COVID Stressed, but Not due to the Virus.

INTRODUCTION: Acute care surgeons can experience posttraumatic stress disorder (PTSD) due to the cumulative stress of practice. This study sought to document the potential impact of the COVID-19 pandemic on PTSD in acute care surgeons and to identify potential contributing factors. METHODS: The six-item brief version of the PTSD Checklist-Civilian Version (PCL-6), a validated instrument capturing PTSD symptomology, was used to screen Eastern Association for the Surgery of Trauma members. Added questions gauged pandemic effects on professional and hospital systems-level factors. Regression modeling used responses from attending surgeons that fully completed the PCL-6. RESULTS: Complete responses from 334 of 360 attending surgeons were obtained, with 58 of 334 (17%) screening positive for PTSD symptoms. Factors significantly contributing to both higher PCL-6 scores and meeting criteria for PTSD symptomology included decreasing age, increased administrative duties, reduced research productivity, nonurban practice setting, and loss of annual bonuses. Increasing PCL-6 score was also affected by perceived illness risk and higher odds of PTSD symptomology with elective case cancellation. For most respondents, fear of death and concerns of illness from COVID-19 were not associated with increased odds of PTSD symptomology. CONCLUSIONS: The prevalence of PTSD symptomology in this sample was similar to previous reports using surgeon samples (15%-22%). In the face of the COVID-19 pandemic, stress was not directly related to infectious concerns but rather to the collateral challenges caused by the pandemic and unrelated demographic factors. Understanding factors increasing stress in acute care surgeons is critical as part of pandemic planning and management to reduce burnout and maintain a healthy workforce.

A core outcome set for appendicitis: A consensus approach utilizing modified Delphi methodology.

BACKGROUND: Appendicitis is one of the most common pathologies encountered by general and acute care surgeons. The current literature is inconsistent, as it is fraught with outcome heterogeneity, especially in the area of nonoperative management. We sought to develop a core outcome set (COS) for future appendicitis studies to facilitate outcome standardization and future data pooling. METHODS: A modified Delphi study was conducted after identification of content experts in the field of appendicitis using both the Eastern Association for the Surgery of Trauma (EAST) landmark appendicitis articles and consensus from the EAST ad hoc COS taskforce on appendicitis. The study incorporated three rounds. Round 1 utilized free text outcome suggestions, then in rounds 2 and 3 the suggests were scored using a Likert scale of 1 to 9 with 1 to 3 denoting a less important outcome, 4 to 6 denoting an important but noncritical outcome, and 7 to 9 denoting a critically important outcome. Core outcome status consensus was defined a priori as >70% of scores 7 to 9 and <15% of scores 1 to 3. RESULTS: Seventeen panelists initially agreed to participate in the study with 16 completing the process (94%). Thirty-two unique potential outcomes were initially suggested in round 1 and 10 (31%) met consensus with one outcome meeting exclusion at the end of round 2. At completion of round 3, a total of 17 (53%) outcomes achieved COS consensus. CONCLUSION: An international panel of 16 appendicitis experts achieved consensus on 17 core outcomes that should be incorporated into future appendicitis studies as a minimum set of standardized outcomes to help frame future cohort-based studies on appendicitis. LEVEL OF EVIDENCE: Diagnostic Test or Criteria; Level V.

Evaluation of distracting pain and clinical judgment in cervical spine clearance of trauma patients.

BACKGROUND: The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP). METHODS: This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture. RESULTS: A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %. CONCLUSIONS: The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.

COVID-19 induced PTSD: Stressors for trauma and acute care surgeons.

BACKGROUND: At the peak of the pandemic, acute care surgeons at many hospitals were reassigned to treat COVID-19 patients. However, the effect of the pandemic on this population who are well versed in stressful practice has not been fully explored. METHODS: A web-based survey was distributed to the members of the Eastern Association for the Surgery of Trauma (EAST). PTSD and the personal and professional impact of the pandemic were assessed. A positive screen was defined as a severity score of ≥14 or a symptomatic response to at least 5 of the 6 questions on the screen. RESULTS: A total of 393 (17.8%) participants responded to the survey. The median age was 43 (IQR: 38-52) and 238 (60.6%) were male. The majority of participants were surgeons (351, 89.3%), specializing in general surgery/trauma (379, 96.4%). The main practice type and setting were hospital-based (350, 89%) and university hospital (238, 60.6%), respectively. The incidence of PTSD was 16.3% when a threshold severity score of ≥14 was used and 5.6% when symptomatic responses were assessed. Risk factors for a positive PTSD screen included being single/unmarried (p = 0.02), having others close to you contract COVID-19 (p = 0.02), having family issues due to COVID-19 (p = 0.0004), rural (p = 0.005) and suburban (p = 0.047) practice settings, a fear of going to work (p = 0.001), and not having mental health resources provided at work (p = 0.03). CONCLUSION: The COVID-19 pandemic had a psychological impact on surgeons. Although acute care surgeons are well versed in stressful practice, the pandemic nevertheless induced PTSD symptoms in this population, suggesting the need for mental health resources.

Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah.

BACKGROUND: The objective is to determine the rate of preventable mortality and the volume and nature of opportunities for improvement (OFI) in care for cases of traumatic death occurring in the state of Utah. METHODS: A retrospective case review of deaths attributed to mechanical trauma throughout the state occurring between January 1, 2005, and December 31, 2005, was conducted. Cases were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital and hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for OFI according to nationally accepted guidelines. RESULTS: The overall preventable death rate (frankly and possibly preventable) was 7%. Among those patients surviving to be treated at a hospital, the preventable death rate was 11%. OFIs in care were identified in 76% of all cases; this cumulative proportion includes 51% of prehospital contacts, 67% of those treated in the emergency department (ED), and 40% of those treated post-ED (operating room, intensive care unit, and floor). Issues with care were predominantly related to management of the airway, fluid resuscitation, and chest injury diagnosis and management. CONCLUSIONS: The preventable death rate from trauma demonstrated in Utah is similar to that found in other settings where the trauma system is under development but has not reached full maturity. OFIs predominantly exist in the ED and relate to airway management, fluid resuscitation, and chest injury management. Resource organization and education of ED primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in this mixed urban and rural setting. Similar opportunities exist in the prehospital and post-ED phases of care.

Survey of Surgeons' Perspectives of Wound Care Centers and Chronic Wound Care.

Multidisciplinary management of chronic wounds using comprehensive wound centers improves outcomes. With an increasing need for wound providers, little is known about surgeons' roles in wound centers. An online survey of two national surgical organization members covered demographics, wound center characterization, and surgeons' perspectives of wound centers and wound care. Surgeon perspectives were compared by age, gender, and relationship status. Three hundred sixty-four surgeons responded. Respondents were mostly older than 50 years, male, in practice older than 10 years, and used wound centers. Most respondents reported favorable experiences with wound centers but uncertainty about financial details. Most respondents were interested in formal wound care certification and participation in a wound practice, particularly as a transition to the retirement option for older surgeons. Surgeons are interested in pursuing a career focus in wound care. Further efforts are needed to educate surgeons and create a pathway for surgeons to become wound center directors. In a nationwide survey, surgeon perspectives on wound centers and wound specialization were positive, although financial understanding was limited. The importance of this finding is the support of wound care pathways for surgeons.

Research: questions and answers from academic trauma surgeons.

BACKGROUND: The impact of recent social and professional influences on trauma research is unclear. This study characterizes current research practices, opinions on research quality, and barriers to academic productivity, expressed by academic trauma surgeons. METHODS: A survey tool was administered electronically to members of the Eastern Association for the Surgery of Trauma. Questions on demographics, current and past research experience, perceptions of research quality trends, and barriers to academic success were included. RESULTS: Response rate was 40% (322 of 815). The mean age of respondents was 45 with 73% reporting completion of a critical care fellowship and 63% practicing in a university setting. The majority of respondents agreed or strongly agreed that both basic science (75%) and clinical (82%) research have become more difficult to perform. Greater difficulty in obtaining funding from their institutions was reported by 69% and by 61% for industry or private sources. Approximately 70% agreed that Institutional review board (IRB) regulations, confidentiality and consent requirements have impeded their research efforts whereas 86% agreed that increasing clinical requirements have inhibited their research efforts. Factors seen as impeding multi-institutional research, in order, were funding, IRB issues, poor coordination, commitment of investigators, and logistics. Perceived barriers to a successful research career were insufficient protected time (42%), funding (25%), personal motivation (11%), and IRB issues (11%). CONCLUSION: Research is viewed as being more difficult to conduct. The primary barriers to research productivity are perceived to be decreased protected time, decreased funding availability, and increased regulatory requirements.

A clustering of injury behaviors.

BACKGROUND: Alcohol is a well-known risk factor for injury. A number of other behaviors are also associated with injury risk. We hypothesized that risky drinking would be associated with other high risk behaviors, thereby delineating a need for behavioral interventions in addition to alcohol. METHODS: A consecutive sample of trauma patients was interviewed for drinking and risky behaviors including seat belt use, helmet use, and driving behaviors. The Alcohol Use Disorders Identification Test was used to screen for risky drinking and risky behavior questions were taken from validated questionnaires. Behaviors were ranked on a Likert scale ranging from a low to a high likelihood of the behavior or assessed the frequency of behavior in the past 30 days. An Alcohol Use Disorders Identification Test score of 8 or more was considered risky drinking for adults age 21 to 64, and 4 or more for ages 16 to 20 and over 65. Risky and nonrisky drinkers were compared on behavior risk items. A p value of less than 0.05 was considered significant. RESULTS: One hundred sixty patients (mean age, 36.8 years, 72% men,) were interviewed. Risky drinkers were more likely to drive after consuming alcohol, ride with drinking drivers, tailgate, weave in and out of traffic, and make angry gestures at other drivers (all p < 0.05). Risky drinkers were less likely to wear motorcycle helmets. However, risky drinkers were no more or less likely to talk on the cell phone while driving, to use seatbelts, or use turn signals. Although number of lifetime vehicle crashes were similar, risky drinkers were more likely to have been the party at fault for the crash (mean 1.09 vs. 0.64, p = 0.03). CONCLUSIONS: Factors other than alcohol increase injury risk in problem drinkers. Injury prevention programs performing alcohol interventions should consider including behavioral interventions along with alcohol reduction strategies. New screening and intervention programs should be developed for injury behaviors that increase risk but are not alcohol related.

Broken bones and orthopedist groans: can an acute care surgeon fix both?

BACKGROUND: Increasing reluctance of specialty surgeons to participate in trauma care has placed undue burden on orthopedic traumatologists at Level I trauma centers and prompted the exploration of an expanded role for general trauma surgeons in the initial management of select orthopedic injuries (OI) as an acute care surgeon. This study characterizes OI sustained by trauma patients (TPs) to analyze the feasibility of this concept. METHODS: The National Trauma Data Bank was queried for specific information relating to the profile of OI. International Classification of Diseases-9th Revision codes were used to select patients for the study who sustained OI alone or in combination with other injuries as well as to determine body region of injury and a status of open or closed fractures. Skeletal Abbreviated Injury Scale scores were used to determine the severity of fractures, and International Classification of Diseases-9th Revision procedure codes were used to identify the nature of initial operative management. RESULTS: Of the 1,130,093 patients studied, 557,541 (49%) had one or more reported OI. Open injuries constituted 11.4% of all OIs and occurred in 7.5% of all TPs. Distribution of OIs was 23% upper extremity (18% open) and 35% lower extremity (also 18% open). These represent a 15% and 22% occurrence in TP. Pelvic and acetabular fractures occurred in 13% of OI patients (4% open) and 6% of all TP. The mean skeletal Abbreviated Injury Scale of all OIs was 2.3. For upper extremities it was 2.2, for lower extremities and for pelvic or acetabular injuries it was 2.4. Closed reduction of joint dislocation was performed in 2% of OI and 1% of all TPs. Of these, 45% were on the hip, 8% on the knee, 15% on the ankle, 13% on the elbow, and 20% on the shoulder. The distribution of initial interventions for all patients with OI was irrigation and debridement (I&D) 13%, external fixator (ex-fix) application 25%, closed reduction 41%, and closed joint relocation 10%. Of all open injuries, 17% underwent I&D and 31% underwent ex-fix application. The median time to I&D or ex-fix application was 7.2 hours. One percent of these procedures were performed within 1 hour of hospital admission, 11% within 6 hours of hospital admission. CONCLUSION: OI occur in a significant portion of TP reported to the National Trauma Data Bank. They most commonly involve the lower extremities and are of moderate severity. Given this profile, it seems feasible to propose that some initial procedures can be mastered by nonorthopedic surgeons and that select OI management be within the purview of a properly trained and credentialed acute care surgeon.

Medicare's "Global" terrorism: where is the pay for performance?

BACKGROUND: Medicare and Medicaid Services (CMS) payment policies for surgical operations are based on a global package concept. CMS' physician fee schedule splits the global package into preoperative, intraoperative, and postoperative components of each procedure. We hypothesized that these global package component valuations were often lower than comparable evaluation and management (E&M) services and that billing for E&M services instead of the operation could often be more profitable. METHODS: Our billing database and Trauma Registry were queried for the operative procedures and hospital lengths of stay for trauma patients during the past 5 years. Determinations of preoperative, intraoperative, and postoperative payments were calculated for 10-day and 90-day global packages, comparing them to CMS payments for comparable E&M codes. RESULTS: Of 90-day and 10-day Current Procedural Terminology codes, 88% and 100%, respectively, do not pay for the comprehensive history and physical that trauma patients usually receive, whereas 41% and 98%, respectively, do not even meet payment levels for a simple history and physical. Of 90-day global package procedures, 70% would have generated more revenue had comprehensive daily visits been billed instead of the operation ($3,057,500 vs. $1,658,058). For 10-day global package procedures, 56% would have generated more revenue with merely problem-focused daily visits instead of the operation ($161,855 vs. $156,318). CONCLUSIONS: Medicare's global surgical package underpays E&M services in trauma patients. In most cases, trauma surgeons would fare better by not billing for operations to receive higher reimbursement for E&M services that are considered "bundled" in the global package payment.

Comparison of routine chest radiograph versus clinician judgment to determine adequate central line placement in critically ill patients.

BACKGROUND: Central venous catheterization (CVC) is routine in the management of critically ill patients. However, this procedure has complications, generally mandating a postprocedural chest radiograph (CXR) to confirm adequate position and to rule out procedure-related complications. We sought to determine whether clinician judgment could reliably predict complications and malpositioning after CVC placement, thus obviating the need for a postprocedural CXR on all lines placed. METHODS: Prospective observational study of patients undergoing central line placement in the trauma, surgical, and burn intensive care units during a 12-month period. After placement, a questionnaire addressing comorbidities and the technical aspects of the procedure was completed by the clinician placing the line. The clinical impression regarding line placement was then compared with the findings on a postprocedural CXR. RESULTS: In 147 patients, 209 CVCs were performed (mean age of 52 +/- 21 years). The population was 52% burn and 48% trauma or general surgery patients. The subclavian position was used in 78%. Ninety four percent of CVCs were without complication, whereas 3% were malpositioned and 2% resulted in pneumothorax (one delayed diagnosis at 24 hours). The incidence of complications was associated with level of training of the physician placing the line as well as the number of attempts necessary to access the vein. Clinical judgment correctly identified malpositioning in 20% of cases, and pneumothorax in 67% of cases. The person placing the line thought 68% of the CVCs were uncomplicated (corresponding complication rate 2.3%), whereas 25% thought they were technically difficult (corresponding complication rate 1%), and the remainder thought either they were associated with complications or technically not feasible, all with corresponding complications. Overall, clinical judgment had a sensitivity of 71%, specificity of 44%, positive predictive value of 97%, and negative predictive value of 6%, for an overall accuracy of only 70%. CONCLUSION: Clinical judgment does not reliably predict malpositioning after CVC or the presence of postprocedural complications. Chest X-ray after CVC placement in the critically ill should remain the standard of care.

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

OBJECTIVE: The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR). DESIGN: A prospective observational study was done during a 12-month period. SETTING: The study was conducted in a level I trauma center. PATIENTS: Injured patients meeting trauma team activation criteria were enrolled to the study. INTERVENTIONS: Physical examination findings by a clinician were interpreted and CXR was performed. OUTCOME MEASURES: The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR. RESULTS: Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding. The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR. CONCLUSION: Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.

Acute care surgery fellowship graduates' practice patterns: The additional training is an asset.

BACKGROUND: Over the past decade, the American Association for the Surgery of Trauma Acute Care Surgery (ACS) fellowship program has matured to 20 verified programs. As part of an ongoing curricular evaluation, we queried the current practice patterns of the graduates of ACS fellowship programs regarding their view on their ACS training. We hypothesized that the majority of ACS fellowship graduates would be practicing ACS in academic Level I trauma centers and that fellowship training was pivotal in their career. METHODS: Graduates of American Association for the Surgery of Trauma-certified ACS fellowships completed an online survey that included practice demographics, specific categories of cases delineated by the current ACS curriculum, and perceived impact of training. RESULTS: Surveys were submitted by 56 of 77 graduates for a completion rate of 73%. The majority of respondents were male (68%) aged 40 years or younger (80%). All but four completed ACS fellowship training in last 5 years (93%), and 83% completed fellowship in the last 3 years. Regarding their current practice, broadly defined ACS predominated (96%) with 2% practicing only trauma surgery and 2% only general surgery. Practice settings were 64% urban, 29% suburban, and 7% rural locations, with 84% of graduates practicing in a hospital-based group. The practitioner's hospital was identified as university/university-affiliated in 53%, community in 38%, and military in 9%, with 91% identified as a teaching hospital; trauma designation was identified as Level I (55%), Level II (39%), and other (6%). The graduates' average current practice mix is 10% elective general surgery, 29% emergency general surgery, 32% trauma, 25% surgical critical care, and 4% other (burn, bariatric, vascular, and thoracic). Only 16% of graduates do not perform elective cases. Case specifics demonstrated 92% of graduates perform vascular cases, 88% perform thoracic cases, and 70% perform complex hepatobiliary. Practice elements that were satisfiers included (1) scope of practice, (2) case mix, (3) percentage emergency general surgery, (4) lifestyle, (5) case complexity (with 3 and 4 tied). Graduates agreed the ACS fellowship training prepared them well for practice and was worth the time invested (both 82%), increased their marketability and self-confidence (80%), and prepared them well for academics (71%) and administration (63%). Of those surveyed, 93% would encourage others to do an ACS fellowship. CONCLUSION: Although 93% of graduates practice in urban/suburban areas, there was a mixture of university, university-affiliated, and community institutions and an almost even division of Levels I and II designation. Graduates demonstrate ongoing use of their acquired advanced operative training, particularly in vascular and thoracic surgery. The majority of ACS fellowship graduates were practicing ACS and felt fellowship training was valuable in their career path and that they would recommend it to others.

Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities.

BACKGROUND: In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS: A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for χ exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS: Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION: The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level I; therapeutic care, level II.

Do we need neurosurgical coverage in the trauma center?

The undersupply and maldistribution of neurosurgeons coupled with the apparent abandonment of trauma care by a significant number of rank and file neurosurgeons, and perhaps an over demand for their services, has created a crisis in access to neurotrauma care across the country. There is evidence to support that the immediate availability of a neurosurgeon to participate in the care of all trauma patients, including those who have documented head injury, may not be essential to providing optimal care, calling the American College of Surgeons' mandated criterion for trauma center verification into question. Given the volume, nature, and timeliness of head injury and its care, it seems this crisis can be resolved to a great extent by having trauma surgeons or other properly trained, credentialed, and monitored providers assume nonoperative, in-patient neurotrauma care when hospital admission is actually indicated. Although part of the solution lies in increased supply of neurotrauma services regardless of provider type, a second component rests in decreasing demand for these services in cases of mild and extremely severe head injury. Such a solution seems feasible and advantageous in several respects and should be seriously considered by healthcare policy makers, trauma system planners, and the leaders of the neurosurgical and trauma surgery disciplines. What is truly needed in hospitals treating trauma patients (ie, trauma centers) is a philosophy centered on patient services rather than the specific provider. What is needed is a provider who is committed, capable, and competent, who recognizes and meets the patients' needs and provides the appropriate services. These providers, regardless of pedigree, must be supported and valued by the healthcare system and society. In the future this may require regionalization of services. In some hospitals and systems the primary person responsible for providing these services will be a neurosurgeon. In others, it may not and perhaps need not be.

Cervical spine clearance when unable to be cleared clinically: a pooled analysis of combined computed tomography and magnetic resonance imaging.

BACKGROUND: The role of cervical spine magnetic resonance imaging (MRI) in the evaluation of clinically unevaluable blunt trauma patients has been called into question by several recent studies. METHODS: A PubMed search was performed for all studies comparing computed tomography and MRI in the assessment of the cervical spine in patients who cannot be evaluated clinically. The radiologic findings and clinical outcomes from each study were collated for analysis. RESULTS: Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an MRI. There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention. CONCLUSIONS: MRI identifies additional injuries; however, the vast majority are of minor clinical significance. Routine MRI after a negative computed tomography of the cervical spine is not supported by the current literature.