Is low-molecular-weight heparin safe for venous thromboembolism prophylaxis in patients with traumatic brain injury? A Western Trauma Association multicenter study.

BACKGROUND: Venous thromboembolism (VTE) is a significant risk in trauma patients. Although low-molecular weight heparin (LMWH) is effective in VTE prophylaxis, its use for patients with traumatic intracranial hemorrhage remains controversial. The purpose of this study was to evaluate the safety of LMWH for VTE prophylaxis in blunt intracranial injury. METHODS: We conducted a retrospective multicenter study of LMWH chemoprophylaxis on patients with intracranial hemorrhage caused by blunt trauma. Patients with brain Abbreviated Injury Scale score of 3 or higher, age 18 years or older, and at least one repeated head computed tomographic scan were included. Patients with previous VTE; on preinjury anticoagulation; hospitalized for less than 48 hours; on heparin for VTE prophylaxis; or required emergent thoracic, abdominal, or vascular surgery at admission were excluded. Patients were divided into two groups: those who received LMWH and those who did not. The primary outcome was progression of intracranial hemorrhage on repeated head computed tomographic scan. RESULTS: The study included 1,215 patients, of which 220 patients (18.1%) received LMWH and 995 (81.9%) did not. Hemorrhage progression occurred in 239 of 995 control subjects and 93 of 220 LMWH patients (24% vs. 42%, p < 0.001). Hemorrhage progression occurred in 32 patients after initiating LMWH (14.5%). Nine of these patients (4.1%) required neurosurgical intervention for hemorrhage progression. CONCLUSION: Patients receiving LMWH were at higher risk for hemorrhage progression. We were unable to demonstrate safety of LMWH for VTE prophylaxis in patients with brain injury. The risk of using LMWH may exceed its benefit. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Western Trauma Association critical decisions in trauma: management of the mangled extremity.

BACKGROUND: The operative management of mangled extremities after trauma remains controversial. We have sought to develop an evidence-based algorithm to help guide practitioners when faced with these relatively infrequent but very challenging clinical dilemmas. METHODS: The Western Trauma Association Critical Decisions Committee queried the literature to identify high-quality managements that would help guide the care of mangled extremities. When good data were not available, the Committee relied on expert opinions, either from the literature or from our senior members. RESULTS: Virtually, all the scoring systems used to guide therapy have not been proven to be valid. Hemodynamically unstable patients who failed to respond to initial resuscitation should be taken to the operating room for exploration and vascular control. Those who are stable should undergo a stepwise vascular and neurologic evaluation process. A comprehensive evaluation of factors that may help predict the appropriateness of limb salvage should be done in the operating room. Patients who are not candidates for salvage should undergo primary amputation. Those who are should undergo attempts at limb salvage. CONCLUSIONS: Patients with mangled extremities remain a significant management challenge. This algorithm represents a guideline based on the best evidence available in the literature and expert opinion. It does not establish a standard of care. It should provide a framework for treating physicians and other healthcare professionals to guide therapy, considering individual patients' clinical status and institutional resources.

Sew it up! A Western Trauma Association multi-institutional study of enteric injury management in the postinjury open abdomen.

BACKGROUND: Use of damage control surgery techniques has reduced mortality in critically injured patients but at the cost of the open abdomen. With the option of delayed definitive management of enteric injuries, the question of intestinal repair/anastomosis or definitive stoma creation has been posed with no clear consensus. The purpose of this study was to determine outcomes on the basis of management of enteric injuries in patients relegated to the postinjury open abdomen. METHODS: Patients requiring an open abdomen after trauma from January 1, 2002 to December 31, 2007 were reviewed. Type of bowel repair was categorized as immediate repair, immediate anastomosis, delayed anastomosis, stoma and a combination. Logistic regression was used to determine independent effect of risk factors on leak development. RESULTS: During the 6-year study period, 204 patients suffered enteric injuries and were managed with an open abdomen. The majority was men (77%) sustaining blunt trauma (66%) with a mean age of 37.1 years±1.2 years and median Injury Severity Score of 27 (interquartile range=20-41). Injury patterns included 81 (40%) small bowel, 37 (18%) colonic, and 86 (42%) combined injuries. Enteric injuries were managed with immediate repair (58), immediate anastomosis (15), delayed anastomosis (96), stoma (10), and a combination (22); three patients died before definitive repair. Sixty-one patients suffered intra-abdominal complications: 35 (17%) abscesses, 15 (7%) leaks, and 11 (5%) enterocutaneous fistulas. The majority of patients with leaks had a delayed anastomosis; one patient had a right colon repair. Leak rate increased as one progresses toward the left colon (small bowel anastomoses, 3% leak rate; right colon, 3%; transverse colon, 20%; left colon, 45%). There were no differences in emergency department physiology, injury severity, transfusions, crystalloids, or demographic characteristics between patients with and without leak. Leak cases had higher 12-hour heart rate (148 vs. 125, p=0.02) and higher 12-hour base deficit (13.7 vs. 9.7, p=0.04), suggesting persistent shock and consequent hypoperfusion were related to leak development. There was a significant trend toward higher incidence of leak with closure day (χ for trend, p=0.01), with closure after day 5 having a four times higher likelihood of developing leak (3% vs. 12%, p=0.02). CONCLUSIONS: Repair or anastomosis of intestinal injuries should be considered in all patients. However, leak rate increases with fascial closure beyond day 5 and with left-sided colonic anastomoses. Investigating the physiologic basis for intestinal vulnerability of the left colon and in the open abdomen is warranted.

Improving surgical site infections: using National Surgical Quality Improvement Program data to institute Surgical Care Improvement Project protocols in improving surgical outcomes.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) began with the Veterans Affairs system to reduce morbidity and mortality by evaluating preoperative risk factors, postoperative occurrences, mortality reports, surgical site infections, and patient variable statistics. Our institution enrolled in NSQIP July 2006. The Surgical Care Improvement Project (SCIP) was developed to reduce surgical complications, including surgical infections. We began instituting SCIP protocols in July 2007. STUDY DESIGN: This is a retrospective review of the NSQIP data collected by our NSQIP nurse. The colorectal surgical site infection (SSI) data pre- and post-institution of SCIP guidelines are analyzed. Data from the July 2006 to June 2007 and July 2007 to June 2008 reports are compared. Rates of SCIP compliance are analyzed. RESULTS: There were 113 colorectal cases in the July 2006 to June 2007 NSQIP report. The rate of superficial SSI was 13.3%, with an expected rate of 9.7% (p = 0.041). The observed-to-expected ratio was 1.39. Compliance with SCIP was 38%. There were 84 colorectal cases in the July 2007 to June 2008 NSQIP report. The rate of superficial SSI was 8.3%, with an expected rate of 10.25% (p = 0.351). The observed-to-expected ratio was 0.81. Compliance with SCIP measures was 92%. CONCLUSIONS: Participation in NSQIP can identify areas of increased morbidity and mortality. Our institution was a high outlier in superficial SSI in colorectal patients during the first NSQIP evaluations. SCIP guidelines were instituted and a statistically significant reduction in our rates of SSI was realized. As our compliance with SCIP improved, our rates of superficial SSI decreased. Reduction in superficial SSI decreases cost to the patient and decreases length of stay.

Critical evaluation of pulmonary contusion in the early post-traumatic period: risk of assisted ventilation.

This study attempts to accurately quantify pulmonary contusion and predict those patients most likely to require assisted ventilation early in their hospital course. Patients admitted to a Level I trauma center were evaluated for pulmonary contusion by helical CT scan. Scans were reviewed by a single radiologist who attempted to accurately quantify contusion as a percentage of total lung volume. These patients were then followed for 48 hours in an attempt to use CT measurements of contusion to predict those that would require assisted ventilation early in their hospital course. After using numerous exclusion criteria, 152 patients were included in the study. Of these, 31 patients (20%) required assisted ventilation within 48 hours of hospital admission. Twenty per cent pulmonary contusion proved to be a highly predictive variable leading to need for assisted ventilation. Of patients sustaining <20 per cent contusion, only 7 of 92 (8%) required assisted ventilation versus 24 of 60 (40%) sustaining >20 per cent contusion. Pulmonary contusion is a significant injury especially when contusion volume exceeds 20 per cent of total lung volume. With accurate measurement of contusion, we can identify those patients at high risk of requiring assisted ventilation early in their hospital course.

Four years of an aggressive prophylaxis and screening protocol for venous thromboembolism in a large trauma population.

BACKGROUND: This retrospective review of a prospectively collected database was conducted to analyze the efficacy of 4 years of aggressive prophylaxis and screening protocols for venous thromboembolism (VTE) in a large population of trauma patients. METHODS: Trauma patients at a Level I Trauma Center found to be nonambulatory or otherwise high risk were placed on a protocol of lower-extremity (LE) compression devices and subcutaneous enoxaparin as soon as feasible after admission. Duplex scans of LEs were conducted weekly. RESULTS: During 4 years, 2,939 patients were admitted to trauma with length of stay >2 days. There was a 3.2% incidence of VTE in the length of stay >2 days population, 2.5% rate of deep venous thrombosis (DVT), and 0.7% pulmonary embolism. All VTE patients had factors known to increase risk of VTE and were included in our prophylaxis and screening protocol. Twenty-one percent of these received pharmacologic prophylaxis within the first 2 days of admission; 62% received enoxaparin at some point before diagnosis of VTE. Duplex scans were conducted in 982 patients. Notably, 86% of LE DVTs were found on routine screening duplex. CONCLUSION: To our knowledge, this is the largest population of trauma patients followed by screening duplexes. All patients with VTEs were identified as high risk, and screening revealed multiple patients with an asymptomatic DVT. We conclude our aggressive prophylaxis regimen lead to low rates of VTE and think screening duplex is a critical component for identifying unsuspected DVT.

All-terrain vehicle injuries: are they dangerous? A 6-year experience at a level I trauma center after legislative regulations expired.

All-terrain vehicles (ATVs) have increased in popularity and sales since 1971. This rise in popularity led to an increase in injuries resulting in voluntary industry rider safety regulations in 1988, which expired without renewal in 1998. Our purpose was twofold, to determine the incidence and severity of ATV injuries in our patient population and what, if any impact the safety regulations had. To further characterize the risk of ATV use, we compared them to a vehicle generally recognized as dangerous, the motorcycle (MC). Our trauma registry was reviewed from January 1998 through August 2004 for ATV or MC injured. Data collected included age, gender, mortality, Injury Severity Score (ISS), helmet use, and injury distribution. These were compared to our data from the decade of regulation. There were 352 MC and 221 ATV patients. ATV injured demonstrated a higher proportion of pediatric and female patients (P < 0.001 and P < 0.01, respectively), a decrease in helmet use (8.6% vs 64.7%, P < 0.001), and increased closed head injuries (CHI) (54.2% vs 44.9%, P < 0.05) compared with MC injured. ISS and mortality were similar. The average number of patients from 1988 to 1998 was 6.9/yr compared to 31.6/yr (P < 0.001) during 1998-2004 with equal ISS. Our data show that there has been a dramatic and progressive increase in the number of ATV crashes since expiration of industry regulations. ATVs are as dangerous as MCs based on patient ISS and mortality. There are significantly more children and women injured on ATVs. The lower rate of helmet use in ATVs may account for the significantly greater incidence of CHI. These data mandate the need for injury prevention efforts for ATV riders, in particular children, through increased public awareness and new legislation.

Post hoc mortality analysis of the efficacy trial of diaspirin cross-linked hemoglobin in the treatment of severe traumatic hemorrhagic shock.

BACKGROUND: The efficacy trial of diaspirin cross-linked hemoglobin (DCLHb) in traumatic hemorrhagic shock demonstrated an unexpected mortality imbalance, prompting a three-step review to better understand the cause of this finding. METHODS: Patients were enrolled in this DCLHb hemorrhagic shock study using 28-day mortality as the primary endpoint. Mortality data were primarily analyzed using the TRISS method and a nonblinded clinical review, followed by an independent Pennsylvania Trauma Outcome Study (PTOS)-derived probability of survival analyses. Finally, a trauma expert conducted a blinded clinical review of cases incorrectly predicted by these PTOS analyses. RESULTS: More of the DCLHb patients predicted to survive using TRISS actually died than in the control subgroup (24% vs. 3%, p < 0.002). Nonblinded clinical review noted that 72% of the patients who died had prior traumatic arrest, a presenting Glasgow Coma Scale score of 3, or a base deficit > 15 mEq/L. DCLHb patients predicted to survive using PTOS also more often died than did control patients (30% vs. 8%, p < 0.04). Blinded clinical review determined that 94% of the deaths were clinically justified. Both the TRISS and the PTOS models gave an adjusted mortality relative risk of 2.3, similar to the unadjusted risk data. CONCLUSION: Mortality analysis in this shock study involved both clinical case reviews and mortality prediction models. Despite the observation that nearly all of the deaths were clinically justified, the TRISS and PTOS models demonstrated excess unpredicted deaths in the DCLHb subgroup. A combined process, using both mortality prediction models and clinical case reviews, is useful in trauma studies that use a mortality endpoint.

Factors of failure for nonoperative management of blunt liver and splenic injuries.

A review of the literature describing the management of hepatic and splenic injuries indicates that as many as 67% of exploratory celiotomies for blunt trauma are reported as nontherapeutic. Avoiding unnecessary surgery through nonoperative management offers an attractive alternative. Nonetheless, nonoperative management should not be considered unless the patient meets the following criteria: (1) hemodynamic stability, with or without minimal fluid resuscitation; (2) no demonstrable peritoneal signs on abdominal examination; and (3) the absence on computed tomography (CT) scan of any intraperitoneal or retroperitoneal injuries that require operative intervention. Although a patient may meet these criteria, several additional factors can serve as predictors of failure of nonoperative management. Such predictors among patients with hepatic injuries are hemodynamic instability, liver injury of American Association for the Surgery of Trauma grades IV and V (especially when accompanied by hemodynamic instability), and pooling of contrast on CT scan. Formerly thought to be a predictor of failure of nonoperative management, periportal tracking has not been cited as such in recent reports of hepatic injuries. Among patients with blunt splenic injuries, such predictors include hemodynamic instability, injury of grade IV or higher, large associated hemoperitoneum, and contrast blush on CT scan. Although preexisting splenic disease and age older than 55 years have traditionally been considered predictors of failure, recent reports have shown that these characteristics do not appear to be associated with an increased need for surgical intervention.

Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis.

BACKGROUND: The use of ultrasound (U/S) for the evaluation of patients with blunt abdominal trauma is gaining increasing acceptance. Patients who would have undergone computed tomographic (CT) scan may now be evaluated solely with U/S. Solid organ injuries with minimal or no free fluid may be missed by surgeon sonographers. OBJECTIVE: The purpose of this study was to describe the incidence and clinical importance of liver and splenic injuries with minimal or no free intraperitoneal fluid visible on CT scan. We hypothesized that these solid organ injuries occur infrequently and are of minor clinical significance. METHODS: Patient records and CT scans were reviewed for the presence of and outcome associated with blunt liver and splenic injuries with minimal (<250 mL) or no free fluid detected by an attending radiologist. Data were collected from six major trauma centers during a 4-year period before the introduction of U/S and included demographics, grade of injury (American Association for the Surgery of Trauma scale), need for operative intervention, and outcome. RESULTS: A total of 938 patients with liver and splenic injuries were identified. In this group, 11% of liver injuries and 12% of splenic injuries had no free fluid visible on CT scan and could be missed by diagnostic peritoneal lavage or U/S. Of the 938 patients, 267 (28%) met the inclusion criteria; 161 had injury to the spleen and 125 had injury to the liver. In the 267 patients studied, 97% of the injuries were managed nonoperatively. However, 8 patients (3%) required operative intervention for bleeding. Compared with the liver, the spleen was significantly more likely to bleed (p = 0.01), but the grade of splenic injury was not related to the risk for hemorrhage (p = 0.051). CONCLUSION: Data from this study suggest that injuries to the liver or spleen with minimal or no intraperitoneal fluid visible on CT scan occur more frequently than predicted but usually are of minimal clinical significance. However, patients with splenic injuries may be missed by abdominal U/S. We found a 5% associated risk of bleeding. Therefore, abdominal U/S should not be used as the sole diagnostic modality in all stable patients at risk for blunt abdominal injury.

Use of the laryngeal mask airway in air transport when intubation fails.

BACKGROUND: A prospective, nonrandomized cohort study was conducted to determine the effectiveness of the laryngeal mask airway (LMA) for management of the difficult airway in patients requiring air transport. METHODS: The LMA was inserted in those patients who could not be successfully intubated. Data were collected to evaluate the effectiveness of the LMA and to document any complications attributed to its use. RESULTS: Inclusion criteria were met in 17 of the 25 patients receiving an LMA. The device was inserted successfully in 16 of 17 of the patients (94%). In-flight oxygen saturation ranged from 97 to 100%, and end-tidal carbon dioxide ranged from 24 to 35 mm Hg. At arrival, initial arterial blood gas values indicated adequate oxygenation in all patients and adequate ventilation in 15 of 16 patients (94%). There was no evidence of complications. CONCLUSION: Our patient data show that when conventional methods have failed, the LMA can be safely, rapidly, and effectively used for temporary airway control.

Ultrasound: impact on diagnostic peritoneal lavage, abdominal computed tomography, and resident training.

Our objective was to determine the impact of abdominal ultrasound (US) on 1) the use of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (ACT) for diagnosing blunt abdominal trauma (BAT) and on 2) surgical resident training. The study design was a retrospective chart review. Patients sustaining BAT who had ACT or DPL done during the 1-year period before the introduction of US (pre-US) were compared with those from a 1-year period beginning 6 months after US (post-US). Data collected included diagnostic modality, demographic data, mortality, associated injuries, length of stay, mechanism of injury, and number of exploratory laparotomies. Of 128 patients in the pre-US group, 35 patients (27%; P < 0.001) underwent DPL, 0 patients (0%; P < 0.001) received US, and 92 patients (72%) received ACT, with positive results for 31 patients (34%). Exploratory laparotomy was performed on 35 patients (27%) in the pre-US group. Of 140 patients in the post-US group, 8 patients (6%; P < 0.001) underwent DPL, 120 patients (85%; P < 0.001) received US, and 108 patients (77%) received ACT, with positive results for 44 patients (42%). Exploratory laparotomy was performed on 22 patients (15%; P < 0.001) in the post-US group. Resident experience with DPL before and after the introduction of US and availability of US for graduated residents was documented. Chi-square and Fisher's exact test were used for statistical analysis. Resident experience changed from 22 to 3 DPLs per year in the pre- and post-US groups, respectively. Ten per cent of graduating residents had US available for use after leaving this institution. US replaced DPL and resulted in slightly more positive ACT scans in assessing BAT at our institution. Paradoxically, only 10 per cent of graduating residents had US available after leaving this institution. Until the use of US for diagnosing BAT has widespread use in the community, we must question our adequacy of resident preparation for diagnosing BAT.

The role of ultrasound in patients with possible penetrating cardiac wounds: a prospective multicenter study.

BACKGROUND: Ultrasound is quickly becoming part of the trauma surgeon's practice, but its role in the patient with a penetrating truncal injury is not well defined. The purpose of this study was to evaluate the accuracy of emergency ultrasound as it was introduced into five Level I trauma centers for the diagnosis of acute hemopericardium. METHODS: Surgeons or cardiologists (four centers) and technicians (one center) performed pericardial ultrasound examinations on patients with penetrating truncal wounds. By protocol, patients with positive examinations underwent immediate operation. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS: Pericardial ultrasound examinations were performed in 261 patients. There were 225 (86.2%) true-negative, 29 (11.1%) true-positive, 0 false-negative, and 7 (2.7%) false-positive examinations, resulting in sensitivity of 100%, specificity of 96.9%, and accuracy of 97.3%. The mean time from ultrasound to operation was 12.1+/-5 minutes. CONCLUSION: Ultrasound should be the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate and rapid.

Focused Assessment with Sonography for Trauma (FAST): results from an international consensus conference.

OBJECTIVE: To assemble an international panel of experts to develop consensus recommendations on selected important issues on the use of ultrasonography (US) in trauma care. SETTING: R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md. The conference was held on December 4, 1997. PARTICIPANTS: A committee of two co-directors and eight faculty members, in the disciplines of surgery and emergency medicine, representing four nations. Each faculty member had made significant contributions to the current understanding of US in trauma. RESULTS: Six broad topics felt to be controversial or to have wide variation in practice were discussed using the ad hoc process: (1) US nomenclature and technique; (2) US for organ-specific injury; (3) US scoring systems; (4) the meaning of positive and negative US studies; (5) US credentialing issues; and (6) future applications of US. Consensus recommendations were made when unanimous agreement was reached. Majority viewpoints and minority opinions are presented for unresolved issues. CONCLUSION: The consensus conference process fostered an international sharing of ideas. Continued communication is needed to advance the science and technology of US in trauma care.

Acute intracranial boxing-related injuries in U.S. Marine Corps recruits: report of two cases.

Serious acute intracranial injuries from boxing are a recognized, albeit rare, event. Acute brain injuries such as concussion, hemorrhage, and contusion are easily recognized because of their rapid onset of neurological impairment. The sequelae of such injuries range from transient diminished cognitive function to irreversible brain damage and, on occasion, death. The more serious injuries are certainly minimized as a result of regulatory policy, improved medical awareness, and the use of safety equipment. The incidence of serious acute head injury in amateur boxing and noncompetitive boxing is lower than that found in the professional ranks. Our survey of instructional boxing in U.S. Marine Corps basic training during an 8-year period detected only three serious acute brain injuries incurred by approximately 180,000 participants, equating to one serious head injury per 60,000 participants. Serious head injuries constituted an extremely small percentage (0.3%) of the approximately 1,100 total boxing-related injuries surveyed during the period. We present two cases of serious acute brain injury incurred during noncompetitive boxing skills instruction as a part of U.S. Marine Corps basic training. A review of the data leads us to conclude that the risk of serious head injury in a well-supervised, instructional boxing program is relatively minimal. In any case, we recommend that any boxing be appropriately supervised and that specialized trauma care and an adequate transport mechanism to secure that care be readily available.

Safety and health conditions, practices, and priorities for OSHA reform: a comparison of views of New Jersey union members and safety and health professionals.

This article draws on survey and interview data from New Jersey occupational health and safety professionals and union members to provide insights into the interactions among workers, management, unions, and health and safety professionals that shape work place conditions and practices. A substantial number of both professionals and union members reported: serious or very serious health and safety problems; limited access to effective resources for addressing these problems; and the presence of serious barriers to resolving these problems. Fewer than half of the union and professional respondents reported that effective participatory mechanisms such as union/management health and safety committees existed at their work sites, and many interview respondents described situations in which serious problems might be aired but seldom resolved.

Early detection of hemoperitoneum by ultrasound examination of the right upper quadrant: a multicenter study.

BACKGROUND: The focused assessment for the sonographic examination of the trauma patient (FAST) is a rapid diagnostic test that sequentially surveys for hemopericardium and then the right upper quadrant (RUQ), left upper quadrant (LUQ), and pelvis for hemoperitoneum in patients with potential truncal injuries. The sequence of the abdominal part of the examination, however, has yet to be validated. The objectives of this multicenter study were as follows: (1) to determine where hemoperitoneum is most frequently identified on positive FAST examinations; and (2) to determine if a relationship exists between that areas and the organs injured. METHODS: Ultrasound registries from four Level I trauma centers identified patients who had true-positive FAST examinations. Demographic data, areas positive on the FAST, and organs injured were recorded; injuries were classified as multiple, single solid organ (liver or spleen), isolated hollow viscus, or retroperitoneal. Relationships between positive locations on the FAST examinations and the associations of organs injured to areas positive were assessed using McNamara's chi2 test; a p value < 0.05 was considered statistically significant. RESULTS: The RUQ was the most common site where hemoperitoneum was detected, and this was statistically significant compared with either the LUQ or the pelvis. Also, statistically significant correlations (p < 0.001) were observed between positive RUQ areas on the FAST and multiple injuries, single solid organ (liver or spleen) injury, and retroperitoneal injuries. CONCLUSION: Blood is most often found on the FAST in the RUQ area in patients with multiple intraperitoneal injuries or isolated injury to the liver, spleen, or retroperitoneum, but not when there is injury to a hollow viscus.

Factors which support effective worker participation in health and safety: a survey of New Jersey industrial hygienists and safety engineers.

Strategies for increasing worker involvement in health and safety are widespread and have received emphasis in various OSHA reform proposals; however, much remains unknown about the effectiveness of these strategies. This paper draws on a survey of more than 400 New Jersey members of the American Industrial Hygiene Association (AIHA) and the American Society of Safety Engineers (ASSE) which addressed a broad range of issues relating to health and safety conditions and practices, including the use of worker or labor/management health and safety committees (HSCs) and worker health and safety representatives. Stepwise discriminant analysis was used to explore the relationships between effective participation and variables which describe worksites and potential health and safety resources and barriers. Effective strategies for involving workers appear to be conditional on a number of variables, most importantly on worker activism and the effective use of formal union negotiations. Findings are consistent with studies from both the U.S. and abroad which emphasize the role of unions in shaping opportunities for effective worker participation.

Swine and dynamic ultrasound models for trauma ultrasound testing of surgical residents.

BACKGROUND: Trauma ultrasound workshops have been recommended for training surgical residents. We assessed the teaching effectiveness of the workshop, comparing swine and dynamic patient ultrasound models. MATERIALS AND METHODS: MCQ exams on ultrasound physics and practical skills tests with and without pericardial or peritoneal fluid using four swines and eight dynamic patient ultrasound videos were used to compare pre- and postworkshop performance in 18 surgical residents (Group I) and a matched control group of 18 (Group II). Paired t tests and unpaired t tests for paired and unpaired data, respectively, were used for analysis with a P < 0.05 being considered statistically significant. RESULTS: Mean scores (% correct response) +/- SD were as follows (*P < 0.05 vs Group I). [table: see text] For the swine model, the best scores were with pericardial fluid (25.0% pre vs 69.4% post in Group I) and the worst scores were with RUQ fluid (5.6% pre vs 22.2% post in Group I). Postworkshop dynamic video scores were always higher than the swine model scores in Group I (100% correct video scores for pericardial fluid). CONCLUSIONS: This study confirms the trauma ultrasound workshop teaching effectiveness. For testing, the swine model (especially RUQ) was more difficult. In postcourse evaluation, the dynamic human video was considered more relevant, realistic, and less costly for repeated testing of the residents.