Wei-Che Lee

Building an ethical environment improves patient privacy and satisfaction in the crowded emergency department: a quasi-experimental study

BackgroundTo evaluate the effectiveness of a multifaceted intervention in improving emergency department (ED) patient privacy and satisfaction in the crowded ED setting.MethodsA pre- and post-intervention study was conducted. A multifaceted intervention was implemented in a university-affiliated hospital ED. The intervention developed strategies to improve ED patient privacy and satisfaction, including redesigning the ED environment, process management, access control, and staff education and training, and encouraging ethics consultation. The effectiveness of the intervention was evaluated using patient surveys. Eligibility data were collected after the intervention and compared to data collected before the intervention. Differences in patient satisfaction and patient perception of privacy were adjusted for predefined covariates using multivariable ordinal logistic regression.ResultsStructured questionnaires were collected with 313 ED patients before the intervention and 341 ED patients after the intervention. There were no important covariate differences, except for treatment area, between the two groups. Significant improvements were observed in patient perception of “personal information overheard by others”, being “seen by irrelevant persons”, having “unintentionally heard inappropriate conversations from healthcare providers”, and experiencing “providers’ respect for my privacy”. There was significant improvement in patient overall perception of privacy and satisfaction. There were statistically significant correlations between the intervention and patient overall perception of privacy and satisfaction on multivariable analysis.ConclusionsSignificant improvements were achieved with an intervention. Patients perceived significantly more privacy and satisfaction in ED care after the intervention. We believe that these improvements were the result of major philosophical, administrative, and operational changes aimed at respecting both patient privacy and satisfaction.

Combination of white blood cell count with liver enzymes in the diagnosis of blunt liver laceration

BACKGROUND It is sometimes difficult to decide whether to perform abdominal computed tomographic (CT) scans for possible liver laceration in patients who have sustained less severe or minor blunt abdominal trauma. This study was conducted to find out whether the basic laboratory workup could provide information of possible liver laceration in blunt abdominal trauma patients and act as an indication for CT scans. METHODS In this retrospective case-control study, we included 289 patients who had sustained blunt abdominal injury for which they received abdominal CT scans in our emergency department. Of the 289 patients, the study group (n = 42) included patients who had been found to have liver lacerations after obtaining the CT; the controls (n = 42) were those not found to have such injuries by the same method with matching of age and sex. RESULTS In patients with blunt abdominal injuries, there is a strong difference in liver laceration between elevation of white blood cell (WBC) counts (P = .001), aspartate aminotransferase (AST) (P < .001), and alanine aminotransferase (ALT) (P < .001). A logistic regression model demonstrated that WBC count and AST were independently associated with liver laceration. With elevations of serum AST greater than 100 IU/L, ALT greater than 80 IU/L, and WBC count greater than 10 000/mm(3), we found a sensitivity and specificity of 90.0% and 92.3%, respectively, in the 42 liver laceration victims. CONCLUSION In patients with blunt abdominal trauma, elevated WBC counts together with elevated AST and ALT are strongly associated with liver laceration and warrant further imaging studies and management.

Traumatic hyoid bone fracture in patient wearing a helmet: a case report

Fractures of hyoid bone are rare and most of the injuries cause by strangulation. Hyoid bone fractures are usually the result of direct trauma to the neck through manual strangulation or hanging, blunt trauma or from projectiles. But hyoid bone fracture caused by helmet strap has not been reported before. We present a young man wearing a helmet had an isolated hyoid bone fractures after a motorcycle-to-motorcycle accident. So, we should be more aware that helmet wearing riders are prone to have this kind of injury.

Neck collar used in treatment of victims of urban motorcycle accidents: over- or underprotection?

BACKGROUND Cervical collar brace protection of the cervical spine at the scene of the incident is the first priority for emergency medical technicians treating patients who have sustained trauma. However, there is still controversy between over- or underprotection. The objective of this study was to survey the cervical spine injury of lightweight motorcycle accident victims and further evaluate the neck collar protection policy. MATERIALS AND METHODS We retrospectively reviewed patients who sustained lightweight motorcycle injuries, assumed to have been at a low velocity, with incidence of cervical spine damage, from a single medical centers trauma registration from 2008 to 2009. Patients were divided into 2 groups: those who were immobilized by cervical collar brace and those who were not. RESULTS Of the 8633 motorcycle crash victims, 63 patients had cervical spine injury. The average of the injury severity score in these patients was 14.31 ± 8.25. There was no significant correlation of cervical spine injury between the patients who had had the neck collar applied and those who had not (χ(2), P = .896). The length of stay in intensive care unit was longer in the patients who had the neck collar applied, but the total hospital length of stay was not statistically different to the patients who did not have the neck collar applied. CONCLUSION The incidence of cervical spinal injuries in the urban area lightweight motorcyclists is very low. Prehospital protocol for application of a cervical collar brace to people who have sustained a lightweight motorcycle accident in the urban area should be revised to avoid unnecessary restraint and possible complications.

Closed internal degloving injury with conservative treatment.

In the emergency department, we frequently manage patients with multiple contusions and bruise over the trunk without severe injuries. Emergency department discharge is a common option for these patients, and we may neglect the existence of closed internal degloving injury, which is a soft tissue injury with pelvic trauma, combining the subcutaneous tissue torn away from the underlying fascia followed by a cavity being filled with hematoma and liquefied fat created in the next few days (Harefuah 2006;145:111-3:66, J Trauma 1997;42:1046). We report the unusual occurrence of this entity in an 18-year-old man. He encountered a scooter accident and experienced a few days of hospitalization because of thoracispinal (T10 and T11) process fracture. He was discharged, but a fluctuating mass developed at the lumbar area 10 days later. The comprehensive survey excluded the cerebrospinal fluid leakage associated with spinal fracture, and internal degloving injury was diagnosed. Percutaneous drainage with compressive bondage was aggressively used. Even though the treatment course was time consuming, the lesion eventually disappeared 10 months after his first visit.

ASSOCIATION OF HEAD, THORACIC AND ABDOMINAL TRAUMA WITH DELAYED DIAGNOSIS OF CO-EXISTING INJURIES IN CRITICAL TRAUMA PATIENTS

BACKGROUND Management of critically injured patients is usually complicated and challenging. A structured team approach with comprehensive survey is warranted. However, delayed diagnosis of co-existing injuries that are less severe or occult might still occur, despite a standard thorough approach coupled with advances in image intervention. Clinicians are easily distracted or occupied by the more obvious or threatening conditions. We hypothesised that the major area of injured body regions might contribute to this unwanted condition. METHODS A retrospective study of all trauma patients admitted to our surgical intensive care units (ICU) was performed to survey the incidence of delayed diagnosis of injury (DDI) and the association between main body region injured and possibility of DDI. Demographic data and main body regions injured were compared and statistically analysed between patients with and without DDI. RESULTS During the two-year study period, a total 976 trauma patients admitted to our surgical ICU were included in this study. The incidence of DDI was 12.1% (118/976). Patients with DDI had higher percentages of thoracic, abdominal, and pelvic injuries (30.5%, 16.1%, and 7.6% respectively) than the non-DDI group (14.7%, 7.5%, and 3.0% respectively) (p<0.001, 0.003, and 0.024 respectively). A logistic regression model demonstrated that head (odds ratio=1.99; 95%CI=1.20-3.31), thoracic (odds ratio=2.44; 95%CI=1.55-3.86), and abdominal injuries (odds ratio=2.38; 95%CI=1.28-4.42) were independently associated with increasing DDI in patients admitted to the surgical ICU. DISCUSSION In conclusion, critical trauma patients admitted to the surgical ICU with these categories of injuries were more likely to have DDI. Clinicians should pay more attention to patients admitted due to injuries in these regions. More detailed and dedicated secondary and tertiary surveys should be given, with more frequent and careful re-evaluation.

The Effect of Alcohol Intoxication on Mortality of Blunt Head Injury

Alcohol is found to have neuroprotection in recent studies in head injuries. We investigated the association of blood alcohol concentration (BAC) with mortality of patients with blunt head injury after traffic accident. All patients sustaining blunt head injury caused by traffic accident brought to our emergency department who had obtained a brain computed tomography scans and BAC were analyzed. Patients with unknown mechanisms, transfers from outside hospitals, and incomplete data were excluded. Logistic regression was used to identify independent predictors of mortality. During the study period, 3,628 patients with brain computed tomography (CT) were included. Of these, BAC was measured in 556 patients. Patients with the lowest BAC (less than 8 mg/dl) had lower mortality; intoxicated patients with BAC between 8 and less than 100 mg/dl were associated with significantly higher mortality than those patients in other intoxicated groups. Adjusted logistic regression demonstrated higher BAC group and Glasgow coma scale (GCS) scores, and lower ISS and age were identified as independent predictors of reduced mortality. In our study, we found that patients who had moderate alcohol intoxication had higher risk of mortality. However, higher GCS scores, lower ISS, and younger age were identified as independent predictors of reduced mortality in the study patients.

Management of motorcycle accident-related blunt hepatic injury-a different strategy.

BACKGROUND In motorcycle accidents, especially in an urban area with lightweight motorcycles, the belly of the motorcyclist is not protected, and this makes this type of trauma a cause of blunt hepatic injuries. This study investigated the effect and safety of using nonoperative management and selective early angioembolization to treat patients with blunt liver injuries as a result of motorcycle accident. METHODS This was a retrospective study of the hepatic injuries sustained by motorcyclists involved in traffic accidents. We collected patient demographic information, the severity of total injuries, grade of liver injury, associated concomitant injuries, management scheme, and outcome of patients from 2006 to 2007. These patients were treated nonoperatively with selective early angioembolization and close monitoring in our intensive care unit (ICU). RESULTS We reviewed the cases of 266 patients sustaining blunt abdominal injuries. Thirty-four patients (12.78%) had hepatic injuries. All survived with no obvious morbidity, and no further invasive procedures were performed after admission to ICU. There was no significant association between grade of injury and ICU length of stay (P = .073), but there was a significant association between grade and in-patient length of stay on our regular ward (P = .001). CONCLUSION Most patients with hepatic injury caused by motorcycle accidents can be treated safely by nonoperative management. Early selective angioembolization improved the success of nonoperative management of blunt liver injury without other surgical intervention. Routine follow-up with computed axial tomography scans and endoscopic retrograde cholangiopancreatography may not be necessary because complications associated with hepatic injuries were rare.

Eosinophilic Cellulitis After Honeybee Sting

Stings by honeybees are not uncommon and most cases cause pain but no significant medical problems. Some patients, however, have lethal complications such as acute anaphylactic shock. Cellulitis caused by honeybee sting is very rare and can be a late complication in some patients. We report a 45-year-old female patient who was stung by a honeybee, and whose right forearm showed progressive swelling with bullous formation after the sting. She was sent to our emergency department with the diagnosis of right hand cellulitis. After treatment with antibiotics for 5 days, the lesions showed no response. Then, systemic steroid was used and the lesion gradually resolved. Diagnosis of Wells syndrome was made according to clinical appearance, course and characteristic histopathological findings.

Neck hyperflexion causing isolated thyroid cartilage fracture--a case report

Isolated thyroid cartilage fracture is very rare, and most cartilage fractures are caused by direct impact to the laryngotracheal complex of the neck. Isolated thyroid cartilage fracture caused by hyperflexion of the neck has not been reported before. We present a case where an unrestrained front seat car passenger struck his forehead on the windshield during a motor vehicle accident. Direct impact of his forehead with sudden and forceful flexion of his neck caused isolated thyroid cartilage fracture without direct impact to the neck. Therefore, injury to the thyroid cartilage should be kept in the list of detailed evaluation with high index of suspicion in patients presenting with trauma mechanism possibly causing neck hyperflexion, even without signs of direct neck trauma.