care system that is complex, troubled, and challenging, the physician CEO brings a unique set of skills to the business of medicine. The successful physician leader, however, must understand the business of medicine as well as or better than he or she understands the practice of medicine. Training, developing, and equipping our future physician leaders with the necessary skill sets will be one of medicines' many challenges as it expands into the 21 st century.

Introduction: Mechanism of injury has been widely used to enhance the ability of EMS providers to recognize predictable injury patterns. One such pattern, referred to as "Waddell's triad," identifies a triad of injuries associated with pedestrian/motor vehicle collision (MVC), including trauma to the head, abdomen, and lower extremities. We questioned this choice as a common injury pattern for this mechanism. Methods: A retrospective chart review of 4444 pediatric trauma patients admitted to a regional pediatric trauma center between 1992 and 1996. The source of this information was the medical center's trauma registry. Results: Four-hundred-sixty-five patients suffered a pedestrian/MVC and were included in the study; 231 suffered head injury, and 78 experienced a combination of head and leg injury. Only 11 patients (2.4%) suffered the predicted "triad" of head, leg, and abdominal injury as a result of pedestrian/MVCs. Two of these children suffered minor head injury, and only one patient (0.2%) suffered injury as originally described by Waddell. Conclusion: Although the concept of Waddell's triad is logical, and a high index of suspicion should be maintained, the incidence of this predictable injury pattern is low. Educational emphasis should be placed on other aspects of mechanism of pedestrian injury.

Introduction: How does the stress of a program merger affect job stress in air medical transport?

Introduction: In a rural service area, does the outcome of air medical patients transferred from the scene of injury differ from that of patients transferred from a primary receiving hospital?

Purpose: To quantitate actual request to liftoff (R/L) and dispatch to liftoff (D/L) times and reasons for delay in an active air medical transport program.

The purpose of the study is to determine the prevalence of acute deep venous thrombosis (DVT) in severely injured trauma patients, to investigate the cost effectiveness of a noninvasive surveillance program, and to assess the merit of current methods of prophylaxis against DVT. One hundred and forty-eight patients (295 limbs) with a mean age of 36.5 years, mean trauma score of 13.3, mean injury severity score of 22.4 with predominantly blunt injuries (88.5%), were part of the study. The mean length of stay was 17.6 days. Venous duplex scans (VDS) were performed on inpatients on days 2-5, day 11, and day 30 following admission. Sequential compression device and/or subcutaneous heparin was used in 99% of patients with compliance being monitored by trauma nurse clinicians. A total of 272 VDS were performed with total charges of $111,520. DVT was found by VDS or venography in eight limbs (2.7%) of six patients (4%), four of the limbs being symptomatic. Two additional patients had pulmonary embolism, both with normal VDS. Routine serial VDS in severely injured patients who undergo aggressive prophylaxis against DVT is not cost effective and therefore not justified. (Ann Vasc Surg 1997; 11:626-629.)

Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient.

Objective: To identify the effectiveness of prophylactic phenytoin in preventing posttraumatic epilepsy. Design: Retrospective cohort study. Setting: Urban tertiary-care hospital and trauma center. Subjects: Patients admitted to the trauma service in 1989 with moderate to severe head injury surviving to discharge. Interventions: Divided into two groups based on prophylaxis with phenytoin. Measurements and Main Results: Ninety-one patients with moderate to severe head injury were admitted during the study period; 6 were excluded from analysis for prehospital seizure activity. Forty-one patients received no anticonvulsants; 44 received phenytoin alone or in combination with other agents. None of the patients experienced a seizure during hospitalization. Seventy-four percent of all phenytoin concentrations were subtherapeutic (serum phenytoin 10–20 μg/mL). Conclusions: The lack of seizure activity in the face of absent or subtherapeutic phenytoin concentrations brings into question the benefit of prophylactic therapy.

Introduction: A change in airway management protocol provided the opportunity to evaluate scene airway management by air medical crew before and after the introduction of a rapid sequence induction protocol.

To the Editor: We report an instance of the intrapleural administration of charcoal due to penetration of the pleura by a transbronchial nasogastric tube. A 37-year-old woman jailed for public intoxication was transferred to our center. Before her transport, a nasogastric tube was inserted through which 180 ml of activated charcoal slurry was lavaged to treat a suspected ingestion of drug. On her arrival, the patient was awake but lethargic, with a Glasgow coma score of 15. Her voice was minimally hoarse, and her vital signs normal. Portable chest radiography revealed a pneumothorax and nasogastric intubation of the right mainstem . . .

Introduction: Air medical response and transport for the injured patient in cardiopulmonary arrest remain controversial. This study is a large, single-program experience.

Introduction: This survey attempts to identify the current standard of care for the air medical transport of the patient in cardiopulmonary arrest. Method: An Association of Air Medical Services/National Flight Nurses Association-approved survey by a single mailing with an anonymous response. Setting: All rotor-craft programs with current memberships in AAMS. Results: Fifty-three of the 178 questionnaires mailed were returned. Program demographics, crew composition and transport volumes were typical of other reported national experiences. The majority of programs (84%) had standing operational protocols for trauma and non-trauma cardiopulmonary arrests. The indications for not initiating or discontinuing CPR, the transport of the patient in cardiopulmonary arrest, triage and financial considerations varied widely between air medical programs. Conclusions: This study provides some insight on the current air medical management of the patient in cardiopulmonary arrest. National practice guidelines should be developed and tested prospectively in future studies.

The purpose of this paper is to assess symptomatic macromastia, the relief of symptoms by operation, and predictors of symptom relief. The methods used have been retrospective chart review and a self-assessment patient questionnaire. One-hundred and thirty-three patients underwent an average 1660-gm reduction. Ninety-three percent reported a postoperative decrease in symptoms such as shoulder grooves and shoulder, neck, and back pain. Correlation between breast size and sign or symptom severity achieved significance only for the preoperative submammary rash (r = 0.33, p < 0.001). Patients lost an average of 8.9 lb postoperatively and were less overweight (49 versus 40 percent). Activity level increased postoperatively in 63 percent. Postoperative chest size correlated inversely with activity level (r = 0.35, p < 0.001). Thirty-nine percent of patients who took pain medications preoperatively were able to eliminate these postoperatively. The quantity of tissue removed did not correlate with outcome. A model predictive of symptom relief could not be developed (total R2 = 0.03). Reduction mammaplasty promoted relief of signs and symptoms of macromastia, but a predictive model of successful operation could not be developed.

Introduction: A previous study (1988–1990) suggested that the majority of air medical scene transports for illness in the Columbus, Ohio, service area were inappropriate. The current study followed an aggressive prehospital educational program (1991–1993) that continued during the study. The question asked: Did this educational program make a difference?

Introduction: The purpose of this pilot study was to determine whether flight crew personnel are physically fit in comparison to published standards for the average American adult.

Introduction: This single institutional experience with needle decompression of a tension pneumothorax in the prehospital setting was stimulated because of the paucity of information in the literature.