Making sense of emergency surgery in New South Wales: a position statement.

BACKGROUND: Emergency surgery is a major component of the provision of surgical services and makes up a substantial volume of the workload of surgeons in many hospitals. It is often more complex and surgically challenging than elective surgery. However, little attention has been concentrated on the management or resource requirements of emergency surgery. METHOD: This article identifies principles for models of emergency surgery care and describes how they can be incorporated into a redesign of emergency surgery. They have been developed and are endorsed by experienced surgical staff routinely coping with the challenges of emergency surgery. RESULTS: The benefits of redesigning emergency surgery will be realized by an active partnership between managers, surgeons and surgical teams. The anticipated clinical benefits include improved patient outcomes, enhanced patient and surgical team satisfaction, and increased trainee supervision in emergency surgery. Significant management benefits will ensue from high rates of emergency operating theatre utilization, reduced patient cancellations and reduction in after-hours costs. This unplanned but predictable workload will be managed in a planned and predictable fashion. CONCLUSION: Reform of emergency surgery services is a necessity and not a choice. The development of the emergency surgery guidelines for New South Wales is a step in the right direction. The principles identified in the guidelines should be adapted and implemented across Australia if sustainable, safe and efficient emergency surgery services are to be provided. Patients will expect nothing less.

The epidemiology of pelvic ring fractures: a population-based study.

BACKGROUND: The severity of pelvic ring fractures (PRFs) can range from minor injury with low-energy mechanism to high-energy injury causing prehospital death. The purpose of this study was to prospectively describe the comprehensive pelvic fracture occurrence in an inclusive trauma system. METHODS: A 12-month prospective, population-based epidemiologic study was performed in the Hunter Region, New South Wales, Australia (population of 600,000, served by one Level I trauma center and 7 referring hospitals). Patient demographics, mechanism, injury severity, shock parameters, and outcomes were recorded prospectively. The database included all pelvic fractures from the region: high-energy pelvic fractures (HE-PRFs), low-energy pelvic fractures (LE-PRFs), and prehospital deaths (PD-PRFs). RESULTS: The incidence of PRF in the trauma system was 23 per 100,000 persons (138 fractures). The incidences of HE-PRF and LE-PRF were each 10 per 100,000 persons, whereas there were 3 PD-PRFs per 100,000. HE-PRF compared with LE-PRF occurred predominantly in men (64% vs. 20%, p < 0.05), younger persons (41 +/- 3 vs. 83 +/- 1 years, p < 0.05), those who had a higher Injury Severity Score (23 +/- 3 vs. 6 +/- 1, p < 0.05), and those with lower blood pressure (111 +/- 1 mm Hg vs. 153 +/- 1 mm Hg, p < 0.05), but the inhospital mortality rate was not statistically different (15% vs. 8%, p = NS). The overall mortality of the cohort was 23% (60% of those were from the PD-PRF group). The PRF-related mortality was 7% (HE-PRF: 7%; LE-PRF: 2%; PD-PRF: 33%), which was always attributable to bleeding. The incidence of demonstrated pelvic fracture-related arterial bleeding was 1.3 per 100,000 persons per year. CONCLUSIONS: LE-PRF and HE-PRF are equally frequent among hospital admissions. They represent two distinct demographic groups with similar mortality rate. Most PRF-related deaths occur prehospitally. Bleeding remains the primary cause of PRF-related mortality in all groups.

Clinical examination is an inaccurate predictor of intraabdominal pressure.

This study was designed to establish if clinical examination can accurately predict intraabdominal pressure (IAP). Between August 1998 and March 2000 a prospective blinded observational study of postoperative intensive care unit patients was undertaken at a major trauma center. IAP was measured using an intravesicular technique and compared with clinical evaluation. An IAP of at least 18 mmHg was considered elevated. The sensitivity, specificity, positive predicative value (ppv), negative predictive value (npv), kappa score, and reliability analysis were calculated. A total of 110 patients provided 150 estimates of IAP, which was elevated in 21%. The kappa score was 0.37; sensitivity, 60.9%; specificity, 80.5%; ppv, 45.2%; npv, 88.6%. The mean difference in IAP values between intravesicular readings and clinical estimates was -1.0 +/- 4.1. Prediction of IAP using clinical examination is not accurate enough to replace intravesicular IAP measurements.

Vascular injury in Australia.

Vascular injury poses a small but significant challenge in Australian trauma care. Opportunities such as better practice guidelines and minimum standards will allow surgeons to improve delivery of quality care to the next generation of vascular trauma victims. Training in the management of vascular trauma surgery with integration of vascular and general surgery in trauma care should optimize outcomes. The authors' vision is that all vascular and general surgery trainees would eventually undertake the Definitive Surgical Trauma Care Course and improve vascular trauma outcomes and reduce mortality.