Short- and long-term survival after cardiopulmonary resuscitation.

BACKGROUND: The objective was to evaluate the effect of patient characteristics and other factors on cardiopulmonary resuscitation (CPR) survival, hospital discharge survival and function, and long-term survival. METHODS: All patients 18 years and older experiencing in-hospital CPR from December 1983 through November 1991 at Marshfield Medical Center (Marshfield Clinic and adjoining St Joseph's Hospital), Marshfield, Wis, were selected. We performed a retrospective medical record review and augmented these data with updated vital status information. MAIN OUTCOME MEASURES: Cardiopulmonary resuscitation survival, hospital discharge survival and function, and long-term survival. RESULTS: Of 948 admissions during which CPR was performed, 61.2% of patients survived the arrest and 32.2% survived to hospital discharge. Mechanism of arrest was the most important variable associated with hospital discharge. Patients with pulseless electrical activity had the worst chance of hospital discharge, followed by those with asystole and bradycardia. Follow-up information was available for 298 patients who survived to discharge. One year after hospital discharge, 24.5% of patients, regardless of age, had died. Survival was 18.5% at 7 years in those 70 years or older, compared with 45.4% in those aged 18 to 69 years. Heart rhythm at the time of arrest strongly influenced long-term survival. Bradyarrhythmias produced a nearly 2-fold increased mortality risk compared with normal sinus rhythm. CONCLUSIONS: Survival until hospital discharge after CPR at our institution during an 8-year period was higher than previously reported for other institutions. Long-term survival after discharge was equal to or higher than reported estimates from other institutions. Hospital admission practices and selection of patients receiving CPR may account for these findings.

Relationship of gender to characteristics of patients referred to a Rural Wisconsin Addiction Treatment Unit.

The records of admissions to the inpatient unit of a Rural Wisconsin Addiction Treatment Unit were reviewed, in 1995, for the prior four years (January 1, 1990 through December 31, 1993). After approval by the Institutional Review Board of the Marshfield Medical Research Foundation, the combined medical records were abstracted for presenting information related to social, psychological and medical components. During the four years of observation, there were 821 unique admissions of which 555 (67.6%) were males with a mean age for males and females of 36.3 years. Gender was related to marital status with males more likely to be single and females more likely to be formerly married. Seventy-one (12.8%) of the males were permanently disabled but only 17 (6.4%) of the females. Manufacturing was an occupation for 101 (18.2%) of the males, and 23 (8.6%) of the females considered themselves primarily homemakers. Of the laboratory parameters, only red cell related parameters of MCV and MCH were related to gender. At the time of admission, 99 (37.2%) of the females and 152 (27.4%) of the males were under medical care. One hundred and thirty-two (49.6%) of the females had been a victim of physical assault compared to 89 (16.1%) of the males. A history of disorderly conduct was noted in 274 (49.5%) of the males and 84 (31.6%) of the females. During the period of withdrawal, high blood pressure was noted in 110 (19.9%) of males and 25 (9.4%) of the females. The RAATE estimate of medical and psychological parameters were also related to gender. In this rural setting, the females admitted for treatment were significantly different from males. A substantially higher proportion had previously been victims of physical assault. In addition, females were more likely to have acknowledged psychological problems and to be under medical care. Treatment plans for persons with addiction need to address these issues and plan appropriate treatments.

A self-assessment of Wisconsin prehospital provider needs.

INTRODUCTION: The pressures facing emergency medical services (EMS) in Wisconsin and their effects on the delivery of prehospital emergency medical care were not known by the Wisconsin EMS Board. In an effort to assess these pressures and the needs of the emergency medical services in the State as perceived by the services, the Board undertook a survey of the EMS providers in Wisconsin. METHODS: A survey instrument was developed and approved by the EMS Board and distributed to all of the licensed emergency medical services in Wisconsin. RESULTS: Of the 453 survey instruments distributed, 323 (71.3%) were completed and returned. Intermediate- and paramedic-level services were more likely to respond than were the basic services, but 235 (72.8%) of the respondents identified their service levels as basic. In addition to providing information about the service characteristics, each responding service also rated the importance of their perceived needs. Lack of medical direction was perceived as the greatest need by all levels of service. However, the second greatest area of need for basic and intermediate services related to difficulty in recruiting new staff. For paramedic services, the second greatest need was associated with dispatching. When comparing services by rural versus urban, difficulty in recruiting new staff and collecting ambulance fees were seen as second and third to lack of a medical director by rural services, whereas urban services noted local training to be in the top three. In the assessment of educational needs, patient-care issues dominated. A review of written comments also demonstrated a difference between rural and urban services, but both noted Medicare and Medicaid reimbursement issues more commonly than any other problem. CONCLUSIONS: In the restructuring of health care, it will be important to consider the various needs of prehospital providers and recognize that such needs may be unique to the providers' location and level of service.

Case-control study of agricultural injuries to women in central Wisconsin.

A small number of women are the owner/operators of farms and women often participate in the work of production agriculture. Estimates of the percentage of females involved in agricultural injuries range from 11-45% and it is not clear if the risk factors associated with injuries to women are different from those for men. In a two year case-control study of injuries to farm residents, there were 40 injuries involving adult women. Multivariable analysis revealed that the two major risk factors for agricultural injury to females were number of hours worked and the presence of bulls on the farm. Most (55%) of the women were injured while in a barn. A cow was the primary agent of injury in 17 (42.5%) of the cases. Efforts to reduce the rate of injuries to women in agriculture should be targeted to the particular risks they experience.

A population based case-control study of agricultural injuries in children.

OBJECTIVES: To identify preventable risk factors related to agricultural injuries occurring to children on family farms. SETTING: A geographically defined central region of Wisconsin, USA with nearly 1800 family dairy farms. METHODS: A two year, population based incidence study of occupational injuries among farm residents was conducted. For cases, trained staff abstracted information on the nature, severity, and treatment of the injury from the patient's medical record. Staff also administered a telephone questionnaire to cases and controls, usually answered by parents. RESULTS: There were 60 cases of farm residents younger than 18 years who sought care for acute agriculture related injuries. Farms on which uninjured children lived served as controls (n = 102). Multivariate analyses of 16 different variables revealed three significantly related to injuries to children: hours worked per week (odds ratio (OR) = 1.05; 95% confidence interval (CI) = 1.01 to 1.08); presence of disabled safety device (OR = 2.64; 95% CI = 1.10 to 6.35); and feeding cows by grazing (OR = 0.22; 95% CI = 0.06 to 8.83). CONCLUSIONS: Interventions designed to reduce the risk of agricultural injuries to farm children should acknowledge the participation of children as productive workers on the farm. Although education has been the standard method for encouraging safe practices in farm work, additional approaches, such as limiting the number of hours a child works, avoiding the disabling of safety devices, and using specific methods of managing cows, should also be adopted to minimize injury risks to farm children.

Representativeness of trauma center registries for farm injury surveillance.

Trauma center registries are the foundation for many surveillance systems that attempt to define the frequency and spectrum of various types of injuries. To assess the representativeness of trauma center-based farm injury surveillance, we evaluated data for 1986-1991 from the Marshfield Clinic/St Joseph's Hospital, a major trauma center located in Central Wisconsin. We compared the pattern of farm injuries seen in residents of the Marshfield Epidemiologic Surveillance Area (MESA), a geographically defined, population-based surveillance area, with those from outside MESA, a nonpopulation-based mix of primary care and referral patients typical of most trauma registries. The population-based and nonpopulation-based surveillance data suggested similar patterns with respect to seasonality, circumstances of injury, and source of injury. There were significant differences with respect to the body part injured, severity of injury, and selected aspects of acute medical care. While useful for many purposes, trauma center-based injury surveillance data should be interpreted cautiously.

Evaluation of agricultural rescue course by providers.

STUDY OBJECTIVE: To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful. DESIGN: A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993. SETTING: A rural referral center in central Wisconsin. PARTICIPANTS: The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses. RESULTS: A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed-space rescue. CONCLUSIONS: Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants.

Fall-related occupational injuries on farms.

We assessed risk factors for fall-related farm injuries in a population-based, case-control study. Cases had to reside in a defined geographic region served by a single medical center. Multiple sources reported cases, and a special farm census enabled random selection of controls, The annual risk of farm fall injury was 7.5 (95% CI: 5.7, 10.0) per 1,000 person-years. The crude incidence rate was higher in men, while the rate based on hours of farmwork was higher in women. In a multivariate analysis of risk factors, three factors were significantly associated with the risk. The risk of fall injury increased 2% (95% CI: 1%, 4%) per hour worked. Residents of farms with some farm workers not living on the farm had a fall injury rate 2.5 (95% CI: 1.0, 6.2) times greater than residents of other farms. Residents of farms with registered cows had one-third (95% CI: 0.14, 0.93) the risk of residents of other farms. To identify environmental hazards for fall injuries, researchers from several disciplines may need to collaborate in the design and conduct of studies that include injury site investigations.

An assessment of prehospital provider needs in Wisconsin.

The Emergency Medical Systems Advisory Board assessed via questionnaire the needs of Wisconsin prehospital providers. Overall, 323 out of 453 (71.3%) of the services responded to the query. Intermediate and paramedic services were more likely to respond than those prehospital providers offering basic services. Of the respondents, however, 235 (72.8%) identified their service as basic. In addition to providing information about service characteristics, each responding provider also rated its perceived needs. All prehospital providers, regardless of service level, ranked "lack of medical director" as the issue of greatest concern. Continuing on, intermediate and basic providers rated difficulty in recruiting new staff as the second greatest need. Paramedic providers, however, identified dispatching as their second greatest need. Rural providers rated difficulty in recruiting new staff and difficulty in collecting ambulance fees as their second and third greatest needs, respectively. Urban providers, meanwhile, indicated difficulty in collecting ambulance fees and access to local training as the second and third top needs, respectively. With the proposed new curriculum for basic EMT services, the needs for local medical direction will be even greater.

Machine-related occupational injuries in farm residents.

Farm machinery is an important contributor to the high rates of occupational injury in agriculture. As part of a population-based case-control study, we studied risk factors for machine-related farm injuries. Case patients were farm residents residing in a geographically defined area of central Wisconsin who experienced a farm injury associated with a tractor, farm implement, or other machine which required medical or chiropractic care from May 1990 through April 1992. Controls were selected from an ad hoc census of farm residents in the same area. Telephone interviews regarding demographic characteristics, safety behaviors, and farming practices were completed for 97.8% of 90 case patients and for 82.8% of 221 control subjects. Personal characteristics significantly associated with an increased risk of machine-related injury included the number of hours worked per week and working primarily as a farmer. Dairy farms, farms with nonresident workers, and large farms were associated with an increased risk of injury while farms with registered cows and farms where cows were fed in the barn even in summer experienced fewer injuries. Based on a logistic regression model, the independent risk factors for machine-related farm injury included hours worked per week (2% increased risk/nonresident workers on farm (odds ratio) (OR) = 2.32; 95% confidence interval (CI): 1.07 to 5.06), cows fed in barn in summer (OR = 0.28; 95% CI: 0.12 to 0.64), and registered cows on farm (OR = 0.36; 95% CI: 0.17 to 0.79). Farm safety practices did not appreciably influence the risk of machine-related farm injury.

Incidence of farm-work-related acute injury in a defined population.

To determine occurrence and sources of farm-work-related injury, we conducted a population-based, prospective study in a large clinic and hospital serving a defined rural area. The population at risk was identified through a unique demographic and medical records linkage system and a special agricultural census. Cases were 510 individuals who sought inpatient or outpatient care from May 1990 through April 1992 from a physician or chiropractor for harm resulting from acute exposure to energy. One per 31 farm residents was treated annually for a farm-work-related injury. Eight percent of these cases were hospitalized. Animals were the most frequent source of injury. Severity did not differ between cases associated with animals, machinery, falls, or chemicals. Thirty-eight percent of farm-work-related injury cases occurred in nonfarm residents. Injury risk was 2.5 times greater among dairy farm residents than among nondairy farm residents, 352.0 vs. 141.0 cases per 10,000 person-years, respectively. Adult male farm residents had 556.9 injuries per 10,000 person-years and 21.3 injuries per million hours of farm work.

Summary of hunting injuries in central Wisconsin: a 4-year experience at a rural referral center.

Surveillance of hunting-associated injuries was performed over a 4-year period at a rural Emergency Department in central Wisconsin. Over that period of time, 125 individuals sought treatment for hunting-related injuries. The majority of injuries were related to autumn deer hunting and included both gun and bow and arrow hunting. Over half of the persons injured while hunting with a bow and arrow fell from a height. The admission rate for persons in the immediate area was 35.1%, but for those from outside the area, it was 64.8%. The effects of the referral bias result in severe injuries being seen in rural Emergency Departments during hunting seasons, necessitating such departments to be prepared for a wide range of injuries.

The relationship of farm residency status to demographic and service characteristics of agricultural injury victims in central Wisconsin.

This study performed a surveillance of a defined population in central Wisconsin during a two-year period that included six months of follow-up. The study included those who worked and lived on farms and those who only worked on farms. The injury rate for farm residents was 3.15 injuries per 100 persons per year. However, 195 of the 510 injuries (38.2%) involved persons who were not farm residents. For nonfarm residents, 88.7 percent of the victims were male, whereas for farm residents 79 percent of the victims were male. More than one half of the farm residents who were injured were the owners and an additional 21 percent were juvenile children. Of those aged 18 to 29 years, 51.3 percent were nonfarm resident victims and 15.2 percent were farm resident victims. Of nonfarm residents, 41.1 percent were married; of farm residents, 65.3 percent were married. More than one half of all injured nonfarm residents were seen within two hours of injury while one quarter of the injured farm residents were seen more than 24 hours after the injury. Only 4 percent of the injured farm residents were self-insured, but 15 percent of the nonfarm residents were self-insured. However, the time of injury, actual injuries, diagnoses rendered, and services received were similar for injured farm residents and injured nonfarm residents. Effective attempts to intervene on agricultural injuries will need to consider different risk factors for injuries for nonfarm residents as compared to farm residents.

Recreational injuries and deaths in northern Wisconsin: analysis of injuries and fatalities from snowmobiles over 3 years.

Snowmobiles represent the second most common cause of trauma related to motorized vehicles in northern Wisconsin. The epidemiology of these injuries is evaluated. Specific comparisons between snowmobiles and other vehicles are made. We conclude that snowmobiles represent a controllable etiology for injuries and death. Our data suggest some interventions to prevent injuries and improve treatment.

Prehospital care of agricultural injuries.

In the United States, farming has become one of the most dangerous occupations. There are unique challenges for the providers of prehospital care to victims of agricultural trauma. The machinery and the work environment associated with agricultural trauma are different from those encountered in other occupations. The unique features of the machinery and risks are discussed. In addition, solutions unique to the problems of agricultural prehospital care are discussed. Effective care of the victims of agricultural trauma has a potential to reduce morbidity.

Posterior hip dislocation in a rural emergency department.

Traumatic posterior dislocation of the hip is an infrequent but potentially severe injury. A commonly recognized cause of such injuries is motor vehicle accidents. There is increasing recognition, however, that this injury can be associated with other activities including several sports. Appropriate care requires recognition and prompt treatment to prevent long-term sequelae. A review of these experiences in a rural emergency department demonstrates additional causative agents and associated events as well as makes recommendations for care.

Agricultural injuries in children in central Wisconsin.

Agriculture is widely recognized as one of the most dangerous occupations in the United States. The risk of agricultural trauma extends beyond the adult work force to include farm children. During a 2-year study of agricultural trauma conducted at the Marshfield Clinic/St. Joseph's Hospital, 246 (26.9%) of all agricultural injury victims were children (age less than 19 years). Teenagers were at greatest risk, but there were also many injuries among preschool children under the age of 6 years. Injuries occurred most often during the summer months, on weekends, and during the evening hours from 6:00 PM to 10:00 PM. There were relationships between the body part injured and the age of the child as well as between the agent associated with the injury and the age and gender of the child. Preschool farm children are particularly liable to experience head and neck trauma and injuries resulting from falls. Any successful effort to address either the prevention or treatment of agricultural trauma will need to consider that children have a unique pattern of injuries that differs from that of adults.

All-terrain vehicle injuries in central Wisconsin: a continuing problem.

All-terrain vehicles (ATVs) have become well recognized as associated with injuries. This recognition has resulted in attempts at education and regulation to reduce the number and severity of injuries and number of deaths. The Marshfield Clinic and St. Joseph's Hospital surveyed all-terrain vehicle accidents in the Emergency Department in 1985 and again in 1988 and followed these patients for at least 1 year after the injury. Between the two dates, extensive educational and legislative activity had taken place. The actual number of all-terrain vehicle accidents had increased. The characteristics of victims who were involved in all-terrain vehicle accidents did not change. The actual number of accidents associated with three-wheeled ATVs did not appreciably decrease but the number of accidents associated with four-wheeled ATVs did increase. To date, it is not clear that legislative and educational activities are effective in reducing the number of ATV accidents or in changing the pattern of the accidents.