Hugh M. Foy

Patterns of Errors Contributing to Trauma Mortality: Lessons Learned From 2594 Deaths

Objective:To identify patterns of errors contributing to inpatient trauma deaths. Methods:All inpatient trauma deaths at a high-volume level I trauma center from 1996 to 2004 inclusive were audited. Data were collected with daily trauma registry chart abstraction, weekly morbidity and mortality reports, hospital quality assurance reports, and annual trauma registry analyses of risk of death using TRISS and HARM methodology. Deaths that met criteria for low to medium probability of mortality or those with quality of care concerns were analyzed for errors and then subjected to 3-stage peer review at weekly departmental, monthly hospital, and annual regional forums. Patterns of errors were constructed from the compiled longitudinal data. Results:In 9 years, there were 44,401 trauma patient admissions and 2594 deaths (5.8%), of which 601 met low to medium mortality risks. Sixty-four patients (0.14% admissions, 2.47% deaths) had recognized errors in care that contributed to their death. Important error patterns included: failure to successfully intubate, secure or protect an airway (16%), delayed operative or angiographic control of acute abdominal/pelvic hemorrhage (16%), delayed intervention for ongoing intrathoracic hemorrhage (9%), inadequate DVT or gastrointestinal prophylaxis (9%), lengthy initial operative procedures rather than damage control surgery in unstable patients (8%), over-resuscitation with fluids (5%), and complications of feeding tubes (5%). Resulting data-directed institutional and regional trauma system policy changes have demonstrably reduced the incidence of associated error-related deaths. Conclusions:Preventable deaths will occur even in mature trauma systems. This review has identified error patterns that are likely common in all trauma systems, and for which policy interventions can be effectively targeted.

Penetrating cardiac injuries: a population-based study.

BACKGROUND Wide variances exist in reports of survival rates after penetrating cardiac injuries because most are hospital-based reports and thus are affected by the local trauma system. The objective of this study was to report population-based, as well as hospital-based, survival rates after penetrating cardiac injury. METHODS Retrospective cohort analysis was performed during a 7-year period of 20,181 consecutive trauma admissions to a regional Level I trauma center and 6,492 medical examiners reports. A meta-analysis was performed comparing survival rates with available population-based reports. RESULTS There were 212 penetrating cardiac injuries identified, for an incidence of approximately 1 per 100,000 man years and 1 per 210 admissions. The overall survival rate was 19.3% (41 of 212) for the population studied, with survival rates of 9.7% (12 of 123) for gunshot wounds and 32.6% (29 of 89) for stab wounds. Ninety-six of the 212 patients were transported to the trauma center for treatment, resulting in an overall hospital survival rate of 42.7% (41 of 96), with a hospital survival rate of 29.3% (12 of 41) for gunshot wounds and 52.7% (29 of 55) for stab wounds. CONCLUSION Review of population-based studies indicates that there has been only a minor improvement in the survival rates for the treatment of penetrating cardiac injuries.

Acquiring basic surgical skills: is a faculty mentor really needed?

BACKGROUND We evaluated the impact of expert instruction during laboratory-based basic surgical skills training on subsequent performance of more complex surgical tasks. METHODS Forty-five junior residents were randomized to learn basic surgical skills in either a self-directed or faculty-directed fashion. Residents returned to the laboratory 2 days later and were evaluated while performing 2 tasks: skin closure and bowel anastomosis. Outcome measures included Objective Structured Assessment of Technical Skill, time to completion, final product quality, and resident perceptions. RESULTS Objective Structured Assessment of Technical Skill, time to completion, and skin esthetic ratings were not better in the faculty-directed group, although isolated improvement in anastomotic leak pressure was seen. Residents perceived faculty-directed training to be superior. CONCLUSIONS Our data provided minimal objective evidence that faculty-directed training improved transfer of learned skills to more complex tasks. Residents perceived that there was a benefit of faculty mentoring. Curriculum factors related to training of basic skills and subsequent transfer to more complex tasks may explain these contrasting results.

Factors influencing outcome in stab wounds of the heart

BACKGROUND The purpose of this study was to identify factors associated with unfavorable outcome following stab wounds to the heart in order to improve selection of patients who may benefit from aggressive resuscitative efforts. METHODS Preoperative and operative variables were reviewed for all patients treated for cardiac stab wounds at a level I trauma center from 1987 to 1993 in an attempt to identify factors influencing survival. RESULTS Twenty-nine (53%) of the 55 patients who were resuscitated following stab wounds to the heart during the study period survived. Although profound hypotension (systolic blood pressure < 40 mm Hg), cardiopulmonary resuscitation, and emergency room thoracotomies were associated with poor outcome, none were uniformly predictive of death. Some patients survived with each of these characteristics. CONCLUSIONS We recommend that all patients suspected of having cardiac stab wounds be fully resuscitated and undergo thoracotomy, as significant survival can be achieved and death is not always the outcome.

Engine block burns: Dupuytren's fourth-, fifth-, and sixth-degree burns

We recently treated two patients with engine block-muffler contact burns and greatly underestimated the devastating injuries to bone, deep fascia, and muscle. As a result, each patient required multiple procedures to close their burn wounds. Ten-year data from the University of Washington Burn Unit confirmed our observation that these burns tend to be considerably deeper than suspected. Eighteen patients with contact burns from engine parts were identified from 1980 through 1990. Nine (50%) of these were initially recognized to be fourth-degree and five (28%) were third-degree thermal injuries, showing that these are deep burns. Eight patients required fascial excisions and four required debridement of devascularized bone. The mean burn size was only 6% total body surface area; however, the patients with fourth-degree burns had an average graft take of only 56% and required a mean hospital stay of 44 days. Patients with third-degree burns also had suboptimal graft take and some required prolonged hospitalization. Thirty-six percent of patients required flaps either as the initial procedure or as a second procedure following an autograft. The four patients with partial-thickness burns healed without surgery and their average length of hospital stay was 3 days. Of the entire group, only four healed without surgery and only five healed with a single operation. Our 10-year data indicate that engine block contact burns are usually small, but most are deceptively deep, involving tendon, muscle, or bone. If the burn appears full thickness, suspicion must be very high at the initial surgical procedure that there is deep tissue destruction.(ABSTRACT TRUNCATED AT 250 WORDS)

Excision and grafting of large burns: operation length not related to increased morbidity.

In order to study the relation between length of operation and postoperative morbidity in patients with burns greater than 30% TBSA a retrospective review was done. Seven categories of morbidity were chosen and points assigned for significant change from the preoperative state. There were no intraoperative or immediate postoperative deaths. The overall morbidity was 19%. The eventual mortality was 19%. There was no correlation between length of operation and postoperative morbidity.

Abdominal Impalement from Motor Vehicle Crash

A 21-year-old unrestrained male driver was impaled by a 2 15.2 cm wooden board that penetrated the car during a motor vehicle collision (Fig 1). Oral and intravenous contrast-enhanced computed tomogram (CT) showed the board overlying the expected location of the left common iliac artery and vein, which were not visualized as discrete contrast-containing structures (Fig 2). The right common iliac artery and vein were clearly identified. There was no evidence of extravasation. Surgical exploration following proximal arterial control demonstrated transection of the left common iliac vein, intimal injury of the left common iliac artery with thrombosis extending into the right common iliac artery, and large leftflank and right groin wounds. Significant venous bleeding occurred following removal of the board. Impalement injuries are an uncommon subset of penetrating injuries, in which an elongated object penetrates and remains imbedded in the patient. 1 Impalements usually occur in construction accidents or in motor vehicle crashes. 2 Fortunately impalement victims do not always sustain serious injuries to critical structures, as the impaling object frequently displaces organs rather than penetrating them. However, critical vascular injuries may be tamponaded by the impaling object. Recognition of these injuries before surgery is essential in identifying sites of potentially severe bleeding during removal of the object. The path of the impaling object is sometimes challenging to understand, especially when the impalement occurs in 1 position while hospital evaluation and imaging occurs in another (ie, a driver sitting in a car with flexed hips vs a supine patient). Such position differences may also make surgical extraction of the impaled object difficult. Once the spine has been cleared, flexion or extension of the patient may ease removal of the object, which is otherwise under tension in the supine patient. The impaled object should only be removed in the operating room, not in the field. In this case, the board both transected and tamponaded the left common iliac vein. Significant venous bleeding occurred after intraoperative removal of the board. Removal of the board in the field would likely have resulted in exsanguination. In thefield, external portions of the impaled object can be separated from the patient with appropriate tools, such as saws or acetylene torches. Transporting the patient with external stabilization of the impaling object will minimize its’ movement. These same principles should be considered when imaging the patient, and creative