Peter B. Angood

Urban firearm deaths: a five-year perspective

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%..(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic intimal injuries from blunt trauma: resolution profile in nonoperative management.

OBJECTIVE To provide preliminary data on the resolution profile of aortic intimal injuries treated nonoperatively and on the safety of nonoperative management of these injuries. METHODS Five blunt trauma patients diagnosed by transesophageal echocardiography (TEE) with traumatic intimal injury of the aorta were assigned to nonoperative management. This included beta-blockade to maintain systolic blood pressure between 80 and 90 mm Hg and heart rate between 60 and 80 beats/min, serial TEE studies, and invasive monitoring in the intensive care unit. The evolution of injury, the effectiveness of nonoperative treatment, and the potential need for an operative intervention were monitored. RESULTS The patients had a mean Injury Severity Score of 32 and sustained multiple associated thoracic and extrathoracic injuries. Aortic injuries were located at the level of the ligamentum arteriosum and in the descending aorta adjacent to the diaphragm in three and two patients, respectively. The mean size of injury was 12.5 mm (range, 5-20 mm) and a thrombus attached to the endothelium was present in three of the five patients. Complete resolution of injury occurred within 9.4 +/- 6.6 days (range, 3-19 days). All patients remained hemodynamically stable and adequately perfused. All demonstrated progressive resolution of their aortic intimal injuries. No complications related to the aortic injuries were identified during a mean follow-up of 16.8 months. CONCLUSION This small series suggests that aortic intimal injuries smaller than 20 mm in hemodynamically stable patients treated with beta-blockade resolve within several days. This approach appears safe when monitored by serial TEE studies performed by experienced experts, and continuous invasive hemodynamic monitoring.

A new approach to probability of survival scoring for trauma quality assurance.

This study examined the application of an artificial intelligence technique, the neural network (NET), in predicting probability of survival (Ps) for patients with penetrating trauma. A NET is a computer construct that can detect complex patterns within a data set. A NET must be «trained» by supplying a series of input patterns and the corresponding expected output (e.g., survival). Once trained, the NET can recall the proper outputs for a specific set of inputs. It can also extrapolate correct outputs for patterns never before encountered. A neural network was trained on Revised Trauma Score, Injury Severity Score, age, and survival data contained in 3500 of 8300 state registry records of all patients with penetrating trauma reported in Pennsylvania from 1987 through 1990

The esophageal Doppler monitor in mechanically ventilated surgical patients: does it work?

BACKGROUND Assessment of cardiac volumes and cardiac output (CO) using a pulmonary artery catheter (PAC) in mechanically ventilated patients can be inconsistent and difficult. The esophageal Doppler monitor (EDM) is emerging as a potential alternative to the PAC. This prospective study evaluated the comparative accuracy between the PAC and EDM for preload assessment and CO in mechanically ventilated surgical patients. METHODS The EDM was placed in 15 patients with PACs in place. A total of 187 simultaneously measured EDM and PAC comparative data sets were obtained. The Pearson correlation (r) was used to compare measurements, with significance defined as a value of p < 0.05. RESULTS CO measured by EDM and PAC correlated closely (r = 0.97, p < 0.0001). Corrected flow time (FTc), a measure of left ventricular filling, correlated with PAC CO to the same degree as pulmonary capillary wedge pressure (PCWP) when positive end-expiratory pressure (PEEP) was < 10 cm H2O (FTc, r = 0.51; PCWP, r = 0.56). When PEEP was > or = 10 cm H2O, FTc correlated with PAC CO better than PCWP (FTc, r = 0.85; PCWP, r = 0.29). CONCLUSION FTc correlates with EDM and PAC CO better than PCWP. On the basis of the current study, it is reasonable to conclude that the EDM is a valuable adjunct technology for CO and preload assessment in surgical patients on mechanical ventilation, regardless of the level of mechanical ventilatory support.

On the nature of things still going bang in the night: an analysis of residency training in trauma.

In the 1982 Presidential Address to the Society of University Surgeons, Trunkey reported on the inadequacy of surgical education in trauma care. His conclusions were based on American Board of Surgery operative experience data compiled from residents completing surgical training in 1980. The purpose of this study was to compare current resident operative experience in trauma surgery with the American Board of Surgery data from 1980. Yearly resident operative experience data obtained from the Residency Review Committee from 1987 through 1991 were analyzed. The relationship between the percentile rank and the number of operative cases was defined using linear regression. The percentile rank of residents performing a specified number of operative cases was computed using a linear regression coefficient. The results were then compared with previously published 1980 American Board of Surgery summary data. Resident operative experience in trauma surgery was stable over the 5-year period investigated and no significant trends were identified. Comparison of the data from 1980 to 1991 revealed that the percentage of residents performing less than ten cases decreased markedly, from 18% to 9%. Moreover, the percentage of residents claiming fewer than 50 cases declined from 86% to 29%. Based on this analysis, it appears that resident operative experience dramatically increased from 1980 to 1987 and has since remained stable. The reasons for this are unclear but undoubtedly involve the accuracy of reporting operative experience, Residency Review Committee operative trauma definitions, and the actual number of trauma surgery cases available for trainees.(ABSTRACT TRUNCATED AT 250 WORDS)

Telemedicine, the Internet, and world wide web: overview, current status, and relevance to surgeons.

The Information Age has made profound changes in society and is slowly entering the healthcare field. Some of the most important areas are telemedicine, the Internet, and the world wide web (www). Millions of physicians, healthcare providers, and patients are accessing the web daily for patient information, consultation, and distant learning. Telemedicine is beginning to enter the mainstream of health care after decades of demonstration projects. There are many issues which have been raised, such as access to the information, the security of the information, and the quality of the content on the web. While telemedicine is beginning to flower, there are numerous barriers that prevent its rapid implementation, such as licensure, reimbursement, liability, quality of service, and technical issues. In spite of the numerous challenges, telemedicine over the Internet was practiced in one of the most remote areas of the world-Mt. Everest-demonstrating that it is possible to utilize all the latest healthcare telecommunications tools in even the most extreme of settings.

Structure of surgical critical care and trauma fellowships.

Introduction:Surgical critical care (SCC) and trauma fellowships have developed in a variety of formats. Although SCC fellowships must meet specific requirements for accreditation by the Accreditation Council for Graduate Medical Education, trauma fellowships do not. As the American Board of Surgery is considering combining SCC, trauma, and emergency surgery into “acute care surgery” fellowship training, a better understanding of current program structures is needed. Methods:The Education Committee of the Surgery Section of the Society of Critical Care Medicine sent surveys by e-mail to all SCC program directors. The survey included questions regarding the content of the fellowship, specifically, subspecialty rotations, trauma content, and operative experience. If they offered a trauma fellowship, the survey queried its structure also. Results:A total of 39 of 82 surveys were returned. About one third of the programs have only SCC fellowships, one third combine SCC/trauma in 1-yr programs, and the remainder combine SCC/trauma in 2 yrs. Of the programs, 79% provided operative experience: 15% on a separate rotation and 39% on call during intensive care unit coverage. About half of the operative experiences were related to trauma and one quarter to emergency general surgery. The great majority of rotations were in general surgical or trauma intensive care units. Conclusion:SCC programs already include meaningful trauma and emergency general surgery operative experience. Surgical subspecialty intensive care unit and operative rotations may contribute to optimal training of the “acute care surgeon.”

Critical care medicine education of surgeons : Recommendations from the Surgical Section of the Society of Critical Care Medicine

Perspective: The role of surgeons in critical care medicine has a long and esteemed past. The presence of surgeons in intensive care units provides specific insights and perspectives to the care of surgical patients sometimes not fully appreciated by the nonsurgical practitioners caring for the same patients. The training and education of surgeons is becoming more complex, fragmented, and lengthy. The knowledge base and skill set required to manage critically ill or injured surgical patients is also becoming more extensive but has the potential of becoming lost in the process of providing the overall educational program for surgical trainees. Simultaneously, nonsurgical specialties are continuing to train individuals with special skills in critical care medicine and the concept of “hospitalists” is becoming more accepted by institutions across the United States. The certification exams in critical care medicine remain under the aegis of the individual medical specialty boards, and there is still not a unified examination process in critical care. Surgeons, in particular, have tremendous pressures these days to spend more clinical time in the operating room, and the task of consistently conducting high quality research is also becoming arduous. This list of reasons could continue but are simply examples for why surgeons need to spend focused attention on how best to train and educate upcoming surgical trainees in regards to the principles of critical care medicine. The critically ill or injured patients need this focused attention and the specialty of surgical critical care medicine needs this attention. The Surgical Section of the Society of Critical Care Medicine has developed this position statement in the hopes that ongoing discussion and refinement of this particular aspect of surgery will continue on several levels.

Trovafloxacin-Associated Leukopenia

OBJECTIVE: To report a case of trovafloxacin-associated leukopenia, which occurred in a trauma patient shortly after administration and resolved following discontinuation of the drug. CASE SUMMARY: A 79-year-old white man was admitted to Yale New Haven Hospital after sustaining partial amputation of his right lower leg by an industrial lawn mower. After successful resuscitation, he underwent complete right lower amputation and was treated with intravenous alatrofloxacin mesylate. He developed leukopenia that resolved after discontinuation of the drug. DISCUSSION: Trovafloxacin is a broad-spectrum synthetic fluoroquinolone used for a wide variety of bacterial infections. We report, for the first time in the English-language literature, a case of trovafloxacin-associated leukopenia. The leukopenia resolved promptly after discontinuation of the drug. This association is further supported by the exclusion of other potential causes for this adverse effect. CONCLUSIONS: Leukopenia is a well-recognized adverse effect of several drugs. We report a case of trovafloxacin-associated leukopenia during treatment of a trauma patient. Healthcare personnel should be aware of this possible adverse reaction in patients treated with trovafloxacin.

Characterizing the practice of surgical critical care fellowship graduates: What's a fellow to do?

Abstract In order to characterize further the developing field of surgical critical care, we mailed letters to surgical critical care fellowship directors requesting the addresses of their graduates. We then mailed out surveys to the graduates and analyzed their responses. Resident teaching is a prominent feature for 85% of the graduates, with 94% of them teaching surgical critical care and 84% teaching general surgery residents. Sixty-five percent of the respondents spend at least 25% of their time providing surgical critical care, and 56% actively practice some aspects of general surgery as well. Not surprisingly, trauma care is a large part of the surgical intensivists practice, with 74% also spending at least 25% of their clinical time caring for trauma patients. With this mix of responsibilities, the respondents performed an average of 148 operations annually. Of the surgeons who responded to the survey, 66% have academic practices. Over 75% were salaried, with 95% earning over