Richard E. Burney

Family participation during resuscitation: An option

We began to question the fairness of a policy to exclude close family members from the treatment room during attempted resuscitation of cardiac arrest victims in 1982 after 13 of 18 surviving relatives (72%) who were surveyed about their experiences during the attempted resuscitation of a family member responded that they would have liked to have been present during the resuscitation. We report the results of a program instituted at that time that allowed selected family members to be present during resuscitation efforts. Family members were asked by a chaplain or nurse if they wished to be present in the resuscitation room, and those accepting were accompanied by a supporting emergency staff member who explained the milieu of the code room. None of the participants interfered with resuscitation efforts. Seventy persons who participated were later contacted by one of the chaplains and asked to complete a survey form. Forty-four of 47 respondents (94%) who had been present during resuscitation believed that they would participate again. Thirty-six (76%) thought that adjustment to the death or grieving was facilitated by their witnessing the resuscitation; 30 (64%) felt that their presence was beneficial to the dying family member. We conclude that lay person may wish to be with family members who may be dying even though resuscitation efforts are being made, and that it is reasonable to inquire about this wish. This experience has assisted the grieving process for many and has not interrupted or adversely affected medical efforts at resuscitation.

Influence of prophylactic central lymph node dissection on postoperative thyroglobulin levels and radioiodine treatment in papillary thyroid cancer

BACKGROUND Prophylactic central lymph node dissection with total thyroidectomy (TT) for the treatment of papillary thyroid cancer (PTC) is controversial because of the possibility of increased morbidity with uncertain benefit. The purpose of this study is to determine whether prophylactic central neck dissection provides any advantages over TT alone. METHODS Retrospective cohort study of patients with PTC without preoperative evidence of lymph node involvement undergoing either TT or TT with bilateral central lymph node dissection (TT + BCLND). RESULTS From 2002 to 2009, 143 patients with clinically node-negative PTC underwent either TT (n = 65) or TT + BCLND (n = 78). The groups were similar in age, gender, tumor size, multifocality, angioinvasion, and metastasis/age/completeness-of-resection/invasion/size score. The presence of involved central neck lymph nodes upstaged 28.6% of patients in the TT + BCLND group to stage III disease, which resulted in higher radioactive iodine ablation doses. Stimulated serum thyroglobulin levels and the number of patients with undetectable stimulated thyroglobulin levels before and 1 year after radioactive iodine ablation were equivalent. CONCLUSION The addition of routine central lymph node dissection to TT for the treatment of PTC upstages nearly one third of patients over the age of 45 thereby changing the dose of radioactive iodine ablative therapy, but does not change postoperative thyroglobulin levels after completion of radioiodine treatment.

Health status improvement after surgical correction of primary hyperparathyroidism in patients with high and low preoperative calcium levels

BACKGROUND We conducted a prospective cohort study to determine whether there are differences in functional health status between patients with low (< 10.9 mg/dL) and high (> or = 10.9 mg/dL) serum calcium levels before surgical correction of primary hyperparathyroidism (HPT) and to compare changes in health status after correction of primary HPT. METHODS The SF-36 Health Survey, which provides demographic and condition-specific information, was used to obtain information on patients with primary HPT seen in a university hospital endocrine surgery clinic over a 4-year period before operation and again 2 months and 6 months after operation. RESULTS A total of 155 patients were studied; 86 had calcium levels < 10.9 mg/dL (normal < 10.5 mg/dL) and 69 had serum calcium levels > or = 10.9 mg/dL (range 10.9 to 13.4 mg/dL). One hundred four patients completed 6-month reports, 55 with low calcium levels and 49 with high calcium levels. Both high and low calcium groups showed marked and virtually identical impairment of functional health status. Both groups showed marked improvement in health status at 2 months and additional improvement at 6 months, returning to normal or near normal in 6 of 8 SF-36 domains. CONCLUSIONS Patients with primary hyperparathyroidism have significant functional health status impairment independent of the level of serum calcium. Dramatic improvement is seen after surgical correction. Referral for surgical treatment of primary HPT should not be delayed until serum calcium is elevated, as recommended in the 1990 National Institutes of Health consensus statement.

Blunt rupture of the diaphragm: Mechanism, diagnosis, and treatment

In the absence of respiratory distress and massive visceral herniation, the diagnosis of blunt diaphragmatic disruption can be difficult. This is particularly true for diaphragmatic injuries confined to the right hemidiaphragm. Because diagnostic delay and strangulation are associated with notable increases in mortality and morbidity, it is important to identify the injury as early as possible. Victims of lateral impact motor vehicle collisions are more likely to experience rupture of the diaphragm than victims of frontal collisions. Occupants exposed to left lateral impacts are at greatest risk. The side of diaphragmatic rupture correlates with the direction of impact. The right hemidiaphragm is more resistant to rupture. Deformation shear is a more plausible mechanism for diaphragmatic rupture after lateral impacts. Knowledge of the mechanisms that produce this injury combined with information regarding the victims seat position and direction of the impacting force should lead to a high index of clinical suspicion for diaphragmatic rupture. Chest radiography and diagnostic peritoneal lavage will establish the correct diagnosis in almost 90% of the patients with acute diaphragmatic disruption. Additional diagnostic studies are reserved for the remaining 10% of patients. Due to the pressure differential between abdomen and thorax, the natural history of these injuries is one of enlargement, and none can be expected to heal spontaneously. Once the diagnosis has been established, the treatment of every diaphragmatic disruption is surgical repair.

Complications of Femoral Neck Fracture in Young Adults

Femoral neck fractures are uncommon but serious injuries in young adults, with high rates of nonunion and avascular necrosis reported. This study was undertaken to examine the relationship between the mechanism and severity of injury, anatomic site of fracture, health status, and method of therapy on the incidence of these complications in young adults. The hospital records of 32 skeletally mature patients between the ages of 15 and 50 years (mean, 33) treated for femoral neck fracture between 1975 and 1982 were reviewed, and data analyzed for the 25 patients with a minimum 2-year followup (mean, 61 months). Data pertaining to the cause of injury, fracture pattern, prior health status, overall injury severity, method of fracture treatment, and long-term outcome were analyzed. Nonunion of the fracture site was observed in five (20%); avascular necrosis in nine (36%). Of patients with subcapital fracture 83% developed nonunion or avascular necrosis, compared to 21% with true femoral neck fracture (p = 0.05). There was no difference in cause of injury, overall injury severity, degree of comminution, displacement, method of treatment, or prior health status between those with and without complications. In this study, high rates of nonunion and avascular necrosis were seen after all types of femoral neck fracture in young adults, but were more often associated with subcapital fracture. These complications of hip fracture appeared to be independent of health status, method of treatment, or mechanism or severity of injury.

A study of preventable trauma mortality in rural Michigan.

OBJECTIVE To determine the preventable death rate (PDR) and the frequency and types of inappropriate medical care in a large, rural region of Michigan. DESIGN A prospective study of all deaths caused by injury during a 1-year period. METHODS Preventability of death and appropriateness of care were determined using a structured implicit review process and expert panel. A second panel was convened to confirm the reliability of the review process. MAIN RESULTS One hundred fifty-five injury-related deaths underwent panel review. Four deaths (2.6%) were found to be definitely preventable and 16 (10.3%) possibly preventable, for a combined preventable death rate of 12.9%. Sixty-five deaths (41.9%) occurred in the emergency department or hospital; 18 of these (27.7%) were judged to be definitely preventable or possibly preventable. Forty-three episodes of inappropriate care were identified in 27 (17.4%) of the 155 cases reviewed. These occurred primarily in the emergency department and hospital rather than during prehospital care or transfer. CONCLUSIONS A relatively small percentage of trauma fatalities in rural Michigan could have been prevented by more appropriate or timely medical care. Efforts to improve the care of injured persons in rural Michigan should be directed primarily at the emergency department and inpatient phases of trauma system care.

Mass carbon monoxide poisoning: Clinical effects and results of treatment in 184 victims

An epidemiologic and clinical investigation of 184 persons exposed to toxic levels of carbon monoxide (CO) in a public high school has been carried out. Exposure to 500 ppm of CO for periods up to 150 minutes resulted in carboxyhemoglobin (COHb)levels as high as 30% and symptomatic illness in 87% of persons exposed before the possibility of mass CO poisoning was recognized. Severity of symptoms was a reliable basis for triage of victims for immediate hospital treatment, and correlated both with duration of exposure and the length of time it took for victims to feel normal. Therapy consisting of oxygen delivered by mask achieved a half-life for COHb of 137 minutes in hospital-treated patients (compared to 320 minutes with no treatment), but did not fully reverse the symptoms of CO toxicity.

Is preoperative iodine 123 meta-iodobenzylguanidine scintigraphy routinely necessary before initial adrenalectomy for pheochromocytoma? ☆

BACKGROUND Iodine 123 meta-iodobenzylguanidine (MIBG) scintigraphy has been used in patients with clinical suspicion of pheochromocytoma to confirm the nature of an adrenal or extraadrenal mass or to identify occult disease. Additionally, it may be used to identify unsuspected bilaterality or metastases in the setting of a known unilateral adrenal mass before operation. We sought to determine the role of (123)I MIBG scintigraphy in this apparently routine preoperative setting. Our hypothesis was that (123)I MIBG would provide additional preoperative information that could modify operative intervention. METHODS All patients undergoing (123)I MIBG scintigraphy at our institution between 1992 and 2002 were identified. MIBG results, operative procedures and findings, and pathologic findings were retrospectively reviewed and compared. RESULTS The (123)I MIBG scintigraphy was performed in a total of 315 patients. Of these, 48 were patients with an initial biochemical diagnosis of pheochromocytoma and a unilateral adrenal mass. 47 of the 48 (98%) primary scans were positive for a single focus of activity concordant with anatomic imaging data from computed tomography or magnetic resonance imaging and operative findings. The (123)I MIBG did not reveal unsuspected metastatic or bilateral disease in any patient. CONCLUSION In this large series of patients undergoing (123)I MIBG scintigraphy, the test served only to confirm diagnostic impressions and corroborate anatomic imaging. The (123)I MIBG did not alter the operative management of any patient with a solitary adrenal lesion in the clinical context of biochemically-proven catecholamine excess.

Assessment of patient outcomes after operation for primary hyperparathyroidism.

BACKGROUND We have used the SF-36, an accepted health status assessment tool, in conjunction with condition-specific clinical information, to assess patient-reported health status before and after operation for primary hyperparathyroidism (1 degree HPT). METHODS Beginning in March, 1994, a convenience sample of patients has been asked to complete the SF-36 and provide additional demographic and condition-specific information for study. The SF-36, which measures eight components of functional status and well-being, is completed in person before operation and again by mail at 2 and 6 months after operation. Clinical and condition-specific data are gathered at the same times. RESULTS Fifty-nine patients have entered the study; 56 had abnormal parathyroid tissue removed. Patients with 1 degree HPT have lower SF-36 scores in all health domains at baseline than do healthy patients. At 2 months, scale scores for emotional role limitations and bodily pain improved by more than 10 points. At 6 months all eight scale scores showed improvement, seven of eight by 10 points or more. Commensurate improvements in HPT-specific measures were also seen. CONCLUSIONS Patient-reported measurements of health outcomes after parathyroidectomy for 1 degree HPT show improvement in all aspects of health status 6 months after operation. Most dramatic improvements were reported in reduction of bodily pain and in improved vitality and emotional and physical function. Surgical correction of 1 degree HPT improves patient health status and quality of life.

Emergency aeromedical transport of patients with acute myocardial infarction

Traditional medical treatment of acute myocardial infarction (AMI) calls for immediate admission and observation in a special care unit and prohibits early interhospital transfer of patients. If persons with AMI are to benefit from emergency thrombolytic therapy, angioplasty, and other interventions, they may require emergency transfer within hours to one of the 10% of hospitals that provide these services. We report our experience with the emergency aeromedical treatment and transfer for acute intervention of 104 consecutive patients with suspected AMI. Between May 1983 and December 1984, 104 patients with suspected acute myocardial infarction were transported by an aeromedical team, including a physician and nurse, for emergency cardiac evaluation. AMI was confirmed in 94 (90%), and emergency intervention was carried out in 75 of 104 (72%). Ninety patients (87%) survived to be discharged from the hospital. There were no deaths during transport. Complications requiring treatment occurred in 13 (12%) of the patients during transport; physician skill or judgment was exercised in 27 of 104 transports (26%) and did not correlate with the Killip classification of physical findings. We conclude that emergency transfer of patients with AMI, traditionally considered hazardous, can be carried out safely using an aeromedical team. Physicians appear to play an important role in safe transport.