Regionalization of surgical services in central Florida: the next step in acute care surgery.

BACKGROUND: There is a national loss of access to surgeons for emergencies. Contributing factors include reduced numbers of practicing general surgeons, superspecialization, reimbursement issues, emphasis on work and life balance, and medical liability. Regionalizing acute care surgery (ACS), as exists for trauma care, represents a potential solution. The purpose of this study is to assess the financial and resources impact of transferring all nontrauma ACS cases from a community hospital (CH) to a trauma center (TC). METHODS: We performed a case mix and financial analysis of patient records with ACS for a rural CH located near an urban Level I TC. ACS patients were analyzed for diagnosis, insurance status, procedures, and length of stay. We estimated physician reimbursement based on evaluation and management codes and procedural CPT codes. Hospital revenues were based on regional diagnosis-related group rates. All third-party remuneration was set at published Medicare rates; self-pay was set at nil. RESULTS: Nine hundred ninety patients were treated in the CH emergency department with 188 potential surgical diseases. ACS was necessary in 62 cases; 25.4% were uninsured. Extrapolated to 12 months, 248 patients would generate new TC physician revenue of >$155,000 and hospital profits of >$1.5 million. CH savings for call pay and other variable costs are >$100,000. TC operating room volume would only increase by 1%. CONCLUSION: Regionalization of ACS to TCs is a viable option from a business perspective. Access to care is preserved during an approaching crisis in emergency general surgical coverage. The referring hospital is relieved of an unfavorable payer mix and surgeon call problems. The TC receives a new revenue stream with limited impact on resources by absorbing these patients under its fixed costs, saving the CH variable costs.

Traumatic injuries associated with Segways and personal transporters.

Segways and other personal transporters are emerging as alternative modes of transportation that blur the distinction between pedestrian and vehicular traffic. We reviewed the records of four patients who were traumatically injured while piloting personal transporters. All required hospital admission for major blunt force trauma; three were admitted to the intensive care unit. Two intensive care unit admissions were for neurologic monitoring of severe intracranial hemorrhage. The other critically ill patient had an extensive chest wall injury and respiratory failure resulting in a tracheostomy. The fourth patient suffered an open lower extremity fracture requiring extensive reconstructive orthopedic surgery. Surgeons should be aware of the potential serious nature of associated injuries.

Bioavailability of oral fluconazole in critically ill abdominal trauma patients with and without abdominal wall closure: a randomized crossover clinical trial.

BACKGROUND: Patients with non-apposed fascial edges, known as laparostomy patients, have traditionally been given intravenous medications, because enteral absorption of medications was thought to be unpredictable. We hypothesized that critically ill patients with "open abdomens" would have bioavailability similar to that of matched patients with closed fascial edges. METHODS: Fluconazole, a commonly prescribed anti-fungal with good bioavailability was used as a marker of absorption. Postoperative abdominal trauma patients were enrolled in a case-control (laparostomy versus closed abdomen) crossover design study to receive either an oral or parenteral fluconazole (400 mg loading dose followed by 200 mg QD) for one week. After a washout period, the alternate route of administration was used for the second week. Blood levels were collected at the end of each week of therapy. Rectal swab stool specimens were cultured for fungi on days 0, 7, and 15. RESULTS: Sixteen patients were studied. The mean injury severity score was 23 (range 9-41). The bioavailability of enteral fluconazole was 51% +/- 30% in the open abdomen and 63% +/- 19% (p = 0.347) in the closed abdomen patients. There was great variation in the bioavailability between the individual patients, with a range of 30%-100% in both groups. Three patients developed rectal colonization with Candida krusei. CONCLUSION: The bioavailability of enterally dosed fluconazole was highly variable in both the open and closed abdomen patients. Intravenous administration of pharmaceuticals may provide more reliable serum levels in the first 2 weeks after trauma-related laparotomy.

Morbidity and mortality of children following motor vehicle crashes.

HYPOTHESIS: The use of passenger compartment safety measures has not led to decreases in pediatric morbidity or mortality in our population of patients. DESIGN: Retrospective review. SETTING: University, tertiary care, level I trauma center. PATIENTS: All patients admitted to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport between July 1, 1991, and December 31, 2000, who were younger than 16 years and involved in a motor vehicle crash. MAIN OUTCOME MEASURES: Intensive care complications, postoperative complications, and mortality. RESULTS: We reviewed the experience of all pediatric patients involved in motor vehicle crashes and transported to the Trauma Center at Louisiana State University Health Science Center School of Medicine in Shreveport from July 1, 1991, through December 31, 2000. A total of 191 patients met these criteria. There were 8 deaths, and only 1 of these patients was restrained. There were significantly more injuries in those patients who died compared with those who survived (Modified Injury Severity Score, 29 vs 9; P<.001). We compared the use of restraints in our cohort with the use of restraints in the US pediatric population. Only 20% of our patients were restrained vs 68% of the general pediatric population. This difference was significant (P<.001, chi2) test). CONCLUSIONS: In our population of patients, death was a relatively infrequent occurrence. All patients who died presented in extremis. No patient died as the result of a complication. The rate of seat belt use in our population of patients was low. The exact reason for why we were unable to detect any survival benefit with seat belt use is unclear and demands further investigation.

Use of a human patient simulator for the advanced trauma life support course.

A highly anticipated and rewarding component of the Advanced Trauma Life Support (ATLS) program is the surgical skill station. Logistic, societal, and economic issues have resulted in development of human patient simulators (HPSs) as an alternative to the animal model. We studied initial student reaction to a simulator designed for this skill station. Fourteen participants in an ATLS Provider course completed the standard surgical skill stations and an experimental station using the Simulab Trauma Man HPS. After completion of the stations the students were asked to complete a 13-point satisfaction survey using a modified Likert scale (1 = strongly negative/dissatisfied, 5 = strongly positive/satisfied). Overall response was favorable. Students found the HPS to be superior to the animal model in teaching surgical airways [mean 3.64; standard deviation (SD) 0.93] and for management of pneumothorax (mean 3.86; SD 0.77). The students felt the HPS would be useful in ATLS and should be included as an option in training (mean 4.07; SD 0.92). Preliminary experience with an interactive HPS to teach the ATLS surgical skill station is well received by students when compared with standard methods. This strong acceptance supports inclusion of simulators in teaching ATLS skills.

CT with coronal reconstruction identifies previously missed smaller diaphragmatic injuries after blunt trauma.

Diaphragmatic injuries (DIs) are difficult to diagnose and often go unrecognized after blunt trauma. We proposed that CT scan with coronal reconstruction (CTCR) improves the detection of small DIs missed by chest x-ray (CXR) and CT scan with axial views (CTAX). We performed a retrospective review at a Level I trauma center from 2001 to 2006 and identified 35 patients who underwent operative repair of DI after blunt trauma. The size of the DI and the radiographic test (CXR, CTAX, and CTCR) that identified the defect was compared. Results were analyzed using mean, Mann-Whitney U test, and Fisher exact test. Of the 35 DI repairs, nine were performed after CXR alone and 12 after identification by both a CXR and CTAX. There was no significant difference between the mean DI size identified by CXR with and without CTAX (10.6 vs 9.7, P = 0.88). The remaining 14 DIs were undetected by CXR and CTAX. Seven of these (before CTCR) were found during exploratory laparotomy and seven were identified by CTCR (4.6 cm vs 3.5 cm, P = 0.33). The mean DI size identified by CTCR was significantly smaller than that identified by CXR alone (4.6 cm vs 9.7 cm, P < 0.05) and by CXR and CTAX (4.6 cm vs 10.6 cm, P < 0.0005). CTCR improves the ability to detect smaller DI defects (4 to 8 cm) that were previously missed by CXR and CTAX. CTAX adds little to CXR alone for the diagnosis of large defects (greater than 8 cm).

Long-term physical, mental, and functional consequences of abdominal decompression.

BACKGROUND: The long-term physical, mental, and functional consequences of abdominal decompression for intra-abdominal hypertension are unknown. METHODS: Thirty patients in various stages of abdominal decompression and delayed fascial closure for massive incisional hernia completed the SF-36 Health Survey and answered questions regarding their employment and pregnancy status. RESULTS: Patients awaiting abdominal wall reconstruction demonstrated significantly decreased perceptions of physical, social, and emotional health (p < 0.05), whereas patients who had completed definitive fascial closure demonstrated physical and mental health scores equivalent to the U.S. general population. Ultimately, 78% of patients employed before decompression returned to work. CONCLUSION: Abdominal decompression with skin grafting and delayed fascial closure initially decreases patient perception of physical, social, and emotional health, but subsequent abdominal wall reconstruction restores physical and mental health to that of the U.S. general population. Abdominal decompression does not prevent return to gainful employment and should not be considered a permanently disabling condition.