Recommended medical and non-medical factors to assess military preventable deaths: subject matter experts provide valuable insights.

INTRODUCTION: Historically, there has been variability in the methods for determining preventable death within the US Department of Defense. Differences in methodologies partially explain variable preventable death rates ranging from 3% to 51%. The lack of standard review process likely misses opportunities for improvement in combat casualty care. This project identified recommended medical and non-medical factors necessary to (1) establish a comprehensive preventable death review process and (2) identify opportunities for improvement throughout the entire continuum of care. METHODS: This qualitative study used a modified rapid assessment process that includes the following steps: (1) identification and recruitment of US government subject matter experts (SMEs); (2) multiple cycles of data collection via key informant interviews and focus groups; (3) consolidation of information collected in these interviews; and (4) iterative analysis of data collected from interviews into common themes. Common themes identified from SME feedback were grouped into the following subject areas: (1) prehospital, (2) in-hospital and (3) forensic pathology. RESULTS: Medical recommendations for military preventable death reviews included the development, training, documentation, collection, analysis and reporting of the implementation of the Tactical Combat Casualty Care Guidelines, Joint Trauma System Clinical Practice Guidelines and National Association of Medical Examiners autopsy standards. Non-medical recommendations included training, improved documentation, data collection and analysis of non-medical factors needed to understand how these factors impact optimal medical care. CONCLUSIONS: In the operational environment, medical care must be considered in the context of non-medical factors. For a comprehensive preventable death review process to be sustainable in the military health system, the process must be based on an appropriate conceptual framework implemented consistently across all military services.

Outcomes in acute orthopaedic trauma: a review of 130,506 patients by age.

There is a paucity of large cohort studies that address outcomes after acute orthopaedic trauma. The regional trauma registry is a powerful tool to study trends of large populations over long periods of time. We used such a regional trauma registry to review retrospectively a large subset of orthopaedic trauma patients over a long period of time and to evaluate the relationship between initial presentation, hospital course, hospital charges, and outcomes as a function of age. A retrospective review of 130,506 level I and II trauma admissions with acute orthopaedic injuries over 10 years (1985-1995) was conducted. Aggregate data were analyzed among five age groups. Descriptive analyses were conducted for mechanism of injury, mortality, time to death, injury type, injury severity score (ISS), Glasgow Coma Scale (GCS) on presentation, length of stay (LOS), discharge destination, and hospital charges. Forty-six percent of the patients were in the 18-35-year-old age group; however, 21% of all patients were older than 65 years of age at the time of injury. There were no differences in GCS or ISS on admission. Injury types were similar across all age groups, mostly extremity fractures. Younger patients were much more likely to be injured in a motor vehicle accident (MVA), whereas older patients were injured in a fall. Penetrating trauma was seen almost exclusively in the young. LOS in the hospital was longer in the elderly; however, LOS in the intensive care units were similar across all age groups. Time to death from initial presentation differed across age groups. Elderly patients who eventually died were much more likely to survive more than 24 h in the hospital as compared with young patients. Hospital charges per hospitalization increased with age, although the total charges to the youngest age group were higher due to the group's high volume. Younger American trauma patients with acute orthopaedic injuries are much more likely than their older counterparts to sustain penetrating trauma and pass the socioeconomic burden to society by way of large opportunity costs, lack of insurance, and high rates of recidivism. Elderly patients fared as well as younger patients after acute orthopaedic trauma, although their hospital stays were longer and resulted in increased hospital charges. The excessive costs of trauma, $100 billion and more than 150,000 deaths annually, necessitate study of general population trends. Indirect costs, including rehabilitation costs and opportunity costs, as well as direct costs, are incurred during the post-trauma hospitalization. Attention must focus on prevention of penetrating injuries in the young and falls in the elderly to reduce morbidity, mortality, and the costs of trauma.

A critical analysis of on-scene helicopter transport on survival in a statewide trauma system.

BACKGROUND: Recently, questions have been raised regarding the effectiveness of helicopters in trauma care. We conducted a retrospective study to evaluate the effect of on-scene helicopter transport on survival after trauma in a statewide trauma system. METHODS: Data were obtained from a statewide trauma registry of 162,730 patients treated at 28 accredited trauma centers. Patients transported from the scene by helicopter (15,938) were compared with those transported by ground with advanced life support (ALS) (6,473). Interhospital transfers and transports without ALS were excluded. Statistical analysis was performed using one-way analysis of variance and logistic regression. RESULTS: Patients transported by helicopter were significantly (p < 0.01) younger, were more seriously injured, and had lower blood pressure. They were also more likely to be male and to have systolic blood pressure < 90 mm Hg. Logistic regression analysis revealed that when adjusting for other risk factors, transportation by helicopter did not affect the estimated odds of survival. CONCLUSION: A reappraisal of the cost-effectiveness of helicopter triage and transport criteria, when access to ground ALS squads is available, may be warranted.

Blunt duodenal rupture: a 6-year statewide experience.

OBJECTIVES: To characterize the incidence, presentation, diagnostic features, injury pattern, and mortality of blunt duodenal rupture. METHODS: The records of 103,864 patients entered into a state-wide trauma registry during a 6-year period were screened for the diagnosis of blunt duodenal injury. The hospital records of all patients meeting diagnostic criteria of blunt duodenal rupture from 28 trauma centers were reviewed. RESULTS: Blunt duodenal injury was identified in 206 (0.2%) patients. Thirty (14.5%) of these had full-thickness rupture of the duodenum. Of these 30 patients, 21 had been involved in motor vehicle crashes. Twenty-five presented with either abdominal pain, tenderness, or guarding on physical examination. Diagnostic peritoneal lavage was performed on 12 patients. Three patients were found to have isolated rupture of the duodenum. Computerized tomography was the primary diagnostic investigation in eighteen cases. Extravasation of contrast was noted in only two cases. Four studies were interpreted as normal. The second portion of the duodenum was most commonly injured, and there was a high incidence of associated intra-abdominal injuries. Seven patients underwent operation >12 hours after admission. Twenty-six patients survived to hospital discharge. Two deaths were caused by duodenal injury-related sepsis. CONCLUSION: Blunt rupture of the duodenum is rare. Most blunt duodenal injuries do not result in full-thickness injury. The majority of patients with duodenal rupture presented with either a history or a physical examination suggestive of intra-abdominal injury. Computerized tomography results were often negative or nonspecific. Delay in diagnosis of duodenal rupture remains common but does not appear to affect mortality. Overall mortality was lower than previously reported.