When Equality Is Not Equity: The Ethics of Access to Trauma Care A Surgical Perspective.

OBJECTIVE: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. SUMMARY BACKGROUND DATA: Traumatic injury is a leading cause of death and disability in the US. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city leading to a fallacy of distributive justice. METHODS: A descriptive analysis of community partners, trauma program leadership, trauma surgeons and the violence intervention program director was performed. RESULTS: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes (P<0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018 developing both community-based and medical legal partnerships. CONCLUSIONS: The persistent efforts of the community and key stakeholders led to a system change improving trauma care for the South Side of Chicago.

Isolated right atrial rupture from blunt trauma: a case report with systematic review of a lethal injury.

BACKGROUND: Isolated right atrial rupture (IRAR) from blunt chest trauma is rare. There are no physical exam findings and non-invasive testing specific to the condition, which result in diagnostic delays and poor outcomes. We present a case of IRAR along with a systematic review of similar cases in the literature. CASE REPORT: A 23-year-old male presented following a motor vehicle accident (MVA). He was bradycardic and hypotensive during transportation; and required intubation. There were contusions along the right chest wall with clear breath sounds, and no jugular venous distension, muffled heart sounds. Hemodynamic status progressively worsened, ultimately leading to his death. However, no external sources of bleeding or evidence of cardiac tamponade was found. METHODS: A search of PubMed, Ovid, and the Cochrane Library using: (Blunt OR Blunt trauma) AND (Laceration OR Rupture OR Tear) AND (Right Atrium OR Right Atrial). Articles were included if they were original articles describing cases of IRAR. RESULTS: Forty-five reports comprising seventy-five (n = 75) cases of IRAR. CONCLUSION: IRAR most commonly occurs following MVAs as the result of blunt chest trauma. Rupture occurs at four distinct sites and is most commonly at the right atrial appendage. IRAR is a diagnostic challenge and requires a high index of suspicion, as patients' hemodynamics can rapidly deteriorate. The presentations vary depending on multiple factors including rupture size, pericardial integrity, and concomitant injuries. Cardiac tamponade may have a protective effect by prompting the search for a bleeding source. A pericardial window can be diagnostic and therapeutic in IRAR. Outcomes are favourable with timely recognition and prompt surgical intervention.

The Feasibility of Venovenous ECMO at Role-2 Facilities in Austere Military Environments.

INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been gaining use to bridge the recovery from acute respiratory distress syndrome (ARDS) refractory to conventional treatment. However, these interventions are often limited to higher echelons of military care. We present a case of lung salvage from severe ARDS in an Afghani soldier with VV-ECMO at a Role-2 (R2) facility in an austere military environment in Afghanistan. CASE: A 25-year-old Afghani soldier presented to an R2 facility with blast lung injury and multiple penetrating injuries following an explosion. The patient underwent immediate damage control laparotomy. The abdomen was left open for subsequent washouts and ongoing resuscitation. Due to his ineligibility for evacuation and worsening ARDS, despite 5 d of conventional ventilation strategies, he was started on VV-ECMO. The patient had immediate improvements in oxygenation, which continued for 10 d. Moreover, he underwent three transportations to the operating room without accidental decannulation or disruption of the VV-ECMO device. Despite significant improvements, the patient expired on postoperative day 15, due to an overwhelming intra-abdominal sepsis. CONCLUSION: As future advancements are sought, VV-ECMO may become a consideration for casualties with severe ARDS at the point of injury and at lower echelons of military care.

The Association of Race, Socioeconomic Status, and Insurance on Trauma Mortality.

BACKGROUND: Although race, socioeconomic status, and insurance individually are associated with trauma mortality, their complex interactions remain ill defined. METHODS: This retrospective cross-sectional study from a single Level I center in a racially diverse community was linked by socioeconomic status, insurance, and race from 2000 to 2009 for trauma patients aged 18-64 years with an injury severity score more than 9. The outcome measure was inpatient mortality. Multiple logistic regression analyses were performed to investigate confounding variables known to predict trauma mortality. RESULTS: A total of 4,007 patients met inclusion criteria. Individually, race, socioeconomic status, and insurance were associated with increased mortality rate; however, in multivariate analysis, only insurance remained statistically significant and varied by insurance type with age. Odds of death were higher for Medicare (odds ratio [OR] = 3.63, p = .006) and other insurance (OR = 3.02, p = .007) than for Private Insurance. However, when grouped into ages 18-40 years versus 41-64 years, the insurance influences changed with Uninsured and Other insurance (driven by Tricare) predicting mortality in the younger age group, while Medicare remained predictive in the older age group. CONCLUSIONS: Insurance type, not race or socioeconomic status, is associated with trauma mortality and varies with age. Both Uninsured and Tricare insurance were associated with mortality in younger age trauma patients, whereas Medicare was associated with mortality in older age trauma patients. The lethality of the Tricare group warrants further investigation.

Forearm-Based Ulnar Gutter versus Hand-Based Thermoplastic Splint for Pediatric Metacarpal Neck Fractures: A Blinded, Randomized Trial.

BACKGROUND: Use of a hand-based thermoplastic splint for treatment of isolated fifth metacarpal neck fractures in pediatric patients has not previously been studied in a randomized blinded trial. METHODS: The authors conducted a blinded, 1:1 allocation, two-arm parallel group, superiority design, randomized controlled trial in patients aged 16 years or younger with isolated fifth metacarpal neck fractures. Patients were immobilized for 3 weeks in a conventional forearm-based ulnar gutter or hand-based thermoplastic splint. Primary outcome was difference in active range of motion between splint groups. Secondary outcomes included fracture union, treatment adherence, grip strength, and patient-reported pain and functional outcomes. RESULTS: Between February of 2013 and August of 2014, 40 patients were enrolled in the trial. No differences were observed in baseline characteristics between groups. Mean range of motion was significantly better in the thermoplastic splint group compared with the ulnar gutter splint group at 3 weeks (p = 0.048). All patients had full range of motion at 12 weeks. Treatment adherence was 75 percent and 59 percent for ulnar gutter and thermoplastic splint groups, respectively (p = 0.46). Among ulnar gutter splint patients, decreased grip strength (injured versus noninjured) was observed at 3 and 6 weeks, and was significantly weaker compared with thermoplastic splint patients (p = 0.01). Reported pain scores were similar between groups. Patient-reported functional outcome scores were similar between groups at each time point. No nonunions were observed at 12 weeks. CONCLUSION: In pediatric patients, hand-based thermoplastic splints resulted in improved early range of motion and grip strength, with no increased pain, nonadherence, or complications compared with conventional ulnar gutter splints. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Klebsiella pneumoniae Liver Abscess and Metastatic Endophthalmitis.

Introduction. Klebsiella pneumoniae is a well-known cause of liver abscess. Higher rates of liver abscess associated with Klebsiella pneumoniae are seen in Taiwan. Metastatic endophthalmitis is a common complication associated with a poor prognosis despite aggressive therapy. Case Report. We report a case of a 67-year-old Korean female with Klebsiella pneumoniae liver abscess. The patient developed metastatic endophthalmitis and ultimately succumbed to her disease despite aggressive medical and surgical treatment. Conclusion. Dissemination of Klebsiella pneumoniae is associated with significant morbidity and mortality. Liver abscesses preferably should be treated with percutaneous drainage, but surgical treatment is needed in some cases. Metastatic spread to the eye is a common complication that must be treated aggressively with intravenous antibiotics and surgical intervention if necessary.

Impact of MRI on changing management of the cervical spine in blunt trauma patients with a 'negative' CT scan.

BACKGROUND: Owing to the potential risks associated with missed injury, many blunt trauma patients with suspected cervical spine injury undergo some form of imaging technique which has progressed from primarily using plain radiography to relying on CT. Recently, studies have shown that in certain situations, adding MRI may improve the diagnostic accuracy over solely relying on CT. METHODS: Retrospective study of 3468 adult blunt trauma patients at a level I trauma center of which 94 with an initial negative CT scan underwent subsequent MRI. These 94 patients were classified as reliable or unreliable for examination; coded as either having a positive or negative MRI result; and assessed for a change in management. RESULTS: Of the 94 patients in the study population, 69 (73.4%) were deemed reliable and 25 (26.6%) deemed unreliable for examination. Overall, 65 (69.1%) patients had a positive MRI result-49 (71.0%) reliable and 16 (64.0%) unreliable-with some patients testing positive for more than one finding. There was no significant difference in positive MRI rates between reliable and unreliable patients. None of the 29 patients who had negative MRI had a change in management, while 31 of the 65 (47.7%) patients with positive MRI did have a change in management of either continued cervical collar immobilization or neck surgery. CONCLUSIONS: The use of CT scans should be continued as the primary imaging technique for patients with suspected cervical spine injuries. In cases where obtundation or clinical suspicion exists for a false-negative CT scan, MRI should be considered as a supplement and should not be rejected solely based on the negative result of the CT. LEVEL OF EVIDENCE: Level IV.

Chronic Otitis Media with Effusion Is Associated with Increased Risk of Secondary Speech Surgery.

BACKGROUND: Velopharyngeal insufficiency and chronic otitis media with effusion following primary cleft palate repair can be attributed to persistent abnormalities in the levator and tensor veli palatini muscles, respectively. The purpose of this case-control study was to examine the association between otitis media with effusion requiring myringotomy tubes and the need for secondary speech surgery. METHODS: Records of patients who underwent primary palatoplasty at the authors' institution from 1990 to 2006 were reviewed. Data included age at primary palatoplasty, sex, Veau classification, surgeon, number of postpalatoplasty myringotomy tube procedures, hearing loss, 22q deletion syndrome diagnosis, and fistula. The primary outcome was need for secondary speech surgery. RESULTS: Of 249 patients meeting inclusion criteria, forty-four patients (17.7 percent) had secondary speech surgery recommended or performed. Univariate analysis revealed a significant association between Veau classification, 22q deletion syndrome diagnosis, and two or more myringotomy tube procedures with secondary speech surgery. Adjusting for multiple covariates, children requiring two or more myringotomy tubes were 2.55 times more likely to require secondary speech surgery than patients who required one or fewer myringotomy tubes procedures (95 percent CI, 1.24 to 5.21; p = 0.009). CONCLUSIONS: The authors demonstrate that chronic otitis media with effusion requiring two or more myringotomy tube procedures is associated with a significantly increased likelihood of requiring secondary speech surgery. Using otitis media with effusion as a clinical predictor for secondary velopharyngeal insufficiency could lead to early identification of at-risk patients in need of intensive speech therapy and timely secondary speech surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Using augmented reality as a clinical support tool to assist combat medics in the treatment of tension pneumothoraces.

This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance.

Choice of motorcycle helmet makes a difference: a prospective observational study.

BACKGROUND: Although many states mandate that motorcyclists wear helmets, their laws do not indicate which type of helmet should be used. In addition, there are no prospective studies in the literature evaluating patterns of injuries as they relate to helmet type. The hypothesis in this study was that full-face helmets (FFHs) reduce craniofacial injuries associated with motorcycle collisions when compared with other helmet types. METHODS: A prospective observational study was conducted at a Level I trauma center to evaluate the efficacy of helmet types relative to craniofacial injuries. Data included patient demographics, helmet types, injuries, and outcomes. The incidences of facial fractures, skull fractures, and traumatic brain injuries (TBIs) were compared in patients wearing FFHs versus other helmet types (OH) during motorcycle crashes. RESULTS: From 2011 to 2012, 151 patients of motorcycle crashes (135 males, 16 female; mean age, 38.4 years; range, 19-74 years) whose helmet types were identified by health care providers were entered into the study. The distribution of helmets was 84 FFH and 67 OH (39 half and 28 modular). Facial fractures were present in 7% of the patients wearing FFH (95% confidence interval, 0.015-0.125) versus 27% (95% confidence interval, 0.164-0.376) of those wearing OH (p = 0.004). In addition skull fractures were present in 1% of the patients wearing FFH versus 8% in those wearing OH (p < 0.05). While there was a trend for patients wearing FFH to have a lower incidence of TBI (13% vs. 25% in those wearing OH), this was not statistically significant (p = 0.053). There were no differences in Injury Severity Score (ISS), length of stay, or mortality between the two groups. CONCLUSION: Victims of motorcycle crashes who are wearing FFH have a significant reduction in facial and skull fractures when compared with those wearing OH. Further studies will be needed to assess whether FFH will significantly decrease the incidence of TBI. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.

Pediatric trauma experience in a combat support hospital in eastern Afghanistan over 10 months, 2010 to 2011.

We reviewed the pediatric trauma experience of one Combat Support Hospital (CSH) in Afghanistan to focus on injuries, surgery, and outcomes in a war zone. We conducted a review of all pediatric patients over 10 months in an eastern Afghanistan CSH. We studied 41 children (1 to 18 years; mean, 8.5 years; median, 9 years), 28 (68.2%) with penetrating injuries. Blasts (13 patients) and burns (nine) were the most common mechanisms. At arrival 19 (46.3%) underwent endotracheal intubation, four (9.8%) had no palpable blood pressure, 10.6 per cent (four of 38) a Glasgow coma score of 5 or less, 30.6 per cent (11 of 36) base deficits of 6 or less, and 41.7 per cent (15 of 36) hematocrit 30 or less. Red cells were given in 14 (34.1%) and plasma in 11 (26.8%). Of 32 total nonburn patients, 12 (37.5%) had multiple system injuries. Three-fourths of injuries were severe (75.8% [47 of 62] Abbreviated Injury Score 3 or greater). Thirty-two patients (78.0%) required major operations: burn and wound care, orthopedic, chest, abdominal, vascular, and neurosurgical. Second operations were performed in 16 (39.0%), most often burn and orthopedic procedures. Six died (14.6%), 13 were transferred to other hospitals (31.7%), and 20 were discharged to home (48.8%; two not noted). Broad experience in operative trauma care, pediatric resuscitation, and critical care is a priority for military surgeons.

Benefit of a Tiered-Trauma Activation System to Triage Dead-on-Arrival Patients.

INTRODUCTION: Although national guidelines have been published for the management of critically injured traumatic cardiopulmonary arrest (TCPA) patients, many hospital systems have not implemented in-hospital triage guidelines. The objective of this study was to determine if hospital resources could be preserved by implementation of an in-hospital tiered triage system for patients in TCPA with prolonged resuscitation who would likely be declared dead on arrival (DOA). METHOD: We conducted a retrospective analysis of 4,618 severely injured patients, admitted to our Level I trauma center from December 2000 to December 2008 for evaluation. All of the identified patients had sustained life-threatening penetrating and blunt injuries with pre-hospital TCPA. Patients who received cardiopulmonary resuscitation (CPR) for 10 minutes were assessed for survival rate, neurologic outcome, and charge-for-activation (COA) for our hospital trauma system. RESULTS: We evaluated 4,618 charts, which consisted of patients seen by the MSM trauma service from December 2001 through December 2008. We identified 140 patients with severe, life-threatening traumatic injuries, who sustained pre-hospital TCPA requiring prolonged CPR in the field and were brought to the emergency department (ED). Group I was comprised of 108 patients sustaining TCPA (53 blunt, 55 penetrating), who died after receiving < 45 minutes of ACLS after arrival. Group II, which consisted of 32 patients (25 blunt, 7 penetrating), had resuscitative efforts in the ED lasting > 45 minutes, but all ultimately died prior to discharge. Estimated hospital charge-for-activation for Group I was approximately $540,000, based on standard charges of $5000 per full-scale trauma system activation (TSA). CONCLUSION: Full-scale trauma system activation for patients sustaining greater than 10 minutes of prehospital TCPA in the field is futile and economically depleting.

Worsening severity of vitamin D deficiency is associated with increased length of stay, surgical intensive care unit cost, and mortality rate in surgical intensive care unit patients.

BACKGROUND: Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. METHODS: We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. RESULTS: Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D-deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant (P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D-deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D-deficient group, which also was clinically significant (P = .027). More importantly, the mortality rate for the severe vitamin D-deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group (P = .125). Because no deaths occurred in the mildly or normal vitamin D-deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups (P = .047). CONCLUSIONS: In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D-deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

A traumatic abdominal wall hernia repair: a laparoscopic approach.

BACKGROUND: Traumatic abdominal wall hernias from blunt trauma usually occur as a consequence of motor vehicle collisions where the force is tangential, sudden, and severe. Although rare, these hernias can go undetected due to preservation of the skin overlying the hernia defect. Open repairs can be challenging and unsuccessful due to avulsion of muscle directly from the iliac crest, with or without bone loss. A laparoscopic approach to traumatic abdominal wall hernia can aid in the delineation of the hernia and allow for a safe and effective repair. CASE DESCRIPTION: A 36-year-old female was admitted to our Level 1 trauma center with a traumatic abdominal wall hernia located in the right flank near the iliac crest after being involved in a high-impact motor vehicle collision. Computed tomography and magnetic resonance imaging of the abdomen revealed the presence of an abdominal wall defect that was unapparent on physical examination. The traumatic abdominal wall hernia in the right flank was successfully repaired laparoscopically. One-year follow-up has shown no sign of recurrence. DISCUSSION: A traumatic abdominal wall hernia rarely presents following blunt trauma, but should be suspected following a high-impact motor vehicle collision. Frequently, repair is complicated by the need to have fixation of mesh to bony landmarks (eg, iliac crest). In spite of this challenge, the laparoscopic approach with tension-free mesh repair of a traumatic abdominal wall hernia can be accomplished successfully using an approach similar to that taken for laparoscopic inguinal hernia repair.