Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century.

The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."

Health care: economic impact of caring for geriatric patients.

National health care expenditures constitute a continuously expanding component of the US economy. Health care resources are distributed unequally among the population, and geriatric patients are disproportionately represented. Characterizing this group of individuals that accounts for the largest percentage of US health spending may facilitate the introduction of targeted interventions in key high-impact areas. Changing demographics, an increasing incidence of chronic disease and progressive disability, rapid technological advances, and systemic market failures in the health care sector combine to drive cost. A multidisciplinary approach will become increasingly necessary to balance the delicate relationship between our constrained supply and increasing demand.

Deployable, portable, and temporary hospitals; one state's experiences through the years.

This article will review the use of temporary hospitals to augment the healthcare system as one solution for dealing with a surge of patients related to war, pandemic disease outbreaks, or natural disaster. The experiences highlighted in this article are those of North Carolina (NC) over the past 150 years, with a special focus on the need following the September 11, 2001 (9/11) attacks. It will also discuss the development of a temporary hospital system from concept to deployment, highlight recent developments, emphasize the need to learn from past experiences, and offer potential solutions for assuring program sustainability. Historically, when a particular situation called for a temporary hospital, one was created, but it was usually specific for the event and then dismantled. As with the case with many historical events, the details of the 9/11 attacks will fade into memory, and there is a concern that the impetus which created the current temporary hospital program may fade, as well. By developing a broader and more comprehensive approach to disaster responses through all-hazards preparedness, it is reasonable to learn from these past experiences, improve the understanding of current threats, and develop a long-term strategy to sustain these resources for future disaster medical needs.

Hospital bioterrorism planning and burn surge.

On the morning of June 9, 2009, an explosion occurred at a manufacturing plant in Garner, North Carolina. By the end of the day, 68 injured patients had been evaluated at the 3 Level I trauma centers and 3 community hospitals in the Raleigh/Durham metro area (3 people who were buried in the structural collapse died at the scene). Approximately 300 employees were present at the time of the explosion, when natural gas being vented during the repair of a hot water heater ignited. The concussion from the explosion led to structural failure in multiple locations and breached additional natural gas, electrical, and ammonia lines that ran overhead in the 1-story concrete industrial plant. Intent is the major difference between this type of accident and a terrorist using an incendiary device to terrorize a targeted population. But while this disaster lacked intent, the response, rescue, and outcomes were improved as a result of bioterrorism preparedness. This article discusses how bioterrorism hospital preparedness planning, with an all-hazards approach, became the basis for coordinated burn surge disaster preparedness. This real-world disaster challenged a variety of systems, hospitals, and healthcare providers to work efficiently and effectively to manage multiple survivors. Burn-injured patients served as a focus for this work. We describe the response, rescue, and resuscitation provided by first responders and first receivers as well as efforts made to develop burn care capabilities and surge capacity.

The price of acute care surgery.

BACKGROUND: Numerous organizations have identified access to emergency surgical care as a crisis. One barrier is the financial disincentive associated with caring for this patient population. We sought to identify contributing factors by analyzing endemic data during the development of an acute care surgery (ACS) service at an academic health care system. METHODS: Financial data (receipts, payer mix, and dollar/relative value unit [RVU]) and productivity measures (OR procedures and RVUs) were obtained for a surgical division for 6-month periods before and after transition to an ACS model. Using national data, a sensitivity analysis was performed to identify salary targets required for an ACS surgeon to have equitable career reimbursement using standard financial modeling (net present value) with comparable surgical specialists. RESULTS: Post-ACS, operative volume increased 25%, work RVUs increased 21%, but net receipts increased only 11%. Dollar/RVU decreased primarily due to a higher proportion of uncompensated care. As a result, the dollar/RVU for ACS patients was 28% lower in comparison to non-ACS specialties. Increasing ACS salaries proportionate to the observed dollar/RVU discount realigned ACS economic value with other specialties in aggregate. CONCLUSION: A national shortage of ACS surgeons exists due to in part financial misalignment. We demonstrated that despite an increase in clinical activity, transition to an ACS model resulted in a relative reduction in payment. A rational systems-based approach to ACS development that objectively targets the RVU reimbursement disparity would reduce economic disincentives related to careers in ACS and potentially address the emergency surgical care crisis.

The impact of an independent transfer center on the evaluation and transport of patients with burn and maxillofacial injuries to definitive care at a level 1 trauma center.

OBJECTIVE: To assess the impact of an independent call center on facilitation of burn and maxillofacial trauma patient transfer to a level 1 trauma center. METHODS: All patients admitted to our level 1 trauma center for definitive management of either burn or maxillofacial injuries from September 1, 2004 to September 1, 2008, 2 years before and after transfer service initiation on September 1, 2006, were identified using the North Carolina Trauma Registry. Cohort demographics, referral patterns, transfer times/distances, and clinical outcomes were assessed. RESULTS: Burn patients increased from 1031 to 1208, from the 2 years before to after transfer center initiation. Average transport time increased from 113 to 165 minutes and average distance traveled increased from 84 to 86 miles. Out-of-state admissions increased from 24 to 46; number of referring counties increased from 58 to 60. Maxillofacial trauma patients increased from 390 to 576. Average transport time increased from 87 to 119 minutes, average distance increased from 84 to 89 miles, and number of referring counties jumped from 28 to 43. Length of stay did not change over the study period. CONCLUSIONS: The initiation of an independent call center, designed to facilitate the transfer of patients with burn and maxillofacial injuries to a level 1 trauma center, increased the number of referrals and expanded our geographic footprint, but did not decrease transport times.

Management of recurrent hernia after components separation: 10-year experience with abdominal wall reconstruction at an academic medical center.

PURPOSE: Separation of the components has become the standard of care for abdominal wall reconstruction, especially in the setting of infected, previously infected, or contaminated wounds. Although the safety and efficacy of this technique have been established, less is known about long-term outcomes. This article focuses on the management of recurrent hernia after components separation for abdominal wall reconstruction. METHODS: We performed a retrospective, institutional review board-approved study of components separation for abdominal wall reconstruction at an academic medical center, over a 10-year period. RESULTS: Between 2000 and 2009, we performed components separation in 136 patients (mean follow-up, 4.4 years). Twenty-six patients (19.1%) developed recurrent hernia (mean age, 49.8 years; body mass index, 30.7; previous abdominal operations, 3.5; hernia size, 342 cm; length of stay, 9.1 days). Mean time to recurrence was 319 days. Of the 16/26 patients who underwent repair of recurrence, 15 had successful repair, leaving 11/136 patients (8.1%) with persistent hernia. Of the 26 recurrences, 22 (85%) occurred within the first half of the study. Repair of recurrent hernias was accomplished by placement of additional mesh in 14/15 patients. CONCLUSIONS: Recurrent hernia after components separation may be related to procedural learning curves and can be successfully treated through repeat repair, yielding high rates of successful abdominal wall reconstruction.

Use of the novel hemostatic textile Stasilon(R) to arrest refractory retroperitoneal hemorrhage: a case report.

INTRODUCTION: Stasilon(R) is a novel hemostatic woven textile composed of allergen-free fibers of continuous filament fiberglass and bamboo yarn. The development of this product resulted from controlled in vitro thrombogenic analysis of an array of potentially hemostatic textile materials and it has been cleared for both external and internal use by the United States Food and Drug Administration for the arrest of hemorrhage. The goal of the study was to assess the hemostatic and adhesive properties of Stasilon(R) in the setting of life-threatening refractory hemorrhage. CASE PRESENTATION: A 39-year-old Caucasian man presented with severe necrotic pancreatitis that failed multiple aggressive attempts to control associated bleeding with electrocautery, suture ligation, and sequential anatomic packing with cotton-based sponges. Subsequent retroperitoneal packing with Stasilon(R) produced a non-adherent wound-dressing interface and resulted in the achievement of persistent hemostasis in the operative field. CONCLUSION: In our patient, Stasilon(R) was demonstrated to be effective in the arrest of refractory hemorrhage.

The design and testing of a dual fiber textile matrix for accelerating surface hemostasis.

The standard treatment for severe traumatic injury is frequently compression and application of gauze dressing to the site of hemorrhage. However, while able to rapidly absorb pools of shed blood, gauze fails to provide strong surface (topical) hemostasis. The result can be excess hemorrhage-related morbidity and mortality. We hypothesized that cost-effective materials (based on widespread availability of bulk fibers for other commercial uses) could be designed based on fundamental hemostatic principles to partially emulate the wicking properties of gauze while concurrently stimulating superior hemostasis. A panel of readily available textile fibers was screened for the ability to activate platelets and the intrinsic coagulation cascade in vitro. Type E continuous filament glass and a specialty rayon fiber were identified from the material panel as accelerators of hemostatic reactions and were custom woven to produce a dual fiber textile bandage. The glass component strongly activated platelets while the specialty rayon agglutinated red blood cells. In comparison with gauze in vitro, the dual fiber textile significantly enhanced the rate of thrombin generation, clot generation as measured by thromboelastography, adhesive protein adsorption and cellular attachment and activation. These results indicate that hemostatic textiles can be designed that mimic gauze in form but surpass gauze in ability to accelerate hemostatic reactions.

Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy.

OBJECTIVE: Elevated inflammatory cytokine levels have been implicated in the pathogenesis of non-healing chronic venous insufficiency (CVI) ulcers. The goal of this study was to determine the protein levels of a wide range of inflammatory cytokines in untreated CVI ulcer tissue before and after 4 weeks of high-strength compression therapy. These levels were compared to cytokines present in healthy tissue. METHODS: Thirty limbs with untreated CVI and leg ulceration received therapy for 4 weeks with sustained high-compression bandaging at an ambulatory wound center. Biopsies were obtained from healthy and ulcerated tissue before and after therapy. A multiplexed protein assay was used to measure multiple cytokines in a single sample. Patients were designated as rapid or delayed healers based on ulcer surface area change. RESULTS: The majority of pro-inflammatory cytokine protein levels were elevated in ulcer tissue compared to healthy tissue, and compression therapy significantly reduced these cytokines. TGF-beta1 was upregulated in ulcer tissue following compression therapy. Rapid healing ulcers had significantly higher levels of IL-1alpha, IL-1beta, IFN-gamma, IL-12p40, and granulocyte macrophage colony stimulating factor (GM-CSF) before compression therapy, and IL-1 Ra after therapy. IFN-gamma levels significantly decreased following therapy in the rapidly healing patients. CONCLUSION: CVI ulcer healing is associated with a pro-inflammatory environment prior to treatment that reflects metabolically active peri-wound tissue that has the potential to heal. Treatment with compression therapy results in healing that is coupled with reduced pro-inflammatory cytokine levels and higher levels of the anti-inflammatory cytokine IL-1 Ra.

North Carolina all-terrain vehicle (ATV) safety legislation: an assessment of the short-term impact on ATV-related morbidity and mortality.

OBJECTIVE: All-terrain vehicle (ATV)-related morbidity and mortality has increased in the US, and states have attempted to combat this trend with ATV-specific safety legislation. The objective of this study was to examine the short-term changes in ATV-related injuries and deaths following the enactment of legislation regulating the operation and sale of ATVs in North Carolina. STUDY DESIGN AND DATA COLLECTION: The study is a retrospective analysis comparing ATV collisions during the six month pre and post period of the effective date of legislation. Demographics, medical outcomes, passenger seat position, helmet use, and alcohol use were analyzed. DATA: Subjects were identified through the North Carolina Trauma Registry and data from the Office of the Chief Medical Examiner. FINDINGS: A total of 102 (51 in both pre- and post-legislation) subjects required medical treatment or were declared dead secondary to ATV collisions in North Carolina. Children under the age of eight years, who were forbidden from using ATVs under the new legislation, had significantly fewer total medical evaluations and deaths in the post-legislative time period. There was no association between legislative time period and ATV-related passenger, helmet, or alcohol use. CONCLUSIONS: In the six months following the enactment of North Carolina's ATV bill, children under the age of eight years were seriously injured or died less often due to ATV-related crashes. No other significant changes in ATV riding patterns were seen between the two time periods, and the morbidity and mortality of all ATV riders did not change. LIMITATIONS: The examined data sets do not include data from all North Carolina hospitals.

Nonfocused enhanced CT evaluation of acute appendicitis increases length of stay in the emergency department but does not increase perforation rate.

Nonfocused enhanced CT (NFECT) using intravenous and oral contrast is highly sensitive and specific for the diagnosis of acute appendicitis but requires additional time for transit of oral contrast and imaging interpretation. The aim of this study was to review our use of NFECT for the evaluation of acute appendicitis. Over a 2-year period, 295 adult patients presented to our emergency department and were diagnosed with acute appendicitis. Of these patients, 240 (81%) had undergone some form of cross-sectional imaging of the abdomen, and the majority (n = 193 [65%]) had NFECT scans performed during their evaluation. Fifty-five (19%) patients did not undergo cross-sectional radiographic evaluation (nonimaging group). Compared with the nonimaging group, patients who underwent NFECT were older (37 vs 32 years; P = 0.015) and more likely to be female (49% vs 20%; P < 0.001). Length of stay in the emergency department was significantly greater for patients who underwent NFECT (606 vs 321 minutes; P < 0.001), but there was no significant difference in the rate of acute appendiceal perforation (15% vs 9%; P = 0.297). In conclusion, use of NFECT for the diagnosis of acute appendicitis nearly doubles the patient's time in the emergency department with no significant increase in the acute perforation rate.

Volunteerism among surgeons: an exploration of attitudes and barriers.

BACKGROUND: In a recent survey, the American College of Surgeons found great interest in surgically related volunteerism, but it was unclear if the interest reflected participation. The purpose of the current study was to explore attitudes and barriers to volunteering. METHODS: To assess surgeons' experiences and beliefs about volunteerism, we mailed a questionnaire to Nathan A. Womack Society members. We analyzed respondents' demographics and attitudes, and associations between physician characteristics and volunteer status. RESULTS: The response rate was 42.5%. More than half (56%) of respondents volunteered surgical skills at least once, and 48% actively volunteer a mean of 9 days per year. Full-time practicing status was associated with being an active volunteer (57.8% vs 17.2% not full-time, P <.001). Modifiable barriers were identified. CONCLUSIONS: Many different kinds of surgeons volunteer their surgical skills, reflecting the interest found by the College. Knowledge of barriers can be used to develop strategies to help interested surgeons pursue volunteer interests.

Infrared imaging of trauma patients for detection of acute compartment syndrome of the leg.

OBJECTIVE: Early compartment syndrome is difficult to diagnose, and a delay in the diagnosis can result in amputation or death. Our objective was to explore the potential of infrared imaging, a portable and noninvasive technology, for detecting compartment syndrome in the legs of patients with multiple trauma. We hypothesized that development of compartment syndrome is associated with a reduction in surface temperature in the involved leg and that the temperature reduction can be detected by infrared imaging. DESIGN: Observational clinical study. SETTING: Level I trauma center between July 2006 and July 2007. PATIENTS: Trauma patients presenting to the emergency department. INTERVENTIONS: Average temperature of the anterior surface of the proximal and distal region of each leg was measured in the emergency department with a radiometrically calibrated, 320 x 240, uncooled microbolometer infrared camera. MEASUREMENTS AND MAIN RESULTS: The difference in surface temperature between the thigh and foot regions (thigh-foot index) of the legs in trauma patients was determined by investigators blinded to injury pattern using thermographic image analysis software. The diagnosis of compartment syndrome was made intraoperatively. Thermographic images from 164 patients were analyzed. Eleven patients developed compartment syndrome, and four of those patients had bilateral compartment syndrome. Legs that developed compartment syndrome had a greater difference in proximal vs. distal surface temperature (8.80 +/- 2.05 degrees C) vs. legs without compartment syndrome (1.22 +/- 0.88 degrees C) (analysis of variance p < .01). Patients who developed unilateral compartment syndrome had a greater proximal vs. distal temperature difference in the leg with (8.57 +/- 2.37 degrees C) vs. the contralateral leg without (1.80 +/- 1.60 degrees C) development of compartment syndrome (analysis of variance p < .01). CONCLUSIONS: Infrared imaging detected a difference in surface temperature between the proximal and distal leg of patients who developed compartment syndrome. This technology holds promise as a supportive tool for the early detection of acute compartment syndrome in trauma patients.

Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy.

Elevated matrix metalloproteinases (MMP) levels have been implicated in the pathogenesis of chronic venous insufficiency ulcers. Quantitative measurements of a broad range of MMP proteins in human tissue treated with compression bandaging have not been reported. The goal of this study was to determine the expression of a wide range of proteases in untreated venous leg ulcer tissue and the changes in these levels after 4 weeks of high-strength compression therapy. Twenty-nine limbs with new or untreated chronic venous insufficiency and leg ulceration received therapy for 4 weeks with sustained high compression bandaging. Biopsies were obtained from healthy tissue and from ulcerated tissue before and after therapy. A novel multiplexed protein assay was used to measure multiple MMPs in a single sample. MMP protein activity, TIMP protein levels, and gene expression levels were also addressed. MMP1, 2, 3, 8, 9, 12, and 13 protein levels were elevated in ulcer tissue compared with healthy tissue. MMP8 and 9 were highly expressed in ulcer tissue. MMP3, 8, and 9 significantly decreased following treatment. Reduction in the levels of MMP1, 2, and 3 was associated with significantly higher rates of ulcer healing at 4 weeks. We conclude that compression therapy results in a reduction of the pro-inflammatory environment characterizing chronic venous ulcers, and ulcer healing is associated with resolution of specific elevated levels of protease expression.