Crossing the line: access to trauma care across state borders.

Objective: This study investigates the challenge posed by state borders by identifying the population, injury, and geographic scope of areas of the country where the closest trauma center is out-of-state, and by collating state emergency medical services (EMS) policies relevant to cross-border trauma transport. Methods: We identified designated levels I, II, and III trauma centers using data from American Trauma Society. ArcGIS was used to map the distance between US census block groups and trauma centers to identify the geographic areas for which cross-border transport may be most expedient. National Highway Traffic Safety Administration data were queried to quantify the proportion of fatal crashes occurring in the areas of interest. State EMS protocols were categorized by stance on cross-border transport. Results: Of 237 596 included US census block groups, 18 499 (7.8%) were closest to an out-of-state designated level I or II trauma center. These census block groups accounted for 6.9% of the US population and 9.5% of all motor vehicle fatalities. With the inclusion of level III trauma centers, the number of US census block groups closest to an out-of-state designated level I, II, or III trauma center decreased to 13 690 (5.8%). These census block groups accounted for 5.1% of the US population and 7.1% of all motor vehicle fatalities. Of the 48 contiguous states, 30 encourage cross-border transport, 2 discourage it, 12 are neutral, and 4 leave it to local discretion. Conclusion: Cross-border transport can expedite access to care in at least 5% of US census block groups. While few states discourage this practice, more robust policy guidance could reduce delays and enhance care. Level of Evidence: III, Epidemiological.

Preparedness Tested: Severe Cerebral Malaria Presenting as a High-Risk Person Under Investigation for Ebola Virus Disease at a US Hospital.

In 2019, a 42-year-old African man who works as an Ebola virus disease (EVD) researcher traveled from the Democratic Republic of Congo (DRC), near an ongoing EVD epidemic, to Philadelphia and presented to the Hospital of the University of Pennsylvania Emergency Department with altered mental status, vomiting, diarrhea, and fever. He was classified as a "wet" person under investigation for EVD, and his arrival activated our hospital emergency management command center and bioresponse teams. He was found to be in septic shock with multisystem organ dysfunction, including circulatory dysfunction, encephalopathy, metabolic lactic acidosis, acute kidney injury, acute liver injury, and diffuse intravascular coagulation. Critical care was delivered within high-risk pathogen isolation in the ED and in our Special Treatment Unit until a diagnosis of severe cerebral malaria was confirmed and EVD was definitively excluded.This report discusses our experience activating a longitudinal preparedness program designed for rare, resource-intensive events at hospitals physically remote from any active epidemic but serving a high-volume international air travel port-of-entry.

Optimizing the patient handoff between emergency medical services and the emergency department.

STUDY OBJECTIVE: Patient handoffs are known as high-risk events for medical error but little is known about the professional, structural, and interpersonal factors that can affect the patient transition from emergency medical services (EMS) care to the emergency department (ED). We study EMS providers' perspectives to generate hypotheses to inform and improve this handoff. METHODS: We conducted focus groups with EMS providers recruited at 3 national and regional conferences from January to March 2011 until theme saturation was reached; 7 focus groups were conducted with 48 EMS providers. Deidentified transcripts and notes were entered into QSR NVivo, coded, and analyzed to identify themes. RESULTS: EMS providers identified themselves as advocates for their patients during the challenging EMS-to-ED handoffs. Providers identified normative challenges they encounter in their communications with hospital staff, and features of EMS and hospital protocols that either facilitate or undermine effective handoffs from the out-of-hospital environment to the ED. They identified 4 key potential ways to improve the structure and process of the handoff: (1) communicate directly with the ED provider responsible for the patient's care; (2) increase interdisciplinary feedback, transparency, and shared understanding of scope of practice between out-of-hospital and hospital-based providers; (3) standardize some (but not all) aspects of the handoff; and (4) harness technology to close gaps in information exchange. CONCLUSION: These exploratory findings suggest that the effect of increasing EMS interactions with emergency physicians, standardizing handoff processes, and fostering interprofessional learning represent opportunities for future study and may serve as potential solutions for the high-risk EMS-ED patient transition.

Team effort: collaboration makes survival possible for thoracic injury patient.

Although most blunt aortic transection cases that present to the trauma bay have contained hematomas, this isn't always the case. This case illustrates the advancement of trauma care in the 21st century. Cases of free aortic rupture rarely end with such positive results. Providers can take home a few key points: accurate field triage linked with a multi-disciplinary approach to such a complex injury is vital to patient survival, and the use of new technology can allow for prompt diagnosis and management.

Injury-adjusted mortality of patients transported by police following penetrating trauma.

BACKGROUND: More than a decade ago, the city of Philadelphia began allowing police transport of penetrating trauma patients. OBJECTIVES: The objective was to determine the relation between prehospital mode of transport (police department [PD] vs. Philadelphia Fire Department (PFD) emergency medical services [EMS]) and survival in subjects with proximal penetrating trauma. METHODS: The authors performed a retrospective cohort study of prospectively collected trauma registry data. All subjects who sustained proximal penetrating trauma and who presented to a Level I urban trauma center over a 5-year period (January 1, 2003, to December 31, 2007) were included. Mortality for subjects presenting by EMS was compared to that of those who arrived by PD transport in unadjusted and adjusted analyses. Unadjusted analyses were performed using the chi-square test, Wilcoxon rank sum test, and Student's t-test. Adjusted analyses were performed using logistic regression using the Trauma Injury Severity Score (TRISS) methodology. Data are presented as percentages, odds ratios (ORs), and 95% confidence intervals (CIs). Total hospital length of stay was examined as a secondary outcome. RESULTS: Of the 2,127 subjects, 26.8% were transported to the emergency department (ED) by PD, and 73.2% by EMS. The mean(±standard deviation [SD]) age of PD subjects was 26.3 (±9.1) years and 92% were male versus EMS subjects whose mean (±SD) age was 31.5 (±11.8) years and of whom 87% were male. Overall, 70.8% sustained a gunshot wound (GSW), and 29.2% sustained a stab wound (SW). Overall Injury Severity Score (ISS) was 11.21 (ISS for PD, 14.2±17.5; for EMS, 10.1±14.5; p<0.001), and 16.6% of the subjects died (PD, 21.4±0.41%; EMS, 14.8±0.36%; p<0.001). In unadjusted analyses, PD subjects were more likely to die than EMS subjects (OR=1.6, 95% CI=1.2 to 2.0; p<0.001). When adjusting for injury severity using TRISS, there was no difference in survival between PD and EMS subjects (OR=1.01, 95% CI=0.63 to 1.61). Median length of hospital stay was 1 day and did not differ according to mode of prehospital transport (p=0.159). CONCLUSIONS: Although unadjusted mortality appears to be higher in PD subjects, these findings are explained by the more severely injured population transported by PD. The current practice of permitting police officers to transport penetrating trauma patients should be continued.

Effect of night vision goggles on performance of advanced life support skills by emergency personnel.

Night vision goggles (NVGs) are used by military personnel operating in low-light environments. It is not known whether NVGs can be used by medical personnel to provide emergency care under such conditions. This was a randomized controlled study to determine the effect of NVGs on the performance of intravenous line insertion (IVI) and endotracheal intubation (El) on training manikins. Emergency physicians and paramedics were randomized to perform EI and IVI in ambient light or in total darkness using NVGs. Each skill was repeated three times, and averages were determined. The average times for EI in ambient light and with NVGs were 48.4 and 188.2 seconds, respectively (SE of 13.4 seconds for both; p < 0.0001). The average times for IVI in ambient light and with NVGs were 34.7 and 73.7 seconds, respectively (SE of 4.1 seconds for both; p < 0.0001). Emergency personnel were able to successfully perform these skills using NVGs, but their times were significantly longer than in ambient light.