First echelon hospital care before trauma center transfer in a rural trauma system: does it affect outcome?

BACKGROUND: Rural trauma has been associated with higher mortality because of a number of geographic and demographic factors. Many victims, of necessity, are first cared for in nearby hospitals, many of which are not designated trauma centers (TCs), and then transferred to identified TCs. This first echelon care might adversely affect eventual outcome. We have sought to examine the fate of trauma patients transferred after first echelon hospital evaluation and treatment. METHODS: All trauma patients transferred (referred group) to a Pennsylvania Level I TC located in a geographically isolated and rural setting during a 68-month period were retrospectively compared with patients transported directly to the TC (direct group). Outcome measures included mortality, complications, physiologic parameters on arrival at the TC, operations within 6 hours of arrival at the TC, discharge disposition from the TC, and functional outcome. Patients with an injury severity score <9 and those discharged from the TC within 24 hours were excluded. RESULTS: During the study period, 2,388 patients were transported directly and 529 were transferred. Mortality between groups was not different: 6% (referred) versus 9% (direct), p = 0.074. Occurrence of complications was not different between the two groups. Physiologic parameters (systolic blood pressure, heart rate, and Glasgow Coma Scale score) at admission to the Level I TC differed statistically between the two groups but seemed near equivalent clinically. Sixteen percent of patients required an operative procedure within 6 hours in the direct group compared with 10% in the referral group (p = 0.001). Hospital and intensive care unit length of stay were less in the referred group, although this was not statistically significant. Performance scores on discharge were equivalent in all categories except transfer ability. Time from injury to definitive care (TC) was 1.6 hours ± 3.0 hours in the direct group and 5.3 hours ± 3.8 hours in the referred group (p < 0.0001). The most common procedure performed at first echelon hospitals was airway control (55% of referred patients). CONCLUSIONS: In this rural setting, care at first echelon hospitals, most (95%) of which were not designated TCs, seemed to augment, rather than detract from, favorable outcomes realized after definitive care at the TC.

Sentinel node mapping for breast cancer: the operative experience of a breast surgeon in a rural community.

Sentinel lymph node biopsy has become an accepted procedure for staging the axilla in early stage breast cancer. Our objectives were to review our practice of sentinel lymph node (SLN) mapping in breast cancer, to determine the impact of frozen section (FS) analysis of the SLN on patient management, and to compare our results to national data. We retrospectively reviewed the medical records of our patients with breast cancer who underwent SLN mapping with or without axillary lymph node dissection (ALND) between 1999 and 2006. During this period, 478 patients were treated for breast cancer, with 227 patients undergoing SLN mapping. The SLN was identified in 201 patients, with a positive SLN found in 52 patients (25.9%). There was a discrepancy between the intraoperative analysis (FS/touch prep) and final pathology in 20 patients (11.3%). Nineteen of those patients had a negative FS with positive final pathology. Six of these patients underwent completion ALND. One patient had a false-positive FS with a negative ALND. No axillary recurrences were observed. Eight patients (3.5%) developed postoperative complications. Our practice has been to use intraoperative evaluation of the SLN to reduce the number of patients requiring a secondary ALND. In our study, six patients returned to the operating room for a completion ALND. Our complication rate and axillary recurrence rates were similar to national data.

Endovascular repair of ruptured abdominal aortic aneurysms: experience in a community hospital.

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66-82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multicenter study may eventually show this method to be helpful in patients who require repair of RAAA.