Neuroanatomical Interpretation of the Painting Starry Night by Vincent van Gogh.

Gogh, Vincent Van (1853-1890). The Starry Night. Saint Rémy, June 1889. Oil on canvas, 29 × 36 1/4″ (73.7 × 92.1 cm). Acquired through the Lillie P. Bliss Bequest. The Museum of Modern Art. Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY.

The Statesmanship of William Crawford Gorgas, M.D., Surgeon General, Medical Corps, United States Army.

If statesmanship can be characterized as a bed rock of principles, a strong moral compass, a vision, and an ability to articulate and effect that vision, then the fortitude, tenacity, imperturbability, and resilience of William Crawford Gorgas cannot be overestimated. As Chief Sanitary Officer in Cuba and as Chief Medical Officer in Panama, he actualized strategies to eradicate the vectors of yellow fever and malaria. His superiors initially pigeonholed his requisitions, refused to provide him with any authority, and clamored for his dismissal. Nevertheless, with dogged persistence he created a coalition of the willing, who eventually implemented those reforms. As Surgeon General in the United States Army, he organized and expanded the Active Duty and Medical Reserve Corps in anticipation of World War I. Skilled university affiliated surgeons and personnel from throughout North America, manned base hospitals in Europe. Those lessons impacted upon subsequent military and civilian surgical care-organizationally, logistically, and clinically. He was universally recognized for his bonhomie, savoir-faire, modesty, discretion, decorum, courtesy, and graciousness. To those attributes must be added his devotion to duty, discipline, integrity, and authenticity, which characterized his leadership and statesmanship. Those attributes are most worthy of emulation and perpetuation by clinicians, academicians, educators, and investigators.

Re-membrance.

Traced sufficiently remotely, all people, profanum vulgus, share a common familial and linguistic heritage. Several Occidental and Oriental religiophilosophical traditions and General Systems (neuro-linguistic/neuro-semantic) Theory propound that resolution of personal illness and intra- and inter-generational psychological conflicts among individuals and within society mandates a figurative, if not a literal return, to the source of conflict or contention-to RE-MEMBER with that source-if healing, peace, resolution, concord, solace, sustenance, and wholeness are to be achieved. Words that communicate effectively, linguistic symbols such as water and the cross, and the action of laying-on-of-hands are methodologies that reaffirm a personal commonality among all traditions and facilitate RE-MEMBRANCE. For those who adhere to the Judeo-Christocentric tradition-who are called and chosen to witness and serve through the sacrament of baptism-healing, support, and sustenance are achieved by RE-MEMBRANCE through the Triune God.

Reduction in deep sternal wound infection with use of a peristernal cable-tie closure system: a retrospective case series.

BACKGROUND: Deep sternal wound infections are a rare but serious complication after median sternotomy. We evaluated the incidence of deep sternal wound infection associated with two techniques for sternal closure. METHODS: In this retrospective case series, we recorded the method of sternal closure in consecutive patients undergoing a variety of cardiothoracic surgical procedures. Sternal closure in the historical control group was performed using trans-sternal, stainless-steel wire sutures; subsequent patients were closed using wire sutures in conjunction with a novel, peristernal cable-tie closure system to reinforce the corpus sterni. Perioperative care was standardized between groups. Demographics, risk factors, and postoperative outcomes were analyzed. RESULTS: Between July 2010 and July 2014, 609 consecutive adult patients underwent sternal closure following open median sternotomy at a single hospital in Mobile, Alabama. Sternal closure was accomplished with wire sutures in the first 309 patients and with cable-tie reinforcement in the subsequent 300 patients. Baseline characteristics were comparable between groups, except that the cable-tie group exhibited greater preoperative comorbidity. Mean body mass index was comparable between groups (30.2 ± 6.6 kg/m(2) wire suture versus 30.5 ± 7.7 cable-tie, p = 0.568). Deep sternal wound infection occurred in 2.6 % (8/309) patients in the wire-suture group, whereas no deep sternal wound infections were observed in the cable tie group (p = 0.008). CONCLUSIONS: The peristernal cable-tie system was a simple and reliable method for sternal closure after open median sternotomy, and was associated with a reduced risk of deep sternal wound infection, even in an obese and comorbid population.

Pharyngostomy.

A retrospective analysis of a prospective observational study of a cohort of patients who required prolonged foregut/midgut decompression/intraluminal stenting and/or enteral nutritional support was conducted. Those patients were intolerant of protracted nasogastric intubation. They also manifested hostile peritoneal cavities and therefore were not candidates for a laparoendoscopic gastrostomy or jejunostomy. Accordingly, they underwent insertion of a pharyngogastric or pharyngojejunal tube. With patients properly positioned and anesthetized and with attention to the anatomy of the superior carotid cervical triangle, those pharyngostomies and cannulations were performed safely and efficiently. The tubes remained indefinitely or were changed/removed ad libitum. Morbidity was nil and no mortality attributable to the procedure was observed. Pharyngostomy should be part of the armamentarium of all general surgeons.

Department of Surgery/College of Medicine University of South Alabama: historical and contemporaneous perspectives.

Many members of the medical profession in Mobile, Alabama, have exemplified a strong commitment to the education of their colleagues and successors, a tradition (L., traditio, "to hand over") that dates from the early 18th century. The Mobile General (city/county) Hospital (1830 to 1970) and its successor, the Medical Center, University of South Alabama (1971 to the present), were the institutional foci of those endeavors. Because it is individuals who create, design, and vitalize institutions, this monograph is an acknowledgment of the accomplishments of those who gave that endeavor purpose, direction, and meaning, particularly with reference to the evolution of surgical education. Numerous clinical and societal forces--cultural, economic, political, and social-influenced that evolution. This compilation gives attribution to a legacy of commitment to health and medical/surgical care, education, and research within southern Alabama.

Prehospital clinical clearance of the cervical spine: a prospective study.

Physician clinical clearance of the cervical spine after blunt trauma is practiced in many trauma centers. Prehospital clinical clearance of the cervical spine (c-spine) performed by emergency medical services (EMS) personnel can decrease cost, improve patient comfort, decrease complications, and decrease prehospital time. The purpose of this study was to assess whether EMS personnel can effectively clinically clear the c-spine of injury in the prehospital setting. All paramedics from a single urban fire department were trained in clinical clearance of the c-spine. During the 14-month period from January 2008 through March 2009, clinical examination of the c-spine was performed by paramedics on blunt trauma patients in the prehospital setting. Paramedics immobilized the c-spine and delivered the patients to the University of South Alabama Medical Center. After trauma center arrival, paramedics documented their clinical examination of the c-spine in a computerized data collection form. Paramedic clinical findings were compared with trauma surgeon clinical examination findings and computed tomographic findings of the c-spine. All patients had prehospital Glasgow Coma Score 14 or greater. Patients were not excluded for distracting injuries. One hundred ninety-three blunt trauma patients were entered. Sixty-five (34%) c-spines were clinically cleared by EMS. There were no known missed injuries in this patient group. Eight (6%) patients who were not clinically cleared by EMS were diagnosed with c-spine injury. Trauma surgeons clinically cleared 135 (70%) of the patients with no known missed injury. EMS personnel in the prehospital setting may reliably and effectively perform clinical clearance of the c-spine. Further prospective study for prehospital c-spine clinical clearance is warranted.

Application of the core competencies after unexpected patient death: consolation of the grieved.

OBJECTIVES: To review and assess educational strategies and formats regarding communication with families/survivors in the aftermath of unexpected and untimely patient death. To propose an integrated curriculum designed and intended to foster proficiency, competence, confidence, and composure in relaying catastrophic information in the context of the professional experience of a cohort of seasoned surgeons. BACKGROUND: Unexpected and untimely patient death is emotionally and psychologically wrenching for families, surgeons, and healthcare providers. We have previously proffered that 2 distinct, but interactive, phases of response are relevant when communicating with a family before and after the event: a proactive phase intended to establish a positive therapeutic relationship with the family; and a reactive phase intended to respond to the family in a compassionate and respectful manner and to ensure self-care for the physicians and health care providers. STUDY DESIGN: Survey of a cohort of senior surgeons (membership of the Southern Surgical Association) and Surgical Residency Program Directors (membership of the Association of Program Directors in Surgery). RESULTS: Sixty percent of the senior surgeons surveyed had experienced unexpected patient death. They advised strategies to cope with that clinical situation commensurate with the core competencies of the Accreditation Council for Graduate Medical Education: Medical Knowledge: maximize objective information/data and minimize subjective opinion; Patient Care: critique the events and conduct postmortem analyses; Interpersonal and Communication Skills: honesty, empathy, and patience; Professionalism: provide emotional and psychological support to family and personnel with privacy and in a nonaccusatory manner; Practice-Based Learning and Improvement: preoperative discussion and documentation in the context of informed consent and advanced directives vis-á-vis risk-benefit, effort-yield, and benefit-burden analyses; and Systems-Based Practice: involve chaplains and hospital personnel. Thirty-six percent of the graduate surgical educational programs surveyed allegedly provided educational venues to enable surgical residents to cope with unexpected patient death, although the formats were not specified. CONCLUSIONS: Graduate, postgraduate, and continuing educational programs aspire to prepare physicians and surgeons for independent professional practice-scientifically, humanistically, and artistically. Incorporating educational strategies to enable graduates to cope with the emotional and psychological turmoil of unexpected patient death is relevant.

Is helicopter evacuation effective in rural trauma transport?

Helicopter transport for trauma remains controversial because its appropriate utilization and efficacy with regard to improved survival is unproven. The purpose of this study was to assess rural trauma helicopter transport utilization and effect on patient survival. A retrospective chart review over a 2-year period (2007-2008) was performed of all rural helicopter and ground ambulance trauma patient transports to an urban Level I trauma center. Data was collected with regard to patient mortality and Injury Severity Score (ISS). Miles to the Level I trauma center were calculated from the point where helicopter or ground ambulance transport services initiated contact with the patient to the Level I trauma center. During the 2-year period, 1443 rural trauma patients were transported by ground ambulance and 1028 rural trauma patients were transported by helicopter. Of the patients with ISS of 0 to 10, 471 patients were transported by helicopter and 1039 transported by ground. There were 465 (99%) survivors with ISS 0 to 10 transported by helicopter with an average transport distance of 34.6 miles versus 1034 (99.5%) survivors with ISS 0 to 10 who were transported by ground an average of 41.0 miles. Four hundred and twenty-one patients with ISS 11 to 30 were transported by helicopter an average of 33.3 miles with 367 (87%) survivors versus a 95 per cent survival in 352 patients with ISS 11 to 30 who were transported by ground an average of 39.9 miles. One hundred and thirty-six patients with ISS > 30 were transported by helicopter an average of 32.8 miles with 78 (57%) survivors versus a 69 per cent survival in 52 patients with ISS > 30 who were transported by ground an average of 33.0 miles. Helicopter transport does not seem to improve survival in severely injured (ISS > 30) patients. Helicopter transport does not improve survival and is associated with shorter travel distances in less severely injured (ISS < 10) patients in rural areas. This data questions effective helicopter utilization for trauma patients in rural areas. Further study with regard to helicopter transport effect on patient survival and cost-effective utilization is warranted.

The core competencies of James Marion Sims, MD.

The concept of core competencies in graduate medical education was introduced by the Accreditation Council for Graduate Medical Education of the American Medical Association to semiquantitatively assess the professional performance of students, residents, practitioners, and faculty. Many aspects of the career of J. Marion Sims, MD, are exemplary of those core competencies: MEDICAL KNOWLEDGE: Author of the first American textbook related to gynecology. MEDICAL CARE: Innovator of the Sims' Vaginal Speculum, Sims' Position, Sims' Test, and vesico-/rectovaginal fistulorrhaphy; advocated abdominal exploration for penetrating wounds; performed the first cholecystostomy. PROFESSIONALISM: Served as President of the New York Academy of Medicine, the American Medical Association, and the American Gynecologic Society. INTERPERSONAL RELATIONSHIPS/COMMUNICATION: Cared for the indigent, hearthless, indentured, disenfranchised; served as consulting surgeon to the Empress Eugénie (France), the Duchess of Hamilton (Scotland), the Empress of Austria, and other royalty of the aristocratic Houses of Europe; accorded the National Order of the Legion of Honor. PRACTICE-BASED LEARNING: Introduction of silver wire sutures; adoption of the principles of asepsis/antisepsis; adoption of the principles of general anesthesia. SYSTEMS-BASED PRACTICE: Established the Woman's Hospital, New York City, New York, the predecessor of the Memorial Sloan-Kettering Center for the Treatment of Cancer and Allied Diseases; organized the Anglo-American Ambulance Corps under the patronage of Napoleon III. What led him to a life of clinical and humanitarian service? First, he was determined to succeed. His formal medical/surgical education was perhaps the best available to North Americans during that era. Second, he was courageous in experimentation and innovation, applying new developments in operative technique, asepsis/antisepsis, and general anesthesia. Third, his curiosity was not burdened by rigid adherence to old doctrines or antiquated theories. Fourth, he broadened his professional experience and knowledge by travels to renowned intellectual centers in Western Europe. Fifth, he was perceived as cautiously optimistic and judiciously positive as he interacted with patients, students, and colleagues. Courage, confidence, creativity, compassion, charisma, character, and controversy marked his career. His legacy is illustrative and exemplary of the core competencies fostered contemporaneously in graduate medical educational programs.

EMS relocation in a rural area using a geographic information system can improve response time to motor vehicle crashes.

OBJECTIVE: To assess whether repositioning of ambulance stations in a rural county of Alabama can improve emergency medical services (EMS) response time to motor vehicle crashes (MVCs) without adversely affecting response time to non-MVC-related emergencies. METHODS: Using geographical information system software, locations of MVCs during a 9-month period in a rural county of Alabama were plotted on a map. A single ambulance station provided EMS for the entire county. Based on the number of ambulances serving the county and concentrated areas of MVCs, the county was geographically divided into two regions. A new ambulance station was assigned to each region based on high MVC concentrations and access to a major thoroughfare. The number of ambulances in-service did not change. Following establishment of both ambulance stations (redeployment), data were prospectively collected for EMS miles to scene, EMS time to scene, fatalities, and type of call (MVC vs. non-MVC) during a 9-month period (January 2006 to September 2006). The prospective data were compared with historical data (non-redeployment) from a similar time period (January 2005 to September 2005). RESULTS: During the redeployment period, 597 EMS calls were documented, 106 (17.8%) of which were MVCs. In all, 764 EMS calls were documented before the redeployment period, 62 (8.1%) of which were MVCs. During the redeployment period, the mean miles EMS traveled to an MVC scene was 8.6 miles versus 10.7 miles before redeployment (p=0.038). The mean time to an MVC scene was 8.0 minutes during redeployment versus 9.5 minutes before redeployment (p=0.03). During the redeployment period, the mean time to non-MVC emergencies was 8.6 minutes versus 9.2 minutes during the period before redeployment (p=0.27). CONCLUSIONS: Utilizing geographical information system software, EMS response time to MVCs could be improved in rural areas by optimal location of ambulance stations based on geographical highest concentration of MVCs and vicinity of major thoroughfares. This can be accomplished without adversely affecting response time to non-MVC-related emergencies.

Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time.

BACKGROUND: Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene. METHODS: A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room. RESULTS: Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route. CONCLUSIONS: EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.

Spirituality within the patient-surgeon relationship.

OBJECTIVE: To assess the attitudes of general and orthopaedic surgical outpatients regarding inquiry into their religious beliefs, spiritual practices, and personal faith. DESIGN: Prospective, voluntary, self-administered, and anonymously-completed questionnaire, regarding religious beliefs, spiritual practices, and personal faith, March-August, 2009. SETTING: General and orthopaedic surgical outpatient settings, Health Services Foundation, College of Medicine, University of South Alabama, a tertiary care academic medical center in Mobile, Alabama. PARTICIPANTS: All patients referred for evaluation and management of general and orthopaedic surgical conditions, pre- and postoperatively, were approached. METHODOLOGY: The questionnaire solicited data regarding patient: (1) demographics; (2) religious beliefs, spiritual practices, and personal faith; and (3) opinions regarding inquiry into those subjects by their surgeon. The latter opinions were stratified on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Statistical analysis was conducted using software JMP(®) 8 Statistical Discovery Software (S.A.S. Institute Inc., Cary, North Carolina) and a 5% probability level was used to determine significance of results. RESULTS: Eighty-three percent (83%) of respondents agreed or strongly agreed that surgeons should be aware of their patients' religiosity and spirituality; 63% concurred that surgeons should take a spiritual history; and 64% indicated that their trust in their surgeon would increase if they did so. Nevertheless, 17%, 37%, and 36% disagreed or strongly disagreed with those perspectives, respectively. CONCLUSIONS: By inference to the best explanation of the results, we would argue that religiosity and spirituality are inherent perspectives of patient-surgeon relationships. Consequently, those perspectives are germane to the therapeutic milieu. Therefore, discerning each patient's perspective in those regards is warranted in the context of an integrative and holistic patient-surgeon relationship, the intent of which is to restore a patient to health and well-being.

Action of student-resident interaction during a surgical clerkship.

BACKGROUND: This study is a qualitative assessment of the effect of clinical encounter documentation cards on medical student-surgical resident interaction during the core surgical clerkship, junior medical school year. METHODOLOGY: The implementation of a clinical encounter documentation card system occurred during academic year 2009-2010. The results were compared with historical control medical student cohorts from antecedent academic years. The perceptions of overall quality of the clerkship and effectiveness of residents as teachers were assessed using a psychometric Likert scale. RESULTS: Ninety percent of the medical students and surgical residents "agreed" or "strongly agreed" that the educational value of clinical encounters was enhanced by the documentation card system. DISCUSSION: Junior medical students receive a substantial and valuable portion of their formal surgical education from surgical residents. We argue that this documentation card system tangibly increased the educational value of clinical encounters and improved the cognitive, technical, and rhetorical skills of both medical students and surgical residents. CONCLUSION: We submit that this clinical encounter documentation card system: improved each student's educational experience and each resident's teaching ability; provided valuable information about residents as teachers; facilitated more refined assessment of their performance in relationship to the core competencies; provided timely information permitting adjustments of clinical service assignments during each rotation; and "clinical context teaching moments" were perceived as a valuable element of the core surgical clerkship.

Retrograde jejunojejunal intussusception status following Roux-en-Y gastrojejunostomy.

Reported herein is an experience with retrograde intussusception. The index case was a 25-year-old African American woman who was status post-multiple previous intraperitoneal procedures, including a truncal vagotomy, distal gastrectomy, and Roux-en-Y gastrojejunostomy for the treatment of gastric outlet obstruction secondary to type 2 peptic ulcer disease. The patient presented most recently with symptoms and signs of a high-grade mechanical intestinal obstruction. Preoperatively, computerized axial tomography revealed retrograde intussusception. Urgent exploratory celiotomy confirmed retrograde intussusception of a segment of the common channel just distal to the jejunojejunostomy. The jejunojejunostomy, including the nonreducible intussusceptum and intussuscipiens, was resected. The alimentary tract was reconstituted in conventional fashion. Light microscopic histopathologic analysis revealed acute greater than chronic inflammation, transmural edema, ischemia/necrosis of the intussusceptum, and hypertrophy of the intussuscipiens. Mechanistically, intussusception has been characterized as an internal prolapse. It usually is aboral/antegrade/isoperistaltic in direction with circumferential intraluminal invagination/prolapse/propagation/telescoping of the proximal/cephalad intussusceptum into the distal/caudad intussuscipiens. Retrograde intussusception is the reverse. More specifically, retrograde intussusception is adoral/retrograde/antiperistaltic in direction with circumferential extraluminal exvagination/propagation/telescoping of the proximal/cephalad intussuscipiens over and around the distal/caudad intussusceptum. We speculate that suture lines, staple lines, adhesive disease, and incomplete closure of mesenteric defects are proximate and determinant causes of retrograde intussusception.

Clinical examination in complement with computed tomography scan: an effective method for identification of cervical spine injury.

OBJECTIVE: The purpose of this study was to prospectively evaluate a protocol that assesses the efficacy and sensitivity of clinical examination in complement with computed tomographic (CT) scan in screening for cervical spine (c-spine) injury. METHODS: During the 26-month period from March 2005 to May 2007, blunt trauma patients older than 13 years were prospectively entered into a study protocol. If patients were awake and alert with Glasgow Coma Score (GCS) >or=14, clinical examination of the neck was performed. Clinical examination was performed regardless of distracting injuries. If the patient had no complaints of pain or tenderness, the cervical collar was removed. Patients with complaints of c-spine pain or tenderness and patients with GCS score <14 underwent CT scanning for evaluation of the entire c-spine. RESULTS: One thousand six hundred eighty seven patients were prospectively assessed for blunt c-spine injury. Fourteen hundred thirty-nine patients had GCS score >or=14, 897 (62%) of which had a negative clinical examination of the c-spine and subsequently had cervical collars removed. Two patients (0.2%) whose clinical examination results disclosed nothing abnormal were later found to have a c-spine injury. Five hundred forty-two patients with GCS score >or=14 had a positive c-spine clinical examination, of which 134 (24%) were diagnosed with c-spine injury. One hundred thirty-three (99%) c-spine injuries were identified by CT scan. The c-spine injury missed by CT scan was a radiologic misinterpretation. For patients with c-spine injury with GCS score >or=14, both sensitivities of clinical examination and CT scan were 99%. Two hundred forty-eight patients had GCS score <14, of which 5 (2.0%) were diagnosed with c-spine injury. CT scan identified all c-spine injuries for patients with GCS score <14. CONCLUSIONS: In awake and alert blunt trauma patients, clinical examination is a sensitive screening method for c-spine injury. Clinical examination allows for the majority of blunt trauma patients to have their c-spines cleared safely without radiologic screening. Clinical examination in complement with CT scan is a sensitive and an effective method for identification of c-spine injury in awake and alert patients with symptoms of c-spine injury. CT scan is the sensitive and effective test for screening and diagnosis of c-spine injury in blunt trauma patients with altered mental status.

Improving rural emergency medical service response time with global positioning system navigation.

OBJECTIVE: Rural emergency medical services (EMS) often serves expansive areas that many EMS personnel are unfamiliar with. EMS response time is increased in rural areas, which has been suggested as a contributing factor to increased mortality rates from motor vehicle crashes (MVCs) and nontraumatic emergencies. The purpose of this study was to assess the effect of a global positioning system (GPS) on rural EMS response time. METHODS: GPS units were placed in ambulances of a rural EMS provider. The GPS units were set for fastest route (not shortest distance) to the scene that depends on traffic lights and posted road speed. During a 1-year period from September 2006 to August 2007, EMS response time and mileage to the scene were recorded for MVCs and other emergencies. Response times and mileage to the scene were then compared with data from the same EMS provider during a similar 1-year period when GPS technology was not used. EMS calls less than 1-mile were removed from both data sets because GPS was infrequently used for short travel distances. RESULTS: During the 1-year period before utilization of GPS, 893 EMS calls greater than 1 mile were recorded and 791 calls recorded with GPS. The mean EMS response time for MVCs was 8.5 minutes without GPS and 7.6 minutes with GPS (p < 0.0001). When MVCs were matched for miles traveled, mean EMS response time without GPS was 13.7 minutes versus 9.9 minutes with GPS (p < 0.001). CONCLUSION: GPS technology can significantly improve EMS response time to the scene of MVCs and nontraumatic emergencies.

Anatomic location of penetrating lower-extremity trauma predicts compartment syndrome development.

BACKGROUND: Compartment syndrome of the lower extremity can be a difficult diagnosis to make with serious consequences if diagnosis and intervention is delayed. Identifying patients who are more likely to develop this syndrome can help prevent the associated complications. The purpose of this study was to evaluate whether the anatomic location of the penetrating lower-extremity injuries can predict development of compartment syndrome. METHODS: A retrospective chart review was performed of all patients admitted for a minimum of 23 hours to the University of South Alabama trauma center for penetrating lower-extremity trauma during the 8-year period from July 1998 through June 2006. Patients were entered in the study if wound trajectory was confined to the lower extremity between the inguinal ligament and the ankle. Injuries were categorized as above knee (AK) or below knee (BK), and whether the injury was in the proximal or distal half of the extremity segment. Clinical examination or compartmental pressures were used to diagnose BK compartment syndrome. RESULTS: A total of 321 patients sustained 393 lower-extremity injuries during the study period, of which 255 (65%) were AK and 138 (35%) were BK. Thirty-one (8%) lower extremities developed BK compartment syndrome with 29 (94%) secondary to penetrating injuries of the BK segment. All BK injuries that developed compartment syndrome were located in the proximal half of the BK segment. Eighteen (7%) AK injuries underwent BK 4-compartment fasciotomy, 16 (6%) of which were prophylactic after surgical intervention for AK vascular injury. Two patients (1%) developed postoperative BK compartment syndrome after superficial femoral vein ligation. All AK injuries that underwent fasciotomy sustained vascular injuries requiring surgical intervention. No BK compartment syndromes occurred in any patients with expectantly managed AK or distal BK injuries. CONCLUSIONS: Injuries to the proximal half of the BK segment are the most common cause for the development of compartment syndrome from penetrating injuries of the lower extremity. Development of BK compartment syndrome because of penetrating AK injury is rare without an associated surgically significant vascular injury. Observational admission for compartment syndrome development in patients with penetrating injury to the AK segment or distal BK segment is unnecessary.

Does increased emergency medical services prehospital time affect patient mortality in rural motor vehicle crashes? A statewide analysis.

BACKGROUND: Fatality rates from rural vehicular trauma are almost double those found in urban settings. It has been suggested that increased prehospital time is a factor that adversely affects fatality rates in rural vehicular trauma. By linking and analyzing Alabama's statewide prehospital data, emergency medical services (EMS) prehospital time was assessed for rural and urban vehicular crashes. METHODS: An imputational methodology permitted linkage of data from police motor vehicle crash (MVC) and EMS records. MVCs were defined as rural or urban by crash location using the United States Census Bureau criteria. Areas within Alabama that fell outside the Census Bureau definition of urban were defined as rural. Prehospital data were analyzed to determine EMS response time, scene time, and transport time in rural and urban settings. RESULTS: Over a 2-year period from January 2001 through December 2002, data were collected from EMS Patient Care Reports and police crash reports for the entire state of Alabama. By using an imputational methodology and join specifications, 45,763 police crash reports were linked to EMS Patient Care Reports. Of these, 34,341 (75%) were injured in rural settings and 11,422 (25%) were injured in urban settings. A total of 714 mortalities were identified, of which 611 (1.78%) occurred in rural settings and 103 (.90%) occurred in urban settings (P < .0001). When mortalities occurred, the mean EMS response time in rural settings was 10.67 minutes and 6.50 minutes in urban settings (P < .0001). When mortalities occurred, the mean EMS scene time in rural settings was 18.87 minutes and 10.83 minutes in urban settings (patients who were dead on scene and extrication patients were excluded from both settings) (P < .0001). When mortalities occurred, the mean EMS transport time in rural settings was 12.45 minutes and 7.43 minutes in urban settings (P < .0001). When mortalities occurred, the overall mean prehospital time in rural settings was 42.0 minutes and 24.8 minutes in urban settings (P < .0001). The mean EMS response time for rural MVCs with survivors was 8.54 minutes versus a mean of 10.67 minutes with mortalities (P < .0001). The mean EMS scene time for rural MVCs with survivors was 14.81 minutes versus 18.87 minutes with mortalities (patients who were dead on scene and extrication patients were excluded) (P = .0014). CONCLUSIONS: Based on this statewide analysis of MVCs, increased EMS prehospital time appears to be associated with higher mortality rates in rural settings.

On-scene intravenous line insertion adversely impacts prehospital time in rural vehicular trauma.

Fatality rates from rural vehicular trauma are almost double those found in urban settings. Increased emergency medical services (EMS) prehospital time has been implicated as one of the causative factors for higher rural fatality rates. Advanced Trauma Life Support guidelines suggest scene time should not be extended to insert an intravenous catheter (IV). The purpose of this study was to assess the association between intravenous line placement and motor vehicle crash (MVC) scene time in rural and urban settings. An imputational methodology using the National Highway Traffic Safety Administration Crash Outcome Data Evaluation System permitted linkage of data from police motor vehicle crash and EMS records. Intergraph GeoMedia software permitted this linked data to be plotted on digital maps for segregation into rural and urban groups. MVCs were defined as rural or urban by location of the accident using the U.S. Bureau of Census Criteria. Linked data were analyzed to assess for EMS time on-scene, on-scene IV insertion, on-scene IV insertion attempts, and patient mortality. Over a 2-year period from January 2001 through December 2002, data were collected from Alabama EMS patient care reports (PCRs) and police crash reports. A total of 45,763 police crash reports were linked to EMS PCRs. Of these linked crash records, 34,341 (75%) and 11,422 (25%) were injured in rural and urban settings, respectively. Six hundred eleven (1.78%) mortalities occurred in rural settings and 103 (0.90%) in urban settings (P < 0.005). There were 6273 (18.3%) on-scene IV insertions in the rural setting and 1,290 (11.3%) in the urban setting (P < 0.005). Mean EMS time on-scene when single IV insertion attempts occurred was 16.9 minutes in the rural setting and 14.5 minutes in the urban setting (P < 0.0001). When two attempts of on-scene IV insertion were made, mean EMS time on-scene in the rural setting (n = 891 [2.6%]) was 18.4 minutes and 15.7 minutes in the urban setting (n = 142 [1.2%; P < 0.005). Excluding dead on-scene patients, mean EMS time on-scene when mortalities occurred in rural and urban settings was 18.9 minutes and 10.8 minutes, respectively (P < 0.005). On-scene IV insertion occurred with significantly greater frequency in rural than urban settings. This incurs greater EMS time on-scene and prehospital time that may be associated with increased vehicular fatality rates in rural settings.