Reduction in Hospital Transfers at a US COVID-19 Alternate Care Site: Maintaining Surge Capacity Support in Imperial County, California.

OBJECTIVE: The transfer rate for patients from an Alternate Care Site (ACS) back to a hospital may serve as a metric of appropriate patient selection and the ability of an ACS to treat moderate to severely ill patients accepted from overwhelmed health-care systems. During the coronavirus infectious disease 2019 (COVID-19) pandemic, hospitals worldwide experienced acute surges of patients presenting with acute respiratory failure. METHODS: An ACS in Imperial County, California was re-established in November 2020 to help decompress 2 local hospitals experiencing surges of COVID-19 cases. The patients treated often had multiple comorbid illnesses and required a median supplemental oxygen of 3 L/min (LPM) on admission. Numerous interventions were initiated during a 2-wk period to improve clinical care delivery. RESULTS: The objectives of this retrospective observational study are to evaluate the impact of these clinical and staff interventions at an ACS on the transfer rate and to provide issues to consider for future ACS sites managing COVID-19 patients. CONCLUSIONS: The data suggest that continuous, real-time process-improvement interventions helped reduce the transfer rate back to hospitals from 36.7% to 14.5% and that an ACS is a viable option for managing symptomatic COVID-19 positive patients requiring hospital-level care when hospitals are overburdened.

Utilization of Alternate Care Sites During the COVID-19 Surge and Mass Care: California, 2020-2021.

The coronavirus disease (COVID-19) pandemic caused critical hospital bed and staffing shortages in parts of California for most of 2020 and 2021. Alternate Care Sites (ACS) were established in several regions to alleviate the hospital patient surge and to maximize staffed bed capacity. Over 1900 patients were successfully provided medical care (with physician, nursing, respiratory therapy, oxygen, and pharmacy services) in relatively austere settings. This paper examines the challenges faced at these ACS facilities and how adaptations were incorporated according to the changing dynamics of the COVID-19 pandemic to successfully manage higher acuity patients. ACS facilities were 1 approach to California's surge of COVID-19 patients, despite limited medical supplies and staffing.

Prehospital response to respiratory distress by the public ambulance system in a Ukrainian city.

BACKGROUND: The capability of the public ambulance system in Ukraine to address urgent medical complaints in a prehospital environment is unknown. Evaluation using reliable sources of patient data is needed to provide insight into current treatments and outcomes. METHODS: We obtained access to de-identified computer records from the emergency medical services (EMS) dispatch center in Poltava, a medium-sized city in central Ukraine. Covering a five-month period, we retrieved data for urgent calls with a patient complaint of respiratory distress. We evaluated ambulance response and treatment times, field diagnoses, and patient disposition, and analyzed factors related to fatal outcomes. RESULTS: Over the five-month period of the study, 2,029 urgent calls for respiratory distress were made to the Poltava EMS dispatch center. A physician-led ambulance typically responded within 10 minutes. Seventy-seven percent of patients were treated and released, twenty percent were taken to hospital, and three percent died in the prehospital phase. On univariate analysis, age over 60 and altered mental status at the time of the call were strongly associated with a fatal outcome. CONCLUSION: The EMS dispatch center in a medium-sized city in Ukraine has adequate organizational infrastructure to ensure that a physician-led public ambulance responds rapidly to complaints of respiratory distress. That EMS system was able to manage most patients without requiring hospital admission. However, a prehospital fatality rate of three percent suggests that further research is warranted to determine training, equipment, or procedural needs of the public ambulance system to manage urgent medical conditions.

A Skeletal Traction Technique for Proximal Femur Fracture Management in an Austere Environment.

Skeletal traction is a useful technique for managing proximal femur fractures in austere environments where fracture stabilization for this injury is difficult. We present a technique and a construct appropriate for field use that facilitates patient evacuation, and we provide guidelines for the use of this technique by an advanced medical provider managing these injuries. The objectives of this article are to enable to reader to (1) recognize the role of skeletal traction in managing proximal femur fractures in an austere environment, (2) identify the key steps in placing transfemoral skeletal traction pins, and (3) identify options and requirements for building a traction construct in resource-limited environments.

Digital intubation: the two-fingered solution to securing an airway.

Digital intubation is a useful technique that is rarely taught in conventional airway management courses. With limited equipment and minimal training, a Special Operations Forces (SOF) medic can use this technique to intubate an unconscious patient with a high degree of success. The objectives of this report are to (1) learn the sequence of events for successful digital intubation, (2) recognize and appreciate the advantages and limitations of this technique, and (3) appreciate the requirements for establishing a unit-level training program.

Diagnosis and management of evacuated casualties with cervical vascular injuries resulting from combat-related explosive blasts.

BACKGROUND: Explosive blasts are common in the modern military environment. These blasts incorporate a concussive component (primary blast injury) and a penetrating component (secondary blast injury). Penetrating injuries are the leading cause of death and injury in these attacks. This review characterizes the vascular injuries associated with penetrating blast injuries to the neck and provides recommendations on the early management of these casualties for the surgeon unfamiliar with these injuries. METHODS: The Landstuhl Regional Medical Center Trauma Registry was queried for admissions from January 1, 2006, to June 30, 2010, coded for a penetrating injury to the neck caused by a blast mechanism. Medical records were abstracted from the patient's initial presentation and care through the deployed military medical system. We recorded the vascular injuries, diagnostic studies, operative events, and early postinjury course for all identified patients. RESULTS: Query of the Landstuhl Regional Medical Center Trauma Registry initially identified 252 patients, of which 53 were excluded because their injuries arose from other mechanisms or were only superficial. Among the remaining 199 patients, 38 (19.1%) sustained 44 vascular injuries requiring treatment. Compelling physical examination findings ("hard signs") were present in 15 (7.5%), who underwent immediate neck exploration. Another 12 patients also underwent neck exploration without any prior imaging studies. Computed tomography (CT) or CT angiography (CTA) examinations were done in 172 patients without hard-sign physical examination findings. Of these, the result of the imaging study was negative in 106 patients, and no further investigation or treatment for cervical vascular trauma was initiated. Of 66 patients who underwent CT/CTA before operative neck exploration, CT/CTA identified a vascular injury in 26 that was later confirmed on neck exploration. The combination of physical examination and CT/CTA resulted in a sensitivity of 96.3% and a specificity of 97.2% in diagnosing cervical vascular injury. CONCLUSIONS: Penetrating cervical wounds from war-related blast trauma are associated with potentially life-threatening vascular injuries. The presenting physical examination, availability of CT/CTA, local surgical expertise, and tactical combat situation all contribute to surgical decision making in these patients. In patients without hard signs of vascular trauma and a normal CT/CTA of the neck, there is no evidence to support mandatory surgical neck explorations or further immediate diagnostic studies to exclude cervical vascular injury.

Recurrent epiphrenic diverticulum after transabdominal diverticulectomy: report of a case and review of the literature.

Epiphrenic esophageal diverticula are uncommon esophageal disorders; reported recurrence after surgical treatment is rare. We describe a case of recurrence in a patient previously treated with a transhiatal diverticulectomy myotomy and fundoplication. Anatomic factors that may have contributed to this recurrence are discussed.

Scapulothoracic dissociation: case report and review of current management.

Scapulothoracic dissociation (SD) was first recognized as a distinct traumatic injury pattern in 1984. This case report and review of the literature will be a comprehensive description of this syndrome and its management. Although the extremity prognosis of this injury is poor, patient outcome can be optimized so that the patient can be returned to the best possible functional status in the most expedient manner.

Complete occlusion after blunt injury to the abdominal aorta.

BACKGROUND: Injury to the abdominal aorta after blunt trauma is uncommon. When this injury results in complete vessel occlusion, the presentation is dramatic. Timely intervention is essential. METHODS: After a case report, we examined all reported cases of complete occlusion after blunt injury to the abdominal aorta and reviewed the cause, presentation, and management of this injury. RESULTS: Complete vessel occlusion arises from intimal injury. The most frequent mechanism is compression from a seat belt or steering wheel during a motor vehicle crash. Patients present with absent femoral and distal pulses in association with lower extremity neuropathy. Intervention commonly involves bypass grafting of the abdominal aorta. CONCLUSION: Complete occlusion after blunt trauma to the abdominal aorta is rare. Neurologic deficits most commonly arise from peripheral nerve ischemia. Reperfusion within 6 hours confers a greater chance of limb salvage and neurologic recovery.