Diana L. Handrahan

The laparoscopic management of appendicitis and cholelithiasis during pregnancy

BACKGROUND Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy remains controversial. We report the single largest series of laparoscopic cholecystectomies and appendectomies during pregnancy. METHODS Medical records of all pregnant patients who underwent open or laparoscopic management of appendicitis/cholelithiasis at LDS Hospital from 1990 to 1998 were reviewed. RESULTS Eighteen open appendectomies (OA) and 13 open cholecystectomies (OC) were performed. Forty-five laparoscopic cholecystectomies (LC) and 22 laparoscopic appendectomies (LA) were performed without birth defects, fetal loss or uterine injury. Preterm delivery rates (PTD) in the LA and OA groups were similar (15.8% versus 11.8%, P>0.9). The PTD rate in the LC group was not significantly different than in the OC group (11.9% versus 10.0%, P>0.9). Neither birth weights nor Apgar scores were significantly different across groups. CONCLUSIONS Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy can be performed with minimal fetal and maternal morbidity when accepted management guidelines are followed.

Adverse drug events in trauma patients.

BACKGROUND Adverse drug events (ADEs) are noxious and unintended results of drug therapy. ADEs have been shown to be a risk to hospitalized patients. The purpose of this study was to determine the rate and nature of ADEs in trauma patients and to characterize the population at risk. METHODS An electronic medical record, a hospital wide computerized surveillance program, and a clinical pharmacist prospectively investigated ADEs in 4,320 trauma patients from 1996 through 1999. RESULTS The rate of ADEs in trauma patients (98/4320, 2.3%) was twice that of non-trauma hospital patients (1,111/96,218, 1.2%, p < 0.001). Traumatized females had ADEs 1.5 times more often than traumatized males (2.7% versus 1.8%, p = 0.052). The medication class most often associated with ADEs was analgesics with 54% involving morphine and 20% involving meperidine. The most common ADEs were nausea, vomiting, and itching. Only one ADE was directly attributed to a medical error. CONCLUSIONS Trauma patients are at double the risk for ADEs. Analgesics are particularly associated with ADEs and use should be carefully monitored.

Outcomes of pediatric trauma patients transported from rural and urban scenes

OBJECTIVES Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes. METHODS Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records. RESULTS Total mileage, flight times, and scene times were significantly longer for rural flights (P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients. CONCLUSIONS Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.

Outcomes of Blunt Trauma Victims Transported by HEMS from Rural and Urban Scenes

Objective. Mortality differences exist between victims of urban andrural trauma; however, it is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, length of hospital stay, anddischarge status of adult blunt trauma victims transported by HEMS from rural andurban scenes to regional trauma centers. Methods. Retrospective review of all adult (age ≥ 15) HEMS transports in 2001; 271 urban and141 rural blunt trauma patients were identified from HEMS transport records andthe trauma registries at three level one trauma centers. Demographic data, scene andhospital interventions, as well as discharge status of the two groups were examined. Results. Total mileage [27 ± 12 vs. 119 ± 64, p < 0.001], total flight times (minutes) [30 ± 10 vs. 79 ± 40, p < 0.001], andscene times (minutes) [16 ± 8 vs. 21 ± 14, p < 0.001] were significantly longer for rural flights. There were no significant differences between the groups with regard to age, gender, receiving hospital, andinitial HEMS vitals. Injury Severity Score, ICU length of stay (LOS), total hospital LOS, andhospital mortality did not differ between the two groups. After controlling for age, gender, andISS, there were no significant mortality differences between the two groups (p = 0.074). Conclusions. Despite longer flight andscene times for rural patients, adjusted in-hospital mortality rates were similar for patients transported from urban andrural scenes. Factors prior to HEMS arrival may contribute to increased mortality rates of rural blunt trauma victims documented nationally.

Scene Transport of Pediatric Patients Injured at Winter Resorts

Objective. To examine the characteristics of pediatric patients (age ≤16 years) injured at winter resort scenes andtransported by helicopter emergency medical services (HEMS) or ground EMS (GEMS) ambulance services to regional trauma centers. Methods. Between 1997 and2001, a total of 119 patients (GEMS = 69; HEMS = 50) were identified from trauma registries andHEMS transport records. Demographic data, initial vital signs, hospital interventions, anddischarge status of the two groups were examined. Results. The distributions of gender, initial vital signs, Injury Severity Score (ISS; either ≤ or > 15), intensive care unit (ICU) length of stay (LOS), total hospital LOS, andhome discharge status were similar between the two groups (p ≥ 0.05). Patients transported by HEMS were older (14 ± 2 vs. 10 ± 4, p < 0.001), less likely to be admitted to the hospital (73% vs. 98.5%; p < 0.001), andmore likely to have multiple injuries [13 (27%) vs. 8 (11.6%), p ≤ 0.032]. The GEMS patients had a higher rate of isolated extremity [33 (80.5%) vs. 8 (19.5%)] andthoracoabdominal [11 (73.3%) vs. 4 (26.7%)] injuries. The high orthopedic injury rate in the GEMS patients contributed to a higher rate of surgery in this group (45% vs. 24%, p ≤ 0.028). Regardless of transport mode, patients requiring immediate interventions (intubation, chest tube placement, or blood product administration) had either a depressed level of consciousness (GCS = 12) on emergency department arrival or thoracoabdominal injuries. No deaths were recorded. Conclusions. Patients transported by HEMS andGEMS had similar hospital characteristics but different injury patterns. A prospective study examining the initial triage of pediatric patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.

Air Medical Transport Personnel Experiences with and Opinions about Research

INTRODUCTION This study examined air medical transport (AMT) personnels experiences with and opinions about prehospital and AMT research. METHODS A Web-based questionnaire was sent to eight randomly selected AMT programs from each of six Association of Air Medical Services (AAMS) regions. Responders were defined by university association (UA) and AMT professional role. RESULTS Forty-eight of 54 (89%) contacted programs and 536 of 1,282 (42%) individuals responded. Non-UA responders (74%) had significantly more work experience in emergency medical services (EMS) (13.5 +/- 8.5 vs. 10.8 +/- 8.3 years, P = .002) and AMT (8.3 +/- 6.3 vs. 6.8 +/- 5.7 years, P = .008), whereas UA responders (26%) had more research training (51% vs. 37%, P = .006), experience (79% vs. 59%, P < .001), and grants (7% vs. 2%, P = .006). By AMT role, administrators had the most work experience, and physicians had the most research experience. Research productivity of responders was low, with only 9% having presented and 10% having published research; and UA made no difference in productivity. A majority of responders advocated research: EMS (66%) and AMT (68%), program (53%). Willingness to participate in research was high for both EMS research (87%) and AMT research (92%). CONCLUSIONS Although AMT personnel were strong advocates of and willing to participate in research, few had research knowledge. For AMT personnel, disparity exists between advocating for and producing research.