Telemedicine and telepresence for trauma and emergency care management.

The use of telemedicine is long-standing, but only in recent years has it been applied to the specialities of trauma, emergency care, and surgery. Despite being relatively new, the concept of teletrauma, telepresence, and telesurgery is evolving and is being integrated into modern care of trauma and surgical patients. This paper will address the current applications of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application. The University Medical Center and the Arizona Telemedicine Program (ATP) in Tucson, Arizona have two functional teletrauma and emergency telemedicine programs and one ad-hoc program, the mobile telemedicine program. The Southern Arizona Telemedicine and Telepresence (SATT) program is an inter-hospital telemedicine program, while the Tucson ER-link is a link between prehospital and emergency room system, and both are built upon a successful existing award winning ATP and the technical infrastructure of the city of Tucson. These two programs represent examples of integrated and collaborative community approaches to solving the lack of trauma and emergency care issue in the region. These networks will not only be used by trauma, but also by all other medical disciplines, and as such have become an example of innovation and dedication to trauma care. The first case of trauma managed over the telemedicine trauma program or "teletrauma" was that of an 18-month-old girl who was the only survival of a car crash with three fatalities. The success of this case and the pilot project of SATT that ensued led to the development of a regional teletrauma program serving close to 1.5 million people. The telepresence of the trauma surgeon, through teletrauma, has infused confidence among local doctors and communities and is being used to identify knowledge gaps of rural health care providers and the needs for instituting new outreach educational programs.

The National Survey of Family Growth, Cycle IV, evaluation of linked design.

Research was undertaken to quantify the effects of costs of alternative methods for selecting sample women for the National Survey of Family Growth (NSFG) from the National Health Interview Survey (NHIS). This report presents estimates of the effects of alternative design options, obtained by statistical modeling techniques, for linking the NSFG with the NHIS; the cost data and the statistical precision of estimates were based on data from the NSFG, Cycle IV. The estimated survey costs and projected response rates for alternative linked design options and for the unlinked design are compared for fixed precision. The findings confirm that substantial gains in the NSFG design efficiency were obtained by linking the NSFG sample design to that of the NHIS.

PIP: This article describes the research methodology used in Cycle IV of the National Survey of Family Growth (NSFG). The NSFG used a subsample of women living in households that participated in the National Health Interview Survey (NHIS), which is a continuous survey in 198 metropolitan areas and clusters of nonmetropolitan counties in the United States. Chapter 1 is devoted to a description of the sampling design and subsampling design, respectively, of the NHIS and NSFG. An intensive follow-up was conducted among a 50% subsample of nonresponse cases. Chapter 2 covers a discussion of the application of "balanced repeated replications," which was the technique used to estimate within-unit variance and within-segment variance. In general the between-segment variance was small for most estimates. There was a 7% between-primary-sampling-unit (PSU) variance for all races combined and an 11% between-PSU variance for Black women. Chapter 3 includes a presentation of a theoretical model of the variance of a ratio-adjusted estimate. The effects of variation in weights is discussed. A fitted model for design effects was compared to a direct design effects model. The aim of examining design effects was to provide a comparison of NSFG and NHIS linked and unlinked designs. Chapter 4 considers four designs which vary in the number of PSUs, the number of segments, the number of designated households, the number of designated women from those households, and the number of interviewed women. The design effect of oversampling of strata with a high proportion of Blacks was calculated. The number of women that would have to be interviewed was calculated in an unlinked design in order to attain the same precision comparable to a linked Cycle IV design. Chapter 5 gives the direct costs for each of the four design options for 10 activities in data collection.

National Survey of Family Growth: design, estimation, and inference.

The purpose of this report is to document the procedures used in the 1988 National Survey of Family Growth (NSFG) to select the sample, weight the data to produce national estimates, impute missing data, and estimate sampling errors. Therefore, this report necessarily contains a great deal of technical detail. For readers who do not need this level of detail, this summary briefly describes the procedures used. The National Survey of Family Growth is conducted every few years by the National Center for Health Statistics (NCHS), a part of the U.S. Department of Health and Human Services. The purpose of the survey is to collect and publish data from a national sample of women on childbearing, factors affecting childbearing (such as contraception, sterilization, and infertility), and related aspects of maternal and infant health. Interviewing for Cycle IV of the survey was done in 1988 by Westat, Inc., under a contract with NCHS. Personal interviews were conducted between January and August of 1988 with a national sample of 8,450 women in the civilian noninstitutionalized population of the United States. Interviews were conducted in person by trained female interviewers and lasted an average of 70 minutes. The interview focused on the woman's pregnancies, if any; her use of contraception; her ability to bear children (fecundity and infertility); her use of medical services for family planning, infertility, and prenatal care; her marriage and cohabitation history, if any; and a wide range of demographic and economic characteristics. This report describes some of the main methodological aspects of the survey, including the sample design, weighting, sampling errors, and imputation of missing data. These topics will be described briefly and less technically in this summary. Each topic is discussed in more detail in the rest of the report.

Spontaneous multivessel coronary artery dissection: repeated presentation in a healthy postmenopausal woman.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction which is infrequently diagnosed antemortem. Most previously reported cases were found in women of whom a significant proportion presented during pregnancy or the postpartum period. We describe the first antemortem case of spontaneous coronary artery dissection, unrelated to pregnancy or the postpartum state, which ultimately resulted in diffuse involvement of both the left and right coronary arteries over a period of 4 months. Pathophysiology and case management of this disorder are discussed.

Rethinking bicycle helmets as a preventive tool: a 4-year review of bicycle injuries.

INTRODUCTION: Traumatic brain injury is a leading cause of disability in bicycle riders. Preventive measures including bicycle helmet laws have been highlighted; however, its protective role has always been debated. The aim of this study was to determine the utility of bicycle helmets in prevention of intra-cranial hemorrhage. We hypothesized that bicycle helmets are protective and prevent the development of intra-cranial hemorrhage. METHODS: We performed a 4-year (2009-2012) retrospective cohort analysis of all the patients who presented with traumatic brain injury due to bicycle injuries to our level 1 trauma center. We compared helmeted and non-helmeted bicycle riders for differences in the patterns of injury, need for intensive care unit admissions and mortality. RESULTS: A total of 864 patients were reviewed of which, 709 patients (helmeted = 300, non-helmeted = 409) were included. Non-helmeted bicycle riders were more likely to be young (p < 0.001) males (p = 0.01). There was no difference in the median ISS between the two groups (p = 0.3). Non-helmeted riders were more likely to have a skull fracture (p = 0.01) and a scalp laceration (p = 0.01) compared to the helmeted riders. There was no difference in intra-cranial hemorrhage between the two groups (p = 0.1). Wearing a bicycle helmet was not independently associated (p = 0.1) with development of intra-cranial hemorrhage. CONCLUSION: Bicycle helmets may have a protective effect against external head injury but its protective role for intra-cranial hemorrhage is questionable. Further studies assessing the protective role of helmets for intra-cranial hemorrhage are warranted.

Health resources on the Internet: a basic list.

With the plethora of health sites on the Internet, it is sometimes hard to know where to start. This is a basic list of health sites that either cover a subject area comprehensively, or are good general sites to lead to more specific information. Most of these sites include both full-text information as well as links to many other sites on the World-Wide Web. Included are medical, nursing, dental, alternative health, consumer health, organization, and government sites.

Rapid admixture blood warming.

A new technique of admixture blood warming allows rapid warming of packed red blood cells by the addition of heated saline. Each 4 degrees C unit of packed red blood cells is mixed with 250 ml of 70 degrees C saline. Diluted blood at 37 degrees C is ready for transfusion in less than 30 seconds.

A dual frame design for sampling elderly minorities and persons with disabilities.

Multiple data sources are sometimes available as potential sampling frames for population surveys, and in some situations the use of a multiple frame sample design is more advantageous than using a single sampling frame. The use of multiple sampling frames, however, has variance and bias implications, as well as sampling, data collection, and logistical considerations. These issues are addressed for a proposed dual frame sampling approach in the National Health Interview Survey (NHIS). The results of an investigation of the sampling efficiencies and operational issues in supplementing the NHIS area frame sample with a sample of elderly African and Hispanic Americans and persons with disabilities selected from Social Security Administration files are presented.

Standards for reference services in health sciences libraries: the reference product.

Standards for reference services were prepared by a committee of the Oregon Health Sciences Libraries Association (OHSLA). The standards are qualitative and address the following: quality control, appropriateness, accuracy, documentation, timeliness, accessibility, confidentiality, and evaluation. The standards are components of minimally competent reference service as reflected in the reference product. A discussion of concerns and prescriptive measures accompanies the statement of each standard. While prepared specifically for health sciences libraries, the standards are applicable to all types of libraries and may be used as guidelines in evaluating the reference product, in upgrading library service, and in writing policies and procedures.

Efficacy of prehospital surgical cricothyrotomy in trauma patients.

OBJECTIVE: The use of surgical cricothyrotomy (SC) in the prehospital setting is controversial, and the need to teach this procedure to paramedics and intermediate emergency medical technicians remains unclear. The purpose of this study is to define the efficacy, complication rate, and overall survival after SC performed in the prehospital setting. METHODS: In our region, emergency medical technicians receive training in this technique using an animal model with bi-annual updates required. We retrospectively reviewed data in our regional trauma register (15,686 injured patients) for the years 1991-1995. RESULTS: Prehospital emergency airway intubation was required in 376 patients, 56 of whom received SC. The primary indications for SC were facial fractures and deformities (32%) and blood in the airway (30%). In 79% of the patients requiring SC, attempted orotracheal intubation prior to SC was unsuccessful, with a mean of 1.9 attempts per patient. SC was judged to provide an adequate airway in the field in 89% of attempts. Complications at the scene included six failed attempts, one case of excessive bleeding, and one adverse patient reaction (agitation). When patients arrived at the trauma center, the SC was judged to be acceptable in 64%, whereas 16% were functioning with some question of adequacy and required airway manipulation (most commonly a mainstem bronchial intubation). Overall survival to hospital discharge was 27%; however, survival to emergency department discharge (an indicator of emergency airway adequacy) was 62%. Using TRISS methodology, there were five unexpected survivors and six unexpected deaths. Only three patients were discharged with a "good neurologic recovery." CONCLUSION: (1) Prehospital SC can be performed effectively with few complications after training on animal models (2) Good neurologic outcome is rare after the use of this procedure. (3) Although it is effective, clear indications must be developed and followed for the prehospital use of SC.

A prospective investigation of the impact of alcohol consumption on helmet use, injury severity, medical resource utilization, and health care costs in bicycle-related trauma.

STUDY OBJECTIVE: To examine if a relationship exists between bicycle-related injuries, consumption of alcohol, helmet use, and medical resource utilization. DESIGN: A prospective cohort study with data from emergency department, operating room, and inpatient records. SETTING: University-based trauma center in a medium-sized metropolitan area. TYPE OF PARTICIPANTS: Adult victims (age > or = 18 years) of bicycle-related injury presenting to the emergency department. A total of 350 patients made up the study population. RESULTS: Group 1 consisted of 29 patients (8.3%) with detectable blood alcohol levels at the time of the incident. Group 2 (321 patients) had a measured blood alcohol level of 0 or no clinical indication of alcohol consumption. Group 1 mean Injury Severity Score was 10.3, with six (20.7%) sustaining at least one severe anatomic injury. Group 2 had an Injury Severity Score of 3.3 (p < 0.0001), with only 4.4% (p = 0.0013) sustaining severe anatomic injury. Mean length of hospitalization for group 1 was 3.5 days, including a mean of 1.4 intensive care unit days. Mean hospitalization (0.5 days, p < 0.0001) and intensive care unit (0.1 days, p < 0.0001) were significantly lower in group 2. Mean combined hospital and physician charges were more than six times greater for group 1 ($7,206) than group 2 patients ($1170, p < 0.0001). CONCLUSION: In patients presenting with bicycle-related injuries, prior consumption of alcohol is highly associated with greater injury severity, longer hospitalization, and higher health care costs. This information is useful in the development of injury prevention strategies to decrease incidence and severity of adult bicycle injuries.

Fatal trauma: the modal distribution of time to death is a function of patient demographics and regional resources.

BACKGROUND: Unlike previous studies in an urban environment, this study examines traumatic death in a geographically diverse county in the southwestern United States. METHODS: All deaths from blunt and penetrating trauma between November 15, 1991, and November 14, 1993, were included. As many as 150 variables were collected on each patient, including time of injury and time of death. Initial identification of cases was through manual review of death records. Information was supplemented by review of hospital records, case reports, and prehospital encounter forms. RESULTS: A total of 710 traumatic deaths were analyzed. Approximately half of the victims, 52%, were pronounced dead at the scene. Of the 48% who were hospitalized, the most frequent mechanism of injury was a fall. Neurologic dysfunction was the most common cause of death. Two distinct peaks of time were found on analysis: 23% of patients died within the first 60 minutes, and 35% of patients died at 24 to 48 hours after injury. CONCLUSIONS: Although there appears to continue to be a trimodal distribution of trauma deaths in urban environments, we found the distribution to be bimodal in an environment with a higher ratio of blunt to penetrating trauma.