Mathematical modeling to define optimum operating room staffing needs for trauma centers.

BACKGROUND: Level II trauma centers may be verified (1999, American College of Surgeons Committee on Trauma) with an on-call operating room team if the performance-improvement program shows no adverse outcomes. Using queuing and simulation methodology, this study attempted to add a volume guideline. STUDY DESIGN: Data from 72 previously verified trauma centers identified multiple demographic factors, including specific information about the first trauma-related operation that was done between 11:00 PM and 7:00 AM each month for 12 consecutive months. RESULTS: The annual admissions averaged 1,477 for 37 Level I trauma centers, 802 for 28 Level II trauma centers, 481 for 4 Level III trauma centers, and 731 for 3 pediatric trauma centers. The annual admissions correlated with the number of operations done between 11:00 PM and 7:00 AM (p < 0.001). These 946 operations were performed by general surgery (39%), neurosurgery (8%), orthopaedic surgery (33%), another specialty (9%), or multiple services (10%). Admission to operation time was within 30 minutes for 12.1% of patients (2.6% for blunt and 24.1% for penetrating injuries). The probability of operation within 30 minutes of arrival varied with the number of admissions and with the percentage of penetrating versus blunt injuries. The likely number of operations from 11:00 PM to 7:00 AM would be 19 for 500 annual admissions, 26 for 750 annual admissions, and 34 for 1,000 annual admissions, with 5.83, 7.98, and 10.13 patients, respectively, going to operation within 30 min. The probability that two rooms would be occupied simultaneously was 0.14 and 0.24 for centers admitting 500 and 1,000 patients, respectively. CONCLUSIONS: Trauma centers performing fewer than six operations between 11:00 PM and 7:00 AM per year could conserve resources by using an immediately available on-call team, with responses monitored by the performance-improvement program.

Surgical management of the acutely obstructed colon. A review of 127 cases.

The surgical results in 127 cases of acute obstruction of the colon are presented. Carcinoma continues to account for the overwhelming number of cases, and there has been no appreciable change in the site of obstruction or age groups affected. In the current study, the overall mortality rate in patients with acute obstruction from all causes was 27 percent, which does not appear to be significantly different than it was 30 years ago. The overall mortality rate in patients with obstruction secondary to carcinoma was 23 percent. Under the specific circumstances of the cases reported herein, and on the basis of a limited experience, total colectomy and left colectomy as initial procedures in acute obstruction secondary to cancer had the same mortality rate as staged resection of the left colon. The only benefit found from either approach was an increase in the disease-free 5 year survival rate with staged resection. The overall survival rate was not enhanced by either approach.

Enterocutaneous fistulas following laparotomy for trauma.

Enterocutaneous fistulas (ECF) are recognized complications of various bowel diseases. Trauma is reported as a rare cause of ECF. ECF following laparotomy for abdominal injury was studied in 15 patients to determine whether traditional principles of management for ECF are applicable in posttraumatic ECF. Thirty-three per cent of patients with posttraumatic ECF spontaneously healed fistulas with appropriate nutritional support without operative intervention. Sixty-six per cent of patients required operative intervention, either because of associated sepsis or failure to spontaneously heal. Five patients had fistulas originate from areas of bowel not injured in the initial injury. This study suggests traditional principles of management for ECF are applicable in ECF following laparotomy for abdominal injury and result in a spontaneous closure of fistulas in one-third of patients. In addition, sepsis is the main indication for early aggressive operative treatment of these fistulas.

Surgical management of chronic pain from chronic pancreatitis.

Chronic pain from chronic pancreatitis remains a difficult clinical problem. We present the results of surgical attempts to control this pain. For the past 3 years, all patients with chronic pancreatitis and pain requiring high-dose narcotics or hospitalization for pain control were evaluated by the following algorithm. Any anatomic pathology causing ductal dilatation was surgically addressed first (Puestow's procedure, pseudocyst drainage, or sphincteroplasty). If there was no evidence of ductal dilatation, or if pain recurred postoperatively, denervation procedures were performed (splenopancreatic flap, thorascopic sympathectomy, or resection). Pain recurrence was defined as the need for further hospitalization or reoperation. Data were analyzed by comparison of two proportions. Follow-up averaged 26 months. Thirty-seven patients underwent 44 operations solely in an attempt to control pain; 62 per cent were male, and 70 per cent had chronic alcoholic pancreatitis. Our results show that surgical management provides relief in 68 per cent of patients, and no one procedure is clearly superior to others.

The natural history of extremity venous repair performed for trauma.

Surgical repair of extremity venous injuries remains controversial. Literature supports both ligation and repair when analyzed for functional recovery. However, few studies review the natural history of venous repair for trauma. Twenty patients were prospectively enrolled in a protocol of immediate repair of major extremity veins. Simple venorraphy and complex reconstructions were performed at the discretion of the operative team. Patients were studied by contrast venogram on postoperative day 3 and 6 weeks after surgery. Patients with occluded repairs at 3 days received a 5-day course of intravenous anticoagulation and were discharged. Overall, patency at 3 days was 55 per cent and increased to 88 per cent at 6 weeks (P < 0.02). Lateral venorraphy and direct reapproximation had higher patency rates than complex repairs at 6 weeks (92% versus 50%; P < 0.05). All veins that were patent at 3 days remained patent (correlation coefficient 1.0). Repair of traumatized extremity veins carries minimal morbidity and has a high rate of early and eventual patency. Long-term anticoagulation in the face of early thrombosis is unnecessary.

The use of serum amylase and lipase in evaluating and managing blunt abdominal trauma.

In order to determine the usefulness of serum amylase and lipase in the initial evaluation and subsequent management of blunt abdominal trauma (BAT) patients, we collected serum amylase and lipase on 85 consecutive BAT patients at admission, hospital day 1, hospital day 3, and hospital day 7. Only one patient had a pancreatic injury. A total of 45 patients (53%) had at least one enzyme abnormality during the study. There was no correlation between amylase or lipase values and age, sex, type of injury, diagnostic tests, operation, and outcome. In a control group of nonabdominal-trauma patients with admit studies only, all enzyme values were normal. We conclude that serum amylase and lipase are randomly elevated in patients with nonpancreatic-BAT both initially and during subsequent hospitalization and are not useful clinical tools in these patients.

Trauma care in Louisiana: problems and possibilities.

Trauma is a major national health problem and is the leading cause of death for Americans under the age of 44. Data about the impact of trauma in Louisiana is lacking and there are currently no statewide initiatives for improving trauma care. Louisiana State University Medical Center Hospital in Shreveport (LSUMCH) has recently been licensed and designated by the state as a "primary trauma center." Additionally, the city of Shreveport has enacted a trauma system which preferentially transports major trauma victims to LSUMCH. This is the only such center and system in the state. Based on this experience, it is suggested that development of a network of trauma centers utilizing the resources of the main state teaching hospitals may be a feasible means to upgrade and enhance trauma care in the state.

Firearm injury in Orleans parish: a 24-month perspective.

This study is a retrospective review of all gunshot wounds treated at Charity Hospital, the Orleans Parish designated trauma center, for the 24-month period from November 1993 to November 1995. Its purpose was to define the magnitude of firearm injury in the parish and the impact on the health care system. One-thousand-six-hundred-sixty-nine gunshot wounds were analyzed. Most involved African-American males. Twenty percent were fatal. Two-thousand-forty-three emergent operations were performed. Ten percent of surviving patients had some permanent disability, 6% required institutional care. In 760 patients, initial hospital charges totaled $5,153,516. Extrapolation of these figures to the entire group yields an initial hospital cost of $11,317,392. Transport by the "911" system and in-house trauma team activation were required in most patients. In summary, firearm injury poses a serious economic problem and is a substantial drain on health care providers and their resources.

Blunt thoracic aortic injuries: initial evaluation and management.

In at least one large study, the average time from arrival at the emergency department to arrival in the operating room was nearly 6 hours. That 30% of survivors will die in the same amount of time underscores the need for rapid diagnosis and treatment. In blunt thoracic aortic injury, beta-blockers have been shown to reduce the incidence of rupture, and their use is rarely contraindicated. A working knowledge of the mechanisms of injury likely to produce this lesion, commonly associated injuries, clinically relevant and easily recognizable chest film findings, and appropriate use of beta-blockade can have a significant impact on mortality. Any physician responsible for evaluation of trauma patients should be familiar with this information.

Retrohepatic vein injuries: experience with 20 cases.

The mortality for injury of the retrohepatic veins is reported to vary from 50 to 100%. The use of hepatic bypass techniques, introduced in the 1960's, has not significantly decreased this mortality. We reviewed our experience with liver injuries over a 5-year period from 1982 to 1987 to determine our results with these particular injuries. Twenty patients had retrohepatic vein injuries. There were 11 patients with penetrating trauma and nine with blunt trauma. A total of 15 patients died, for a mortality rate of 75%. Fourteen patients died intraoperatively from exsanguination and one postoperatively from sepsis. A shunt was used in an attempt to bypass the injury in ten patients, with nine deaths. In the ten remaining patients who were not shunted, there were six deaths. Thus, in ten shunted patients the mortality was 90% and in ten non-shunted patients, 60%. Our review supports other studies reporting a lower mortality by direct exposure and repair of retrohepatic vein injuries. Although total vascular occlusion of the liver may not be well tolerated in hypotensive patients, rapid application of the above approach resulted in better patient survival than the use of shunts.

Acinetobacter calcoaceticus pneumonia and the formation of pneumatoceles.

Pneumatoceles are cystic lesions of the lungs often seen in children with staphylococcal pneumonia and positive-pressure ventilation. Acinetobacter calcoaceticus is an aerobic, short immobile gram-negative rod, or coccobacillus, which is an omnipresent saprophyte. The variant anitratus is the most clinically significant pathogen in this family, usually presenting as a lower respiratory tract infection. Acinetobacter has been demonstrated to be one of the most common organisms found in the ICU. We present three critically ill surgery patients with Acinetobacter pneumonia, high inspiratory pressures, and the subsequent development of pneumatoceles. One of these patients died from a ruptured pneumatocele, resulting in tension pneumothorax. Treatment of pneumatoceles should center on appropriate intravenous antimicrobial therapy. This should be culture directed but is most often accomplished with Imipenem. Percutaneous, computed tomographic-guided catheter placement or direct tube thoracostomy decompression of the pneumatocele may prevent subsequent rupture and potentially lethal tension pneumothorax.

A new technique for exposure of injuries at the confluence of the retrohepatic veins and the retrohepatic vena cava.

Because of difficulties in rapid exposure and control, injuries of the retrohepatic veins and retrohepatic vena cava continue to have mortality rates approaching 100%. Current strategies include shunt and finger fracture techniques, with controversy continuing over the optimal approach. We describe a new technique which involves mobilization of the liver by transecting the superhepatic vena cava, and affords a posterior approach to these injuries. Cadaveric dissection and clinical experience are described.

The use of segmental anatomy for an operative classification of liver injuries.

There is no universally accepted standard classification for liver injuries, and thus accurate comparison of reports on the subject is impossible. Most published reports on liver trauma suggest that both morbidity and mortality have a linear correlation with not only the amount of liver parenchyma injured but also with the magnitude of the surgical intervention. The exceptions are retrohepatic vein injuries, which have a mortality independent of associated parenchymal injury but should be integrated in any classification of liver injury. The classification proposed is based on the segmental anatomy of the liver (as defined by Couinaud): Grade I--Injuries requiring no operative intervention, or any injury that requires operative intervention limited to a segment or less. Grade II--Any injury that requires operative intervention involving two or more segments. Grade III--Any injury with an associated juxta- or retrohepatic vein injury. We reviewed all patients with isolated liver injuries during the past 5 years and prospectively reviewed all patients for the 6-month period from January to June 1988 and applied this classification. Sixty-nine patients had grade I injuries, with one death (1%); thirteen patients had grade II injuries, with six deaths (46%); and 13 patients had grade III injuries with nine deaths (69%). Postoperative morbidity was 7% for grade I, 57% for grade II, and 50% for grade III. This study supports the conclusion that morbidity and mortality from liver injury are directly related to the volume of parenchyma involved, and that segmental anatomy can be applied to define this volume. Mortality from retrohepatic vein injuries is independent of associated parenchymal injury. We believe that this proposed classification will provide a simple, reproducible, and accurate means for reporting and comparing liver injuries.

Timing and dosage of postoperative radiotherapy for squamous cell carcinoma of the upper aerodigestive tract.

Seventy patients who received postoperative irradiation (PI) after curative surgery for stage III or IV squamous cell carcinoma of the upper aerodigestive tract were studied retrospectively to compare the rate of local and regional recurrence (LRR) and the effect of total dose on LRR rate in patients irradiated timely (n = 40) with those who were not (n = 30). Overall, the LRR rate was higher when PI was delayed than when timely (37% vs 20%). No advantage resulted from increasing total dose when PI was delayed; the LRR rate in the primary site and upper neck was 18% with less than 60 Gy and was 26% with 60 Gy or more; the LRR rate in the lower neck was 13% with 50 Gy or less and was 14% with more than 50 Gy. These data seem to corroborate the findings of other investigators regarding the importance of initiating timely PI, but not the observation that a pronounced delay is not detrimental provided higher tumoricidal doses are used.

Early evacuation of clotted blood in hemothorax using thoracoscopy: case reports.

Hemothorax complicated by clotting of the blood is traditionally treated with thoracotomy. Successful treatment using early thoracoscopy in two patients is described. A third patient, in whom thoracoscopic evacuation failed, is also discussed. Early timing of the procedure appears to enhance the opportunity for adequate drainage of the thorax with lung re-expansion.

Duplex ultrasonography versus arteriography in the diagnosis of arterial injury: an experimental study.

Duplex ultrasonography (DUS) and arteriography (ART) were evaluated using an experimental model of arterial trauma in order to determine the accuracy of DUS compared with ART and to define the characteristic ultrasonographic features of arterial injuries. Occlusions (n = 19), blunt injuries (n = 24), lacerations (n = 25), arteriovenous fistulae (n = 13), or no injuries (sham, n = 19) were surgically created in the femoral and carotid arteries of 25 dogs. Following closure of the incisions, DUS was performed and interpreted by a staff vascular surgeon without knowledge of the presence or type of injury. Biplane selective ART was evaluated by an independent staff radiologist. Although DUS and ART were equally accurate in evaluating arterial injuries, DUS was more sensitive (90.1% +/- 3.3% versus 80.2% +/- 4.4%, p = 0.002) and better at identifying lacerated arteries (p = 0.01). However, ART had greater specificity (94.7% +/- 5.1% versus 68.4% +/- 10.7%, p = 0.04) and was more accurate for identifying normal arteries (p = 0.04). The validity of DUS increased in the latter half of the study, thus demonstrating a learning curve. Duplex ultrasonography was a more sensitive screening modality than ART for evaluating arterial injuries in our experimental model, thereby supporting its use in clinical trials to evaluate its accuracy, reliability, and cost effectiveness in the trauma setting. Furthermore, management decisions can be based on the specific type of injury, pathologic condition of the arterial wall, and hemodynamic factors identified by DUS. Clinically occult arterial injuries can be followed by repeat DUS to define the natural history of these injuries.

Whipple procedure for trauma: is duct ligation a safe alternative to pancreaticojejunostomy?

The use of pancreatic duct ligation (DL) during a Whipple procedure for trauma has been reported but not analyzed. We reviewed 13 cases of DL and compared the results with that reported for the Whipple procedure for trauma with pancreaticojejunostomy (PJ). The mortality rate of DL was 53.8%. Pancreatitis occurred in three cases (23.1%) and caused one death. Pancreatic fistulae occurred in 50% of patients surviving two or more days after DL. No long-term survivor developed overt diabetes mellitus. Malabsorption occurred in 50% of the long-term survivors of DL. When the DL and PJ groups were compared no statistically significant difference could be found in either mortality or pancreatic morbidity. The 46.2% survival rate for DL warrants its consideration as a technique available to trauma surgeons when faced with an unstable patient unable to tolerate further operative therapy.

Management of penetrating colon injuries. A prospective randomized trial.

Fifty-six patients with penetrating colon injuries were entered into a randomized prospective study. Management of the colon injury was not dependent on the number of associated injuries, amount of fecal contamination, shock, or blood requirements. Twenty-eight patients were treated with primary repair or resection and anastomosis and 28 patients were treated by diversion (24 colostomy, 3 ileostomy, 1 jejunostomy). The average Penetrating Abdominal Trauma Index score was 23.9 for the diversion group and 26 for the primary repair group. There were five (17.9%) septic-related complications in the diversion group. This included four intra-abdominal abscesses and one subcutaneous wound infection. There were six (21.4%) septic-related complications in the primary repair group. This included one wound infection, two positive blood cultures, and three intra-abdominal abscesses. There were no episodes of suture line failure in the primary repair/anastomosis group. The authors conclude that, independent of associated risk factors, primary repair or resection and anastomosis should be considered for treatment of all patients in the civilian population with penetrating colon wounds.

Accuracy of administrative data in trauma: splenic injuries as an example.

BACKGROUND: Accurate data are needed to evaluate clinical outcomes, therapeutic modalities, and quality of care in trauma. Administrative data, usually used for billing, have been used to evaluate performance and assess therapy in other medical specialties. This study was performed to determine whether administrative databases are accurate in the recording of information about trauma patients with splenic injuries. METHODS: Patients who had blunt splenic injuries were identified using a state trauma registry. The medical records of those patients were reviewed. The data collected by chart review were compared with data in the statewide administrative database of patients who had splenic injuries at the same four Level I and II trauma centers in the same 5-year period. Age, sex, admission date, and hospital were matched to assure comparison of the identical cohort. chi2 analysis was used to compare dichotomous data and Student's t test continuous data. RESULTS: The administrative database identified 641 and the trauma registry identified 529 patients with a diagnosis of splenic injury. A total of 401 patients were found in both databases. Of these, 120 (22.7%) patients were not recorded in the administrative database. Injury Severity Score was underreported by the administrative database (25.74 +/- 14.7 vs. 19.52 +/- 11, p < 0.0001). The administrative database underreported orthopedic, chest, and head injuries (317 vs. 215, 325 vs. 228, and 234 vs. 155, respectively; all p < 0.0001). Use of abdominal computed tomographic scan and diagnostic peritoneal lavage were also underreported (260 vs. 56 and 104 vs.17, both p < 0.0001). The number of operations on the spleen and number of orthopedic procedures were underreported (259 vs. 225, p < 0.014 and 147 vs. 94, p < 0.0001). Complications were markedly underreported by the administrative database (200 vs. 47, p < 0.0001) CONCLUSION: This study shows that administrative data lack accuracy in the recording of associated injuries, injury severity, diagnostics, procedures, and outcomes data in patients with splenic injuries. Whether these data should be used to evaluate treatment modalities or quality of care in trauma is questionable.

The effect of trauma program registry on reported mortality rates.

BACKGROUND: This study assesses the relationship that the brand of trauma program registry (TPR) has on mortality rate (MR) in the reports prepared by the American College of Surgeons Committee on Trauma (ACSCOT) trauma center (TC) site surveyors. METHODS: Data from 242 ACSCOT adult TC survey reports (88 Level I, 115 Level II, and 39 Level III) were analyzed for annual trauma volume, injury severity score (ISS), MR, and TPR. Six TPR (A through F) were identified; group F was a composite of several infrequently used TPRs. This report focuses on the ISS range 16-24 because of the likelihood that the mean for each TC would be near 20 and MR is high enough so that a difference, if present, could be statistically documented. RESULTS: For the total group, MR showed no correlation with TC volume or TC level for ISS 16-24. MR was significantly different according to which TPR was used by the TCs. The MR is less (4.8%) for 14 high volume TCs (over 1200 admits) using TPR A compared with 33 low volume TCs (below 800 admits) using TPR A (6.34%). CONCLUSION: The MR for ISS 16-24 in ACSCOT-surveyed TCs differs within subgroups based on type of TPR utilized. This may reflect improper use of the software programs. Enhanced skill in the application of software programs designed to generate ISS scores is essential if meaningful studies on the effects of improved trauma care on MR are to be conducted. Hand scored ISS by trained personnel may circumvent this problem.