Optimizing Mass Casualty Triage: Using Discrete Event Simulation to Minimize Time to Resuscitation.

BACKGROUND: Urban areas in the US are increasingly focused on mass casualty incident (MCI) response. We simulated prehospital triage scenarios and hypothesized that using hospital-based blood product inventories for on-scene triage decisions would minimize time to treatment. STUDY DESIGN: Discrete event simulations modeled MCI casualty injury and patient flow after a simulated blast event in Boston, MA. Casualties were divided into moderate (Injury Severity Score 9 to 15) and severe (Injury Severity Score >15) based on injury patterns. Blood product inventories were collected from all hospitals (n = 6). The primary endpoint was the proportion of casualties managed with 1:1:1 balanced resuscitation in a target timeframe (moderate, 3.5 U red blood cells in 6 hours; severe, 10 U red blood cells in 1 hour). Three triage scenarios were compared, including unimpeded casualty movement to proximate hospitals (Nearest), equal distribution among hospitals (Equal), and blood product inventory-based triage (Supply-Guided). RESULTS: Simulated MCIs generated a mean ± SD of 302 ± 7 casualties, including 57 ± 2 moderate and 15 ± 2 severe casualties. Nearest triage resulted in significantly fewer overall casualties treated in the target time (55% vs Equal 86% vs Supply-Guided 91%, p < 0.001). These differences were principally due to fewer moderate casualties treated, but there was no difference among strategies for severe casualties. CONCLUSIONS: In this simulation study comparing different triage strategies, including one based on actual blood product inventories, nearest hospital triage was inferior to equal distribution or a Supply-Guided strategy. Disaster response leaders in US urban areas should consider modeling different MCI scenarios and casualty numbers to determine optimal triage strategies for their area given hospital numbers and blood product availability.

Outcomes in Post-operative Delirium Following Bowel Resection: A Single Center Retrospective Review.

INTRODUCTION: Delirium is associated with adverse post-operative outcomes, long-term cognitive dysfunction, and prolonged hospitalization. Risk factors for its development include longer surgical duration, increased operative complexity and invasiveness, and medical comorbidities. This study aims to further evaluate the incidence of delirium and its impact on outcomes among patients undergoing both elective and emergency bowel resections. METHODS: This is a retrospective cohort study using an institutional patient registry. All patients undergoing bowel resection over a 3.5-year period were included. The study measured the incidence of post-operative delirium via the nursing confusion assessment method. This incidence was then compared to patient age, emergency versus elective admission, length of stay, mortality, discharge disposition, and hospital cost. RESULTS: A total of 1934 patients were included with an overall delirium incidence of 8.8%. Compared to patients without delirium, patients with delirium were more likely to have undergone emergency surgery, be greater than 70 y of age, have a longer length of stay, be discharged to a skilled nursing facility, and have a more expensive hospitalization. In addition, the overall mortality was 14% in patients experiencing delirium versus 0.1% in those that did not. Importantly, when broken down between elective and emergency groups, the mortality of those experiencing delirium was similar (11 versus 13%). CONCLUSIONS: The development of delirium following bowel resection is an important risk factor for worsened outcomes and mortality. Although the incidence of delirium is higher in the emergency surgery population, the development of delirium in the elective population infers a similar risk of mortality.

Evaluation of motor vehicle crash rates during and after the COVID-19-associated stay-at-home order in Connecticut.

INTRODUCTION: Recent research suggests that COVID-19 associated stay-at-home orders, or shelter-in-place orders, have impacted intra-and-interstate travel as well as motor vehicle crashes (crashes). We sought to further this research and to understand the impact of the stay-at-home order on crashes in the post order period in Connecticut. METHODS: We used a multiple-comparison group, interrupted time-series analysis design to compare crashes per 100 million vehicle miles traveled (VMT) per week in 2020 to the average of 2017-2019 from January 1-August 31. We stratified crash rate by severity and the number of vehicles involved. We modeled two interruption points reflecting the weeks Connecticut implemented (March 23rd, week 12) and rescinded (May 20th, week 20) its stay-at-home order. RESULTS: During the initial week of the stay-at-home order in Connecticut, there was an additional 28 single vehicle crashes compared to previous years (95% confidence interval (CI): [15.8, 36.8]). However, the increase at the order onset was not seen throughout the duration. Rescinding the stay-at-home order by and large did not result in an immediate increase in crash rates. Crash rates steadily returned to previous year averages during the post-stay-at-home period. Fatal crash rates were unaffected by the stay-at-home order and remained similar to previous year rates throughout the study duration. DISCUSSION: The initial onset of the stay-at-home order in Connecticut was associated with a sharp increase in the single vehicle crash rate but that increase was not sustained for the remainder of the stay-at-home order. Likely changes in driver characteristics during and after the order kept fatal crash rates similar to previous years.

Hospital-Acquired COVID-19: Case Discussions of Two Patients Treated at a Level I Trauma Center.

The community spread of COVID-19 is well known and has been rigorously studied since the onset of the pandemic; however, little is known about the risk of transmission to hospitalized patients. Many practices have been adopted by healthcare facilities to protect patients and staff by attempting to mitigate internal spread of the disease; however, these practices are highly variable among institutions, and it is difficult to identify which interventions are both practical and impactful. Our institution, for example, adopted the most rigorous infection control methods in an effort to keep patients and staff as safe as possible throughout the pandemic. This case report details the hospital courses of two trauma patients, both of whom tested negative for the COVID-19 virus multiple times prior to producing positive tests late in their hospital courses. The two patients share many common features including history of psychiatric illness, significant injuries, ICU stays, one-to-one observers, multiple consulting services, and a prolonged hospital course prior to discharge to a rehabilitation facility. Analysis of these hospital courses can help provide a better understanding of potential risk factors for acquisition of a nosocomial COVID-19 infection and insight into which measures may be most effective in preventing future occurrences. This is important to consider not only for COVID-19 but also for future novel infectious diseases.

Emergency intraoperative vascular surgery consultations at a tertiary academic center.

OBJECTIVE: Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center. METHODS: We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved. RESULTS: There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m2. The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%. CONCLUSIONS: Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.

Functional Superior Mesenteric Artery Syndrome Induced by an Optional IVC Filter.

This patient suffered multiple injuries in a motor vehicle crash. She had an optional IVC filter placed in the usual fashion and location which resulted in a functional obstruction of the third part of the duodenum much as one would expect with a Superior Mesenteric Artery (SMA) syndrome. The symptoms persisted over the sixteen-day filter dwell time and resolved completely with the retrieval of the filter.

Phytobezoar: A Brief Report with Surgical and Radiological Correlation.

Gastrointestinal bezoars, collections of incompletely digested material within the alimentary tract, can present as a diagnostic challenge and should be considered in the differential diagnosis and management of small bowel obstruction, ischemic bowel, or bowel perforation. We present a case of a 37-year-old man with a distant history of laparotomy for superior mesenteric artery thrombosis requiring partial small bowel resection of the jejunum who presented with worsening abdominal pain, nausea, vomiting, and hematemesis. An abdominal computed tomography revealed dilated loops of small bowel with a transition point at the ileum, distal to his prior bowel anastomosis. He was managed initially nonoperatively, but persistent vomiting and worsening distention necessitated urgent exploratory laparotomy. During the procedure, a 4 cm by 3 cm phytobezoar was discovered at the midjejunum. The patient had an unremarkable postoperative course with no further symptoms at 1-year follow-up. Timely diagnosis and treatment of bezoar is essential to minimize patient complications.

A cadaveric procedural anatomy simulation course improves video-based assessment of operative performance.

BACKGROUND: Inadequate anatomic knowledge has been cited as a major contributor to declining surgical resident operative competence. We analyzed the impact of a comprehensive, procedurally oriented cadaveric procedural anatomy dissection laboratory on the operative performance of surgery residents, hypothesizing that trainees' performance of surgical procedures would improve after such a dissection course. MATERIALS AND METHODS: Midlevel general surgery residents (n = 9) participated in an 8 wk, 16-h surgery faculty-led procedurally oriented cadaver simulation course. Both before and after completion of the course, residents participated in a practical examination, in which they were randomized to perform one of nine Surgical Council on Resident Education-designated "essential" procedures. The procedures were recorded using wearable video technology. Videos were deidentified before evaluation by six faculty raters blinded to examinee and whether performances occurred before or after an examinee had taken the course. Raters used the validated Operative Performance Rating System and Objective Structured Assessment of Technical Skill scales. RESULTS: After the course residents had higher procedure-specific scores (median, 4.0 versus 2.4, P < 0.0001), instrument-handling (4.0 versus 3.0, P = 0.006), respect for tissue (4.0 versus 3.0, P = 0.0004), time and motion (3.0 versus 2.0, P = 0.0007), operation flow (3.0 versus 2.0, P = 0.0005), procedural knowledge (4.0 versus 2.0, P = 0.0001), and overall performance scores (4.0 versus 2.0, P < 0.0001). Operative Performance Rating System and Objective Structured Assessment of Technical Skill scales averaged by number of items in each were also higher (3.2 versus 2.0, P = 0.0002 and 3.1 versus 2.2, P = 0.002, respectively). CONCLUSIONS: A cadaveric procedural anatomy simulation course covering a broad range of open general surgery procedures was associated with significant improvements in trainees' operative performance.

Mortality and Resource Utilization After Critical Care Transport of Patients With Hypoxemic Respiratory Failure.

INTRODUCTION: We performed this study to quantify resources required by mechanically ventilated patients with hypoxemia after critical care transport (CCT) and to assess short-term clinical outcomes. METHODS: We performed a retrospective review of transports of patients with severe hypoxemic respiratory failure from referring hospitals to 3 tertiary care hospitals to assess the outcomes including in-hospital mortality, ventilator days, intensive care unit length of stay (LOS), hospital LOS, disposition, and reported neurologic status on hospital discharge as well as medical interventions specific to acute respiratory failure and critical care. RESULTS: Of 230 patients transported with hypoxemic respiratory failure, 152 survived to hospital discharge, for a mortality rate of 34.5%, despite a predicted mortality of 64% by Acute Physiology and Chronic Health Evaluation II (APACHE II) score. Twenty-five percent of patients were treated with neuromuscular blockade, 10.1% received inhaled pulmonary vasodilators, and extracorporeal membrane oxygenation was initiated in 2.6%. CONCLUSIONS: In this cohort with hypoxemic respiratory failure transported to tertiary care facilities, patients had a mortality rate comparable to patients with acute respiratory distress syndrome treated with best practices and a mortality rate lower than predicted based on APACHE-II score. The risks of CCT are outweighed by the benefits of transfer to a tertiary care facility, and pretransport hypoxemia should not be used as an absolute contraindication to transport.

Don't Forget the Abdominal Wall: Imaging Spectrum of Abdominal Wall Injuries after Nonpenetrating Trauma.

Abdominal wall injuries occur in nearly one of 10 patients coming to the emergency department after nonpenetrating trauma. Injuries range from minor, such as abdominal wall contusion, to severe, such as abdominal wall rupture with evisceration of abdominal contents. Examples of specific injuries that can be detected at cross-sectional imaging include abdominal muscle strain, tear, or hematoma, including rectus sheath hematoma (RSH); traumatic abdominal wall hernia (TAWH); and Morel-Lavallée lesion (MLL) (closed degloving injury). These injuries are often overlooked clinically because of (a) a lack of findings at physical examination or (b) distraction by more-severe associated injuries. However, these injuries are important to detect because they are highly associated with potentially grave visceral and vascular injuries, such as aortic injury, and because their detection can lead to the diagnosis of these more clinically important grave traumatic injuries. Failure to make a timely diagnosis can result in delayed complications, such as bowel hernia with potential for obstruction or strangulation, or misdiagnosis of an abdominal wall neoplasm. Groin injuries, such as athletic pubalgia, and inferior costochondral injuries should also be considered in patients with abdominal pain after nonpenetrating trauma, because these conditions may manifest with referred abdominal pain and are often included within the field of view at cross-sectional abdominal imaging. Radiologists must recognize and report acute abdominal wall injuries and their associated intra-abdominal pathologic conditions to allow appropriate and timely treatment. © RSNA, 2017.

Are Older Adults With Hip Fractures Disadvantaged in Level 1 Trauma Centers?

BACKGROUND: Large regional hospitals achieve good outcomes for patients with complex conditions. However, recent studies have suggested that some patient groups might not benefit from treatment in higher-level trauma centers. OBJECTIVE: To test the hypothesis that older adults with isolated hip fractures experience delayed surgical treatment and worse clinical outcomes when treated in higher-level trauma centers. RESEARCH DESIGN: Retrospective cohort study using a statewide longitudinal database that captured 98% of inpatients within California (2007-2011). SUBJECTS: All older adults (aged 65 y and above) admitted with an isolated hip fracture who did not require interhospital transfer. MEASURES: Days to operation, length of stay, inhospital mortality, 30-day risk of unplanned readmission, 30-day venous thromboembolism, decubitus ulcers, and pneumonia. RESULTS: There were 91,401 patients, 6.1% of whom were treated in a level 1 trauma center (L1TC), 17.7% in a level 2 trauma center (L2TC), and 70.2% in a nontrauma center (NTC). Within multivariable logistic and generalized linear regression models, patients treated in L1TCs underwent surgery later (predicted mean difference: 0.30 d; 95% CI, 0.08-0.53), had prolonged inpatient stays (0.99 d, 0.40-1.59), and had higher odds of both 30-day readmission (aOR=1.62; 95% CI, 1.35-1.93) and venous thromboembolism (aOR=1.32, 1.01-1.74) relative to NTCs. There were no differences in mortality, decubitus ulcers, or pneumonias. L2TCs were not different from NTCs across any of the measured outcomes. CONCLUSIONS: Older adults with hip fractures may be disadvantaged in L1TCs. Further research should aim to develop our understanding of this disparity to ensure that all patient groups benefit from the resources and expertise available within these hospitals.

How long should we fear? Long-term risk of venous thromboembolism in patients with traumatic brain injury.

BACKGROUND: Although patients with traumatic brain injury (TBI) are known to be at high risk for venous thromboembolism (VTE), it is not clear how long this risk persists after injury. We aimed to determine the risk of VTE in patients with TBI during one year after injury and to identify associated factors. METHODS: Patients 18 years and older with International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses of isolated TBI (head Abbreviated Injury Scale [AIS] ≥3 and AIS <3 for all other body regions) were identified in the California State Inpatient Database (2007-2011). Patient and admission (injury severity score, length of stay, and discharge disposition) characteristics were assessed. Hospital factors (teaching status, trauma center verification, and bed size) were extracted from the American Hospital Association database. Patients who developed VTE during the index admission and at different time points after discharge were determined. Multivariate logistic regression models were used to assess the associated risk factors for VTE after discharge. RESULTS: There were 38,984 patients with isolated TBI identified. The incidence of VTE was 1.31% during the index admission and the cumulative incidence of VTE involving hospitalization within one year of injury was 2.83%. The major risk factors for VTE one year after injury (not including the index admission) were discharge to extended care facilities versus home [adjusted odds ratio, 2.69 (95% confidence interval, 2.14-3.37)], age older than 64 years versus 18 to 44 years [2.62 (1.80-3.81)], having an operation during the index admission [1.65 (1.36-2.01)], and hospital length of stay of more than 7 days versus 3 days or less [1.64 (1.27-2.11)]. CONCLUSION: The risk of VTE persists long after discharge in a significant proportion of patients with TBI. Demographic and admission characteristics of patients play significant roles in the risk of VTE after discharge. These results highlight the need for sustained surveillance and preventive measures among patients with TBI at increased risk for long-term VTE. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Explaining the excess morbidity of emergency general surgery: packed red blood cell and fresh frozen plasma transfusion practices are associated with major complications in nonmassively transfused patients.

BACKGROUND: Intraoperative blood product transfusions carry risk but are often necessary in emergency general surgery (EGS). METHODS: We queried the American College of Surgery-National Surgical Quality Improvement Program database for EGS patients (2008 to 2012) at 2 tertiary academic hospitals. Outcomes included rates of high packed red blood cell (pRBC) use (estimated blood loss:pRBC < 350:1) and high fresh frozen plasma (FFP) use (FFP:pRBC >1:1.5). Patients were then stratified by exposure to high blood product use. Stepwise logistic regression was performed. RESULTS: Of 992 patients, 33% underwent EGS. Estimated blood loss was similar between EGS and non-EGS (282 vs 250 cc, P = .288). EGS patients were more often exposed to high pRBC use (adjusted odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.11 to 3.66) and high-FFP use (OR = 2.75, 95% CI: = 1.10 to 6.84). High blood product use was independently associated with major nonbleeding complications (high pRBC: OR = 1.73, 95% CI = 1.04 to 2.91; high FFP: OR = 2.15, 95% CI = 1.15 to 4.02). CONCLUSIONS: Despite similar blood loss, EGS patients received higher rates of intraoperative blood product transfusion, which was independently associated with major complication.

A cadaveric procedural anatomy course enhances operative competence.

BACKGROUND: Inadequate anatomy training has been cited as a major contributor to declines in surgical resident operative competence and confidence. We report the impact of a procedurally oriented general surgery cadaveric dissection course on trainee-operative confidence and competence. MATERIALS AND METHODS: After obtaining institutional review board approval, postgraduate year 2 and 3 general surgery residents were prospectively enrolled into two cohorts: (1) an intervention group (n = 7) participating in an 8-wk procedurally oriented cadaver course and (2) controls (n = 7) given access to course materials without participation in cadaver dissection. At both the beginning and end of the study, we used two evaluation instruments: (1) an oral examination using standardized templates and (2) a questionnaire assessing operative confidence. RESULTS: There were no intergroup differences in baseline characteristics, including number of operative procedures performed to date. Residents who took the anatomy course had significantly higher improvements in examination scores on common bile duct exploration (mean ± standard error, 33 ± 8% versus 10 ± 7%, P = 0.04), femoral endarterectomy (43 ± 5% versus 11 ± 7%, P = 0.003), fasciotomies (55 ± 10% versus 22 ± 9%, P = 0.04), inguinal hernia repair (20 ± 9% versus -14 ± 5%, P = 0.005), superior mesenteric artery embolectomy (38 ± 10% versus 2 ± 11%, P = 0.04), and in overall examination scores (31 ± 4% versus 8% ± 3%, P = 0.0006). In addition, they reported higher operative confidence on common bile duct exploration (P = 0.008) and superior mesenteric artery embolectomy (P = 0.02), and a trend toward higher overall operative confidence (P = 0.06). CONCLUSIONS: In this study, we demonstrate that a procedurally oriented cadaver course covering a wide range of essential general surgery procedures resulted in significant improvements in self-reported operative confidence and competence as assessed by oral examination.

Comparing Readmissions and Infectious Complications of Blunt Splenic Injuries Using a Statewide Database.

BACKGROUND: Although non-operative management of blunt splenic injury (BSI) is increasingly common, the long-term infectious complications after adjunct splenic artery embolization (SAE) are not well described. METHODS: Patients aged 18-64 y with BSI were identified in the California State Inpatient Database (2007-2011) and categorized as receiving either non-operative management (NOM) without SAE, NOM with SAE, or operative management (OM). The cumulative incidence of infections (surgical site infections [SSI], pneumonia, urinary tract infections, and sepsis) requiring readmission at different times up to one y after injury were calculated. Patient and treatment factors associated with infectious readmissions were determined using multivariable logistic regression models. RESULTS: Of the 4,360 patients with BSI, 61.6% had NOM without SAE, 5.8% had NOM with SAE, and 32.6% had OM. The cumulative incidences of infectious complications after each of the management modes were 1.27%, 1.59%, and 1.76%, respectively, during admission (p = 0.446); 2.16%, 5.18%, and 4.85%, respectively, at 30 d after injury (p < 0.001); and 4.69%, 9.16%, and 8.85%, respectively, at one y after injury (p < 0.001). Risk factors for infection-associated readmissions within one y after injury were Charlson score ≥2 (adjusted odds ratio [AOR] 3.9; 95% confidence interval [CI] 2.61-6.02), length of stay >seven d (AOR 2.47; 95% CI 1.58-3.85), NOM with SAE (AOR 2.00; 95% CI 1.19-3.34), and OM (AOR 1.47; 95% CI 1.05-2.07). CONCLUSIONS: The long-term risk of infectious complications in patients with BSI who have NOM with SAE is similar to that in patients who are treated with OM, indicating the need for pro-active strategies to reduce long-term infectious complications after SAE.

Cost savings associated with transfer of trauma patients within an accountable care organization.

BACKGROUND: The Patient Protection and Affordable Care Act supports the establishment of accountable care organizations (ACOs) as care delivery models designed to save costs. The potential for these cost savings has been demonstrated in the primary care and inpatient populations, but not for patients with emergency conditions or traumatic injuries. METHODS: Our study evaluated adult trauma patients transferred to the tertiary care hospitals of a pioneer ACO, comparing those who were transferred from within the ACO to those from outside the ACO in terms of overall cost of hospitalization. Hospital length of stay and number of imaging studies were predetermined secondary outcomes. RESULTS: The study population included 7696 hospitalizations for traumatic injuries over a 5-year period, 85.1% of which were for patients transferred from outside the ACO. Patients transferred from within the ACO had a 7.2% lower overall cost of hospitalization (P = .032). Mean injury severity scores were not significantly different between groups. Differences in mortality, intensive care unit length of stay, and overall hospital length of stay were not significant. However, analysis of radiology studies performed during the hospitalization revealed that patients transferred from within the ACO had, on average, 0.47 fewer advanced imaging studies per hospitalization than did those transferred from outside the ACO (3.55 vs 4.02 studies per hospitalization, P = .003). CONCLUSIONS: Adult trauma patients transferred from within an ACO have significantly lower total costs of hospitalization than do those transferred from outside the system, without significant differences in disease burden, hospital length of stay, or mortality.

Improved Oxygenation After Transport in Patients With Hypoxemic Respiratory Failure.

OBJECTIVE: The purpose of this study is to measure the rate and magnitude of changes in oxygenation that occur in patients with hypoxemic respiratory failure after transport by a critical care transport team. METHODS: We performed a retrospective review of 239 transports of patients with hypoxemic respiratory failure requiring a fraction of inspired oxygen (Fio2) > 50% transported from October 2009 to December 2012 from referring hospitals to 3 tertiary care hospitals. We analyzed the change the ratio of the partial pressure of oxygen in the blood to FiO2 from the sending to the receiving hospital as well as the percentage saturation of oxygen (Spo2) before, after, and en route. RESULTS: The mean change in the Pao2/Fio2 ratio from the sending to the receiving hospital was an increase of 27.62 (95% confidence interval [CI], 15.84-39.40; P = .0003). The mean change in Pao2 was an increase of 27.85 mm Hg (CI, 17.49-38.22; P < .0001). The mean Spo2 was not significantly changed at -0.12 (CI, - 1.69 to 1.45, P = .9). Despite improvement in the Pao2/Fio2 ratio and a stable Spo2 on arrival, 28.1% of patients desaturated to Spo2 < 90% in transport. CONCLUSION: In patients with hypoxemic respiratory failure, Pao2/Fio2 and Pao2 increased after transport by a critical care transport team despite 28.1% of patients desaturating with hypoxemia in transit.

BWH emergency radiology--surgical correlation: traumatic spigelian hernia with right colonic injury.

We present a case of a young man who fell off his motorbike 2 days before presentation to the hospital with a complaint of gastrointestinal upset and abdominal pain. Contrast-enhanced CT of the abdomen and pelvis demonstrated a right-sided traumatic spigelian hernia and an ascending colon injury necessitating operative repair of both.