Jeffrey Hammond

Mass casualty triage: an evaluation of the data and development of a proposed national guideline.

Mass casualty triage is a critical skill. Although many systems exist to guide providers in making triage decisions, there is little scientific evidence available to demonstrate that any of the available systems have been validated. Furthermore, in the United States there is little consistency from one jurisdiction to the next in the application of mass casualty triage methodology. There are no nationally agreed upon categories or color designations. This review reports on a consensus committee process used to evaluate and compare commonly used triage systems, and to develop a proposed national mass casualty triage guideline. The proposed guideline, entitled SALT (sort, assess, life-saving interventions, treatment and/or transport) triage, was developed based on the best available science and consensus opinion. It incorporates aspects from all of the existing triage systems to create a single overarching guide for unifying the mass casualty triage process across the United States.

Attitudes of medical students, housestaff, and faculty physicians toward euthanasia and termination of life-sustaining treatment

ObjectivesMedical decisions concerning the prolongation of life, the right to die, and euthanasia are among the most extensively discussed decisions within medicine and law today. The responses of 360 physicians, housestaff, and medical students to a questionnaire were analyzed to identify attitudes toward these issues. DesignCase vignettes were utilized to simulate the clinical context within which to survey decisions regarding whether or not to allow and assist patients requesting to die. Measurements and Main ResultsThe majority of respondents (76%) consider withholding and withdrawing life-support therapy consistent with passive euthanasia. Passive euthanasia is more acceptable to the majority of the respondents (77%) and all three groups (physicians, housestaff, and students) are similarly more disturbed by active euthanasia. Of all respondents, 51% would accede to the patients wishes when lifesaving treatment is refused, but only 16% would do so when a patient requested assistance in dying. Despite the fact that a majority (68%) agree that there is a moral justification for assisting patients to die and feel “understanding” for a physician who assists a patient in dying, only 6% of those persons surveyed were willing to deliberately terminate the life of a patient by administering medication to cause respiratory arrest, and only 1.1% of those persons surveyed were willing to do so to cause cardiac arrest.In the case vignettes, the faculty placed their highest value on disease-based information as strongly determinative to their decisions, while students and housestaff preferred quality-of-life factors. Respondents uniformly found it easier to perform “passive” actions; they were more willing to perform “active” actions in case vignettes where patients had terminal illnesses. ConclusionsSocially and legally created “shades of gray” have blurred the distinctions between withholding or withdrawing therapies and euthanasia and have left physicians without guidelines. Health ethics education should focus on case-based teaching and on reducing the uncertainty at the bedside. (Crit Care Med 1992; 20:683–690)

Assessment of Executive Function in Patients with Mild Traumatic Brain Injury

BACKGROUND The nature of functional deficit after mild traumatic brain injury (TBI) defined by Glasgow Coma Score of 13-15 is not fully described. This study explored the sensitivity of several neuropsychological tests to identify sequelae of mild traumatic brain injury (TBI). METHODS Eleven adult patients with mild TBI admitted to a Level 1 trauma center were studied. The battery of tests included the Wechsler Intelligence Scale for Children -Revised: Mazes Subtest, Trails A and B, the Boston Naming Test, The Multilingual Aphasia Examination: Controlled Oral Word Association Test, and the Paced Auditory Serial Addition Task. RESULTS Control subjects performed significantly better than patients with mild TBI on Trails A and B, the Controlled Oral Word Association Test, and Paced Auditory Serial Addition Task (subtests 2-4). No significant differences in performances between patients and controls was found for the Wechsler Intelligence Scale for Children -Revised: Mazes Subtest, Boston Naming Test, and Paced Auditory Serial Addition Task Subtest 1. CONCLUSION The results suggest that tests of specific frontal lobe executive functions are valuable in diagnosing and monitoring recovery from mild TBI.

Transfers from emergency room to burn center: errors in burn size estimate.

Errors in estimation of burn size are commonplace in community hospital emergency rooms. In 24 of 132 transfers to a burn center the extent of injury was overestimated at the transferring emergency room by 100% or more. This incorrect burn size estimation seems related to reliance on guesswork or use of the Rule of Nines. The incidence of error is greater in smaller burns.

The World Trade Center Attack: Helping the helpers: the role of critical incident stress management

Healthcare and prehospital workers involved in disaster response are susceptible to a variety of stress-related psychological and physical sequelae. Critical incident stress management, of which critical incident stress debriefing is a component, can mitigate the response to these stressors. Critical incident stress debriefing is a peer-driven, therapist-guided, structured, group intervention designed to accelerate the recovery of personnel. The attack on the World Trade Center, and the impact it may have on rescue, prehospital, and healthcare workers, should urge us to incorporate critical incident stress management into disaster management plans.

Computed tomography is inaccurate in estimating the severity of adult splenic injury

Computed tomography (CT) is increasingly utilized in evaluation of adult splenic injury (SI). CT correlation with operative findings, CT relationship to successful nonoperative (NO) management, and CT reading reproducibility were examined. Records of patients > or = 15 years old admitted over a 3-year period were reviewed. Computed tomography scans were graded by two radiologists blinded to clinical results. Computed tomography scans were performed on 49 of 77 patients with SI. Eighteen underwent initial operation (OR) and 31 initial NO. Operative patients had higher Injury Severity Scores and Abdominal Abbreviated Injury Scale scores (p < 0.0001). Grade II readings predominated in the NO group (55%). Nonoperative management was successful for 9 grade III and 3 grade IV readings. Computed tomography matched OR grade in 10 readings, underestimated it in 18, and overestimated it in 6. Computed tomography missed SI in five patients. Radiologists disagreed on 9 of 45 (20%) scans. Computed tomography poorly predicted operative findings. Interobserver variability was common. SI management should not be based solely on CT severity.

Effective use of human simulators in surgical education1

BACKGROUND We initiated a teaching module utilizing a human simulator midway through 2001-2002 to improve student skills specific to the evaluation of patients in shock during a required clerkship in surgery for fourth-year medical students. We tested the hypothesis that student skills would improve after implementation of this module and identified factors that predicted student performance. MATERIALS AND METHODS Students (n = 86) chose one of two hospital sites for a clerkship that focuses on the care of acutely ill surgical patients. A case-based lecture focusing on the diagnosis and management of a patient in shock was replaced midway through the academic year by a simulator session with a computerized life-sized mannequin. A standardized clinical final evaluation (OSCE) was used to assess student skills. We evaluated the effect of the simulator session and other factors on student exam performance using univariate and multivariate analysis. RESULTS The site of the clerkship and the simulator session were significant factors affecting the OSCE score identified by ANOVA, P < 0.05. A stepwise multiple regression analysis testing the effect of simulator module, site, time of year, prior NBME subject exam, and prior OSCE during the third year clerkship identified that the simulator module was the only independent factor that modeled performance on all shock stations, P < 0.01. CONCLUSIONS In a clerkship that already emphasized faculty facilitated case-based learning, the use of a teaching module employing a human simulator significantly improved test scores. This study supports the efficacy of human simulators to improve student skills related to the management of complex critically ill patients.

The Pediatric Risk of Mortality (PRISM) Score and Injury Severity Score (ISS) for predicting resource utilization and outcome of intensive care in pediatric trauma.

OBJECTIVE Mortality prediction in trauma is assessed using the Injury Severity Score (ISS) and Revised Trauma Score using Trauma Injury Severity Score (TRISS) methodology. The Pediatric Risk of Mortality (PRISM) score assesses mortality risk in critically ill children. We compared the ability of PRISM and ISS (using TRISS methodology) to predict resource utilization and outcome in pediatric trauma. DESIGN Retrospective chart and database review. SETTING Pediatric intensive care unit (PICU). PATIENTS Consecutive admissions to a PICU over a 2-yr period. MEASUREMENTS AND MAIN RESULTS Demographic data including PICU resource utilization and outcome were recorded. Data were recorded on 1,052 admissions (31 deaths), including 125 pediatric trauma patients (11 deaths). Patients were stratified into low- and high-risk categories based on PRISM and ISS scores. Patients with PRISM scores <6 and ISS scores <10 were classified as low risk. While both low-risk PRISM and ISS scores readily identified survivors, PRISM was the more sensitive indicator of resource utilization. PRISM, however, performed less well in determining risk-adjusted mortality as compared with ISS. CONCLUSION PRISM readily stratifies pediatric trauma patients for resource utilization. PRISM appears to underestimate mortality in pediatric trauma as compared with ISS using TRISS methodology.

Essentials of Terror Medicine

Essentials of terror medicine / , Essentials of terror medicine / , کتابخانه دیجیتال جندی شاپور اهواز

A one-hour burn prevention program for grade school children: its approach and success

A brief, one-hour program aimed at grade school children combines human moderators, a robot, and cartoons to deliver the burn prevention message. Program efficacy was demonstrated by a pretest and posttest. Performance on the posttest improved with the age of the child.