Automated acuity scoring within a computer based medical record.

This paper describes the initial development of a completely automated acuity scoring system that resides within the TMR bedside computing system at the Duke University Medical Center, Surgical Intensive Unit. The scoring system is based upon the APACHE II acuity scoring system and provides for the recalculation of acuity scoring at 12 hour intervals through the patient's ICU course. When comparing hand calculated versus computer generated acuity scores for 19 patients, discrepancies fell into three broad categories: 1) data available to the application differed from that available to the human scorer. 2) apparent transcription errors 3) data items lost or absent from the paper record. It remains to be determined if computer generated acuity scoring provides for a more accurate representation of the patient's acuity.

Transmural surgical gown pressure measurements in the operating theater.

Transmural gown pressures encountered when the surgeon comes into contact with a patient were measured in the operating theater. The surgical gown industry has assumed these pressures to be less than 5 psi in testing the efficacy of the gown and drape barrier material to impede bacterial transmission through its pores. In this study, pressure-sensitive contact film and resistive strain gauge recordings made from the surgeon's abdominal region and forearms indicated peak contact pressures in excess of 60 psi. This report indicates a need to reassess the basis of test utilization in evaluating barrier materials used in gowns and drapes.

Abdominal musculature abnormalities as a cause of groin pain in athletes. Inguinal hernias and pubalgia.

There has been increasing interest within the European sports medicine community regarding the etiology and treatment of groin pain in the athlete. Groin pain is most commonly caused by musculotendinous strains of the adductors and other muscles crossing the hip joint, but may also be related to abdominal wall abnormalities. Cases may be termed "pubalgia" if physical examination does not reveal inguinal hernia and there is an absence of other etiology for groin pain. We present nine cases of patients who underwent herniorrhaphies for groin pain. Two patients had groin pain without evidence of a hernia preoperatively (pubalgia). In the remaining seven patients we determined the presence of a hernia by physical examination. At operation, eight patients were found to have inguinal hernias. One patient had no hernia but had partial avulsion of the internal oblique fibers from their insertion at the public tubercle. The average interval from operation to return to full activity was 11 weeks. All patients returned to full activity within 3 months of surgery. One patient had persistent symptoms of mild incisional tenderness, but otherwise there were no recurrences, complications, or persistence of symptoms. Abnormalities of the abdominal wall, including inguinal hernias and microscopic tears or avulsions of the internal oblique muscle, can be an overlooked source of groin pain in the athlete. Operative treatment of this condition with herniorrhaphy can return the athlete to his sport within 3 months.

MR imaging of stump neuroma.

Painful stump neuromas in the postamputation patient are difficult to diagnose and treat. We report a case in which magnetic resonance allowed precise preoperative diagnosis and localization of such a lesion. Magnetic resonance, with its ability for long axis imaging in the extremity, is ideally suited for the workup of stump neuromas.

Impact of helicopters on trauma care and clinical results.

This report reviews the history of the development of civilian helicopter ambulance program as a component of a total emergency medical services (EMS) system. Current literature demonstrates significant reduction in trauma mortality for those patients transported by air either from the scene of the accident or from an outlying hospital to a trauma center. The primary factor is not the speed of the transport but administration of life-saving care by the helicopter medical crew at the scene of the accident or at the outlying hospital. Regulations have been developed to assure proper patient selection, quality care, safety, and minimization of misuse of this expensive resource.

Factors improving survival in multisystem trauma patients.

This report analyzes the effect of air versus ground interhospital transport on survival following multisystem injury. There were 136 air-transported patients versus 194 ground-transported patients. The groups were similar in trauma scores, ages, mechanism of injury, and organ systems injured. There was a statistically significant survival advantage for air-transported patients with trauma scores between 10 and 5 (82.8% survival vs. 53.5%, p = less than 0.001). The time interval between accident and admission to the authors' institution was similar for both groups. Important therapeutic interventions contributing to better survival by the air-transported group included higher incidences of endotracheal intubation (50% vs. 25%), blood transfusions (32% vs. 10%), larger volumes of electrolyte fluid (3.3 L per patient vs. 2.1 L per patient) as well as the use of MAST trousers (60.3% vs. 34.9%). Transport charges for both ground and air services were similar. However, helicopter charges met only 15% of the operational budget of the aeromedical service. The remainder of the costs were generated from hospital patient revenues. Overall, total hospital charges were similar for both groups and were influenced by the variability of length of stay, particularly for orthopedic patients.

Toothbrush swallowing.

We encountered four cases of toothbrush swallowing and reviewed the literature on this subject. A total of 31 toothbrushes within the gastrointestinal tract have been reported. None have passed spontaneously. Several have caused significant complications related to pressure necrosis, including gastritis, mucosal tears, and perforation. The recommended treatment is endoscopic retrieval and postoperative monitoring for 24 hours in case of esophageal or gastric injury.

Reducing wound infections. Improved gown and drape barrier performance.

A 21-month study involving 2181 clean and clean-contaminated general surgical procedures was performed to evaluate the effectiveness of a commercially available disposable gown and drape system vs a cotton system in reducing wound infection. The series in which the disposable spun-laced fiber system was used had a significantly lower overall infection rate (2.83% vs 6.5%) as well as better rates in clean (1.8% vs 3.8%) and clean-contaminated (4.8% vs 11.4%) procedures. This effect was independent of all other factors. The odds of developing a wound infection was 2 1/2 times higher with a cotton system than with a disposable system. Actual cost analysis from three types of hospitals showed lower costs with utilization of disposable gown and drape systems. Hospital charges were significantly higher for those patients developing wound infections. The results of the study demonstrated not only significant reduction in wound infection rates but also major cost savings when a disposable gown and drape system was used in the operating room.

Trauma injuries. Triage and stabilization for safe transfer.

Categorization of trauma injuries and identification of special resources and facilities for treatment of major injuries have markedly affected morbidity and mortality. Reduction in trauma morbidity and mortality depends on early identification of severely injured patients, proper initial stabilization, and safe interhospital transfer. The trauma score and the American College of Surgeons anatomical injury categorization are valuable triage tools. Protocols for initial stabilization and for safe transfer have been described to assist the primary referring physician in providing optimal early care.

Emergency care of chemical burns.

Because of the large number of potentially injurious chemicals present in the home and workplace, chemical burns pose a unique challenge to the health care professional. For the majority of injuries, prompt and prolonged hydrotherapy is the cornerstone of therapy. The clinician needs to remember that the extent and depth of chemical injuries are difficult to assess in the acute phase; therefore, careful monitoring of blood values, urine output, and other parameters is necessary to gauge the volume of fluid required with major injury.

Inhalation injury--a major burn complication.

Inhalation injury results from exposure to the toxic gases, chemicals, and particulate matter of smoke to the respiratory tract. New synthetic materials have increased the toxicity of chemicals in smoke and added to the complexity of inhalation injuries. Clinical diagnosis is often difficult, but a high index of suspicion in victims of certain fire situations, coupled with early diagnostic bronchoscopy, will identify most victims. Prior to early bronchoscopy, the mortality rates for the combination of inhalation injury and body surface burn ranged from 75% to 90%. Early diagnosis, expectant management, and meticulous aseptic techniques can decrease the mortality rate to less than 30%.

Perforation of the jejunum from blunt abdominal trauma.

Thirteen cases of jejunal perforation from blunt trauma are presented. There are no reliable signs or symptoms, and a normal physical examination may be seen. Free intraperitoneal air on plain radiograms is characteristically absent. Simple debridement and closure is adequate. Mortality is usually associated with other serious concomitant injuries, and complications are associated with diagnostic delays. Diagnostic peritoneal lavage is a safe and reliable procedure for establishing an early diagnosis of serious intraperitoneal injury. Its routine use in all cases of serious blunt abdominal trauma is advocated.