William H. Frazier

A protocol for selecting patients with injured extremities who need x-rays.

Abstract To help curb excessive radiography, we developed a protocol for selecting patients with injured extremities who need x-ray examination, and we tested the protocol prospectively in 848 pati...

Adequacy of Antitetanus Prophylaxis in Six Hospital Emergency Rooms

We studied the adequacy of antitetanus prophylaxis given to 620 patients with open soft-tissue injuries by 169 physicians in six hospital emergency rooms. Twenty-three per cent of the patients were treated incorrectly (6 per cent were undertreated and 17 per cent were overtreated) with tetanus toxoid or human tetanus immunoglobulin. Undertreatment ranged from 4 to 11 per cent, and overtreatment from 5 to 38 per cent at the different hospitals (P less than 0.01). Patients at highest risk for tetanus (those with tetanus-prone wounds who had never been given a complete initial course of immunizations) had the lowest likelihood (27 per cent) of receiving correct antitetanus treatment. By following an immunization protocol based on time since injury, mechanism of injury, estimated bacterial contamination, presence of devitalized tissue, wound depth, and past immunizations, physicians can better protect the population against tetanus while lowering the risk of adverse drug reactions and not increasing the cost of care.

Quantitative Bacteriology in Adenoid Tissue

Over the past several years the indications for adenoidectomy have become increasingly controversial. Attempts to justify the operation in recurrent otitis media by correlating cultures of the nasopharynx with cultures of middle ear fluid have been inconclusive. Using quantitative bacteriologic techniques, we have studied the levels of aerobic and anaerobic bacteria per gram of tissue in adenoids removed from 48 patients. In seven patients, adenoidectomy was performed for nasal obstruction alone, in 17 patients for chronic serous otitis media, and in 24 patients for recurrent suppurative and serous otitis media. Using the criterion that greater than 105 organisms/gm of tissue constitutes infection, we found that 83% (20) of patients in the third group had infected adenoids, as opposed to only 15% (4) in the first and second group combined. Adenoid size measured radiographically did not correlate with the presence of infection. When recurrent suppurative and serous otitis media are unresponsive to medical therapy including antibiotics and decongestants, adenoidectomy should be considered in addition to myringotomy and ventilation tubes.

Management of sclerodermal finger ulcers

Ninety-three percent of 59 patients with scleroderma reviewed in this study presented with Raynauds phenomenon at a mean age of 43 years; 65% of these developed fingertip ulcers within 4 years. Other common findings were sclerodactyly, distal phalangeal resorption, calcinosis cutis, and digital contractures. Medical management of the digital ulcers with systemic and regional vasodilating drugs was unsatisfactory. Sympathectomy, when performed early, temporarily relieved vasospastic pain but did not affect the course of the ulcers. Severe digital pain was the most incapacitating symptom resulting from vasospasm early in the course of the disease and irreversible arterial luminal narrowing later in the course. Conservative fingertip amputations for nonhealing ulcers constituted the management of choice to eradicate the ulcer, to reduce or eliminate the pain, and to return the hand to early useful function. A decision tree for the management of these ulcers is proposed.

Effectiveness of prophylactic antibiotics in the outpatient treatment of burns.

We compared wound infection rates in 133 outpatient burns treated with prophylactic antibiotics in our emergency room and 161 similar, untreated burns. Infection rates in the treated and untreated groups were 3.8% (5/133) and 3.1% (5/161), respectively. Since this was an observational cohort study, it was necessary to demonstrate the comparability of treated and untreated groups with respect to risk factors for infection, including patient age, size, location, and etiology of the burn injury, time since injury, and presence of co-morbidity. The groups were found to be comparable for all risk factors except size of burn: larger burns were over-represented in the treated group (p less than 0.05). Even after controlling for size, antibiotic use did not lower the infection rate. These results argue strongly against routine use of systemic antibiotics in the treatment of outpatient burns.

Quality assessment and the art of medicine: the anatomy of laceration care.

Assuring high quality medical care has remained an elusive goal because of several problems which have hampered development of effective medical audit programs: inadequate patient data, unreasonable evaluative criteria and insensitive audit procedures. The present study demonstrates the use of a clinical algorithm to help overcome these problems. An examination of medical record data from a series of 703 laceration patients treated in an emergency service yielded only 27 cases (4 per cent) with medical records sufficiently complete to use for auditing physician compliance with algorithmic criteria. Substituting a structured checklist for the handwritten note increased this rate to 86 per cent. A computer-assisted branching audit of 1,400 laceration cases demonstrated that 1) physician compliance with an algorithmic instruction varied significantly (p<.001) according to the specific instruction, and 2) compliance with a given instruction varied significantly (p<.001) across different providers. These results underscore the need for medical audit with educational feedback which is provider specific.

Emergency department trauma care: priorities and documentation.

High priority issues in trauma care and in documentation of the process of care are discussed.