Sandra Strack Arabian

The initial response to the Boston marathon bombing: lessons learned to prepare for the next disaster.

Objective:We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions. Background:Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes. Methods:A collaborative effort among Bostons trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack. Results:A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity. Conclusions:Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

Variability in interhospital trauma data coding and scoring: A challenge to the accuracy of aggregated trauma registries.

BACKGROUND Analyses of data aggregated in state and national trauma registries provide the platform for clinical, research, development, and quality improvement efforts in trauma systems. However, the interhospital variability and accuracy in data abstraction and coding have not yet been directly evaluated. METHODS This multi-institutional, Web-based, anonymous study examines interhospital variability and accuracy in data coding and scoring by registrars. Eighty-two American College of Surgeons (ACS)/state-verified Level I and II trauma centers were invited to determine different data elements including diagnostic, procedure, and Abbreviated Injury Scale (AIS) coding as well as selected National Trauma Data Bank definitions for the same fictitious case. Variability and accuracy in data entries were assessed by the maximal percent agreement among the registrars for the tested data elements, and 95% confidence intervals were computed to compare this level of agreement to the ideal value of 100%. Variability and accuracy in all elements were compared (&khgr;2 testing) based on Trauma Quality Improvement Program (TQIP) membership, level of trauma center, ACS verification, and registrar’s certifications. RESULTS Fifty registrars (61%) completed the survey. The overall accuracy for all tested elements was 64%. Variability was noted in all examined parameters except for the place of occurrence code in all groups and the lower extremity AIS code in Level II trauma centers and in the Certified Specialist in Trauma Registry– and Certified Abbreviated Injury Scale Specialist–certified registrar groups. No differences in variability were noted when groups were compared based on TQIP membership, level of center, ACS verification, and registrar’s certifications, except for prehospital Glasgow Coma Scale (GCS), where TQIP respondents agreed more than non-TQIP centers (p = 0.004). CONCLUSION There is variability and inaccuracy in interhospital data coding and scoring of injury information. This finding casts doubt on the validity of registry data used in all aspects of trauma care and injury surveillance.

Management and outcome of patients with blunt splenic injury and preexisting liver cirrhosis

BACKGROUND The response of liver cirrhosis (LC) patients to abdominal trauma, including blunt splenic injury (BSI) is unfavorable. To better understand the response to BSI in LC patients, the present study reviewed a much larger group of such patients, derived from the National Trauma Data Bank. METHODS The National Trauma Data Bank was queried for 2002 to 2010, and all adult BSI patients without severe brain trauma were identified. LC and non-LC patients were compared using nonoperative management (NOM) failure and mortality as primary outcomes. Predictors of these outcomes in LC patients were identified. RESULTS Of the 77,753 identified BSI patients, 289 (0.37%) had LC. Overall, 90% of the patients underwent initial NOM (86% in LC and 90% in non-LC patients, p = 0.091) with a global 90% success rate. Compared with non-LC patients, LC patients had a lower NOM success rate (83% vs. 90%, p = 0.004) despite increased use of splenic artery angioembolization (13% vs. 8%, p = 0.001). LC patients also had more complications per patient, an increased hospital and intensive care unit lengths of stay, and a higher mortality (22% vs. 6%, p < 0.0001), which was independent of the treatment paradigm. In the LC group, mortality in those who underwent immediate surgery was 35% versus 46% in failed NOM (p = 0.418) and 14% (p = 0.019) in successful NOM patients. LC patients who did not require surgery were more likely to survive than those who had surgery alone (adjusted odds ratio [AOR], 0.30). Preexisting coagulopathy (AOR, 3.28) and Grade 4 to 5 BSI (AOR, 11.6) predicted NOM failure in LC patients, whereas male sex (AOR, 4.34), hypotension (AOR, 3.15), preexisting coagulopathy (AOR, 3.06), and Glasgow Coma Scale (GCS) score of less than 13 (AOR, 6.33) predicted mortality. CONCLUSION LC patients have a higher rate of complications, mortality, and NOM failure compared with non-LC patients. Because LC patients with failed NOM have a mortality rate similar to those undergoing immediate surgery, judgment must be exerted in selecting initial management options. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

Magnitude of rib fracture displacement predicts opioid requirements.

INTRODUCTION It is unknown whether the magnitude of rib fracture (RF) displacement predicts pain medication requirements in blunt chest trauma patients. METHODS Adult blunt RF patients undergoing computed tomography (CT) of the chest admitted to an urban Level 1 trauma center (2007–2012) were retrospectively reviewed. Pain management in those with displaced RF (DRF), nondisplaced RF (NDRF), or combined DRF and NDRF (CRF) was compared by univariate analysis. Linear regression models were developed to determine whether total opioid requirements [expressed as log morphine equianalgesic dose (MED)] could be predicted by the magnitude of RF displacement (expressed as the sum of the Euclidean distance of all displaced RF) or number of RF, after adjusting for patient and injury characteristics. RESULTS There were 245 patients, of whom 39 (16%) had DRF only, 77 (31%) had NDRF only, and 129 (53%) had CRF. Opioids were given to 224 patients (91%). Compared to DRF (mean, 1.7 RF per patient) and NDRF patients (2.4 RF per patient), those with CRF (6.8 RF per patient) were older and had more RF per patient and a higher Injury Severity Score (ISS) and MED (251 vs 53 and 105 mg, respectively, p < 0.0001 and p = 0.0045). They also more frequently received patient-controlled analgesia. Patients with displaced RF had a lower mean ISS and MED and received more epidural analgesia compared with patients with NDRF. Total MED was associated with both the magnitude of RF displacement (p < 0.0001) and the number of RF (p < 0.0001). Every 5-mm increase in total displacement predicted a 6.3% increase in mean MED (p = 0.0035), while every additional RF predicted an 11.2% increase in MED (p = 0.0001). These associations included adjustment for age, ISS, and presence of chest tubes. CONCLUSION The magnitude of RF displacement and the number of RF predicted opioid requirements. This information may assist in anticipating patients with blunt RF who might have higher analgesic requirements. LEVEL OF EVIDENCE Therapeutic study, level IV.

Admission patterns of stable patients with isolated orthopedic or neurosurgical injuries.

OBJECTIVE Although the disposition of stable patients with isolated orthopedic or neurosurgical injuries affects care and resource utilization, no guidelines for optimal admission are available. This study aims to provide the platform for developing such guidelines for these patients by characterizing their admission patterns in trauma centers (TCs). METHODS This study is a Web-based survey of Trauma Medical Directors of Level I and Level II American College of Surgeons (ACS)–verified TCs. RESULTS E-questionnaire was sent to 234 (98%) of 240 ACS-verified Level I and Level II TCs, and 122 (52%) responded. Responses indicate that stable patients with isolated orthopedic injuries and no indication or with an indication for emergent surgery are mostly (58 vs. 31%, p < 0.0001, 59 vs. 37%, p < 0.0001) admitted to the trauma service (TS). Conversely, when surgery was urgent, patients are equally admitted to the TS and orthopedic service (OS). When specific injuries were queried, patients with closed pelvic fractures are mostly admitted to the TS (81 vs. 18%, p < 0.0001), whereas patients with upper extremity injuries are preferentially admitted to the OS (58% vs. 31%, p < 0.05). Patients with isolated lower extremity fractures are equally admitted to the two services. Patients with isolated major traumatic brain injury (TBI) are mostly (78.6% vs. 21.4%, p < 0.0001) admitted to the TS, regardless of the need for emergent surgery. Similarly, most patients with minor TBI are admitted to the TS, independent of the presence of CT scan findings. The majority (73.9% vs. 26.1%, p < 0.0001) of patients with isolated spine injury are admitted to the TS, independent of the level of injury, the presence of multilevel injury, an indication for surgery, or the existence of neurological deficits. CONCLUSION Most stable patients with isolated neurosurgical injuries in ACS-verified Level I and Level II TCs are initially admitted to the TS. The admission of patients with isolated orthopedic injuries is selective. These findings can facilitate investigating the clinical, logistical, and financial effect of this practice.

Distracted biking: an observational study

Commuting via bicycle is a very popular mode of transportation in the Northeastern United States. Boston, MA, has seen a rapid increase in bicycle ridership over the past decade, which has raised concerns and awareness about bicycle safety. An emerging topic in this field is distracted bicycle riding. This study was conducted to provide descriptive data on the prevalence and type of distracted bicycling in Boston at different times of day. This was a cross-sectional study in which observers tallied bicyclists at 4 high traffic intersections in Boston during various peak commuting hours for 2 types of distractions: auditory (earbuds/phones in or on ears), and visual/tactile (electronic device or other object in hand). Nineteen hundred seventy-four bicyclists were observed and 615 (31.2%), 95% CI [29, 33%], were distracted. Of those observed, auditory distractions were the most common (N = 349; 17.7%), 95% CI [16, 19], p = .0003, followed by visual/tactile distractions (N = 266; 13.5%), 95% CI [12, 15]. The highest proportion (40.7%), 95% CI [35, 46], of distracted bicyclists was observed during the midday commute (between 13:30 and 15:00). Distracted bicycling is a prevalent safety concern in the city of Boston, as almost a third of all bicyclists exhibited distracted behavior. Education and public awareness campaigns should be designed to decrease distracted bicycling behaviors and promote bicycle safety in Boston. An awareness of the prevalence of distracted biking can be utilized to promote bicycle safety campaigns dedicated to decreasing distracted bicycling and to provide a baseline against which improvements can be measured.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Bicyclist safety behaviors in an urban northeastern, United States city: an observational study

Bicycling is gaining popularity in the United States, and laws and safety recommendations are being established to keep bicyclists safer. To improve road safety for bicyclists, there is a need to characterize their compliance with road laws and safety behaviors. Adult bicyclists were observed at three high-traffic intersections in Boston, MA, with state recommendations of wearing a helmet and riding in a bike lane. State law compliance for displaying reflectors during the day and of a front light and a rear light/reflector at night, obeying traffic signals, and giving pedestrians the right of way was also observed. Variables were compared between personal and shared/rented bicyclists and analyzed by time of day. A total of 1,685 bicyclists were observed. Because of the speed of the bicyclists and obstructed views, only a sampling of 802 bicyclists was observed for reflectors/front light. Overall, 74% wore a helmet, 49% had reflectors/front lights, 95% rode in bike lanes, 87% obeyed traffic signals, and 99% gave the right of way to pedestrians. Compared with shared bicyclists (n = 122), personal bicyclists (n = 1563) had a higher helmet-wearing behaviors (77% vs. 39%, p = .0001). Shared bicyclists had a higher (p = .0001) compliance with reflectors/lights (100%) than personal bicyclists (39%, n = 265). Boston bicyclists ride in bike lanes, obey traffic signals, give pedestrians the right of way, and wear helmets while having suboptimal compliance with light/reflector use. Educational programs and stricter law enforcement aimed at these safety behaviors should be part of the effort to improve safety for all road users.

0066 Bicyclist safety behaviours in an urban northeastern, united states city: an observational study

Statement of purpose Bicycling is becoming a popular mode of transportation within the United States. Due to the increase of cyclists/vulnerable road users, laws and safety recommendations are being established to keep all road users safe. The purpose of this study was to observe bicycle safety behaviours and road law compliance of personal and bike share users at several high traffic intersections in Boston, MA. Methods/Approach This is a prospective observational study of safety and law compliance behaviours of bicyclists in downtown Boston. Investigators observed bicyclists for specific law and safety compliance behaviours including: wearing a helmet, riding in bike lanes, displaying reflectors at night, and obeying all road laws. The findings of this study were compared to other national and international studies that observed bike share and personal bike users. Results 1685 cyclists were observed. Of all observations, 74% of all bikers wore a helmet and 83% obeyed the road laws. 39% bike share riders and 78% of personal bikers were observed wearing a helmet (p = 0.0001). A sample of 680 cyclists was observed for obedience with mandated reflector laws at night and 39% were in compliance (p = 0.001). Conclusions Boston bicyclists were more compliant with helmet use and road law compliance as compared to prior studies in the US and Canada. The majority of cyclists demonstrated safe cycling practices, however other unsafe cycling behaviours were noted and merit further investigation (i.e. distracted biking). Bicycling is common mode of daily transportation, and more observational studies and interventional studies are needed to assess and mitigate emerging risks for bicyclists in today’s society. Significance and contribution to the field This is one of the first comprehensive bike observation studies in the city of Boston that provides data on multiple cycling safety behaviours. Based on our observations, the use of electronic devices while biking is widespread and requires further investigation.