Emergency response team: Hurricane Georges in Key West.

Hurricane Georges (category 2) struck Key West, Florida, on September 25, 1998. Lower Florida Keys Hospital, which serves Key West and the Lower Keys, had previously been evacuated of inpatients and staff. An emergency response team composed of three emergency medicine (EM) physicians and four EM nurses was sent at the request of the state to maintain emergency department (ED) operations at the hospital. Eighty-six patients presented to the ED during the 72-hour period. Medical problems accounted for the majority of visits (52.3%), with minor trauma next (41.9%). Initially, patients requiring hospitalization were evacuated, but as the storm neared, this was stopped. Six patients required hospitalization at Lower Florida Keys Hospital during the period that evacuations were unavailable. Four deaths occurred during the 24-hour period. Complicating factors included environmental conditions, limited laboratory and radiologic studies, limited medication stocks, and closure of local pharmacies before and after the hurricane. More than 300 nursing home patients were housed at the nearby jail shelter. Knowledge of such high-risk groups that remain in the vicinity is crucial to planning a response plan.

Natural history of infrainguinal vein graft stenosis relative to bypass grafting technique.

PURPOSE: To determine whether the incidence of vein graft stenosis is related to bypass grafting technique and thus modification of postoperative surveillance protocols may be required. METHODS: From 1991 to 1996, 338 infrainguinal vein bypasses constructed using in situ (n = 131), reversed (n = 120), nonreversed translocated (n = 48), or spliced/upper extremity vein (n = 39) grafting techniques were evaluated by intraoperative duplex scanning to optimize bypass construction and serially thereafter to detect developing vein graft stenoses. Bypass procedures were performed in 322 patients for critical limb ischemia (83%), claudication (13%), or popliteal aneurysm (4%). Using life-table analysis, graft patency and revision/failure rates were compared relative to grafting technique, need for operative revision, and intraoperative duplex scan results. RESULTS: Three-year primary and secondary graft patency rates were higher (p < 0.001) for in situ bypass grafts (85%/97%) compared with reversed (57%/83%), nonreversed translocated (62%/78%), or alternative (51%/76%) vein bypass grafts. During a mean follow-up interval of 19 months, the incidence of graft revision was higher for reversed saphenous (23%) and alternative (28%) vein bypass grafts compared with in situ (10%) or nonreversed (16%) saphenous vein bypass grafts. Despite a normal intraoperative graft duplex scan, the revision/failure rate of reversed vein grafts was 2.5 times greater than in situ/nonreversed translocated vein conduits (primary patency rate at 3 years, 60% vs 87%, p = 0.009). Bypass grafts modified at operation on the basis of duplex scanning were two times more likely to require postoperative revision than grafts with normal intraoperative scans. CONCLUSIONS: The incidence of postoperative graft stenosis and need for revision varies with bypass grafting technique. Reversed vein bypasses and grafts modified at operation may be more prone than in situ vein bypass grafts to develop stenosis and thus require intensive surveillance. Infrainguinal vein graft failure and the need for revision may be reduced by the adoption of bypass grafting techniques that include valve lysis and intraoperative duplex scan assessment.