J Trauma
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A new methodology is presented for evaluating the extent to which patients within regionalized systems of trauma care are treated at the appropriate hospitals. Criteria are proposed for retrospectively classifying trauma patients as to whether they should have been treated at a trauma center. The criteria were developed by a panel of nationally recognized trauma experts and are based on the age of the patient and the type and AIS severity of injuries sustained. ⋯ Of those who were classified not to have required care at a trauma center, 62% actually were treated at non-trauma center hospitals. The congruence between where patients should have been treated and the actual level of hospital care received varied by the type and severity of the traumatic injuries sustained. The results of the analysis provide insights into the characteristics of trauma patients at higher risk of not getting the appropriate level of trauma care and should assist in improving guidelines for triage and transfer within a regionalized system of care.
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The presence of major chest wall injury is an indication for transfer to a Level I trauma center. We hypothesized that the presence of three or more rib fractures on initial chest X-ray would identify a small subgroup of patients with a high probability of requiring trauma center care. All trauma discharges in Maryland between 1984 and 1986 (N = 105,683) were reviewed. Patients were divided by the presence of rib fractures (no rib fractures, 1-2 fractures, 3+ fractures) and age in years (0-13, 14-64, 65+). ⋯ The presence of 3 or more rib fractures identifies a small subgroup of patients (2.4%) likely to require tertiary care. This triage tool is useful in all patients over the age of 14 years.
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Biography Historical Article
Samuel D. Gross: pioneer academic trauma surgeon of 19th century America.
It is appropriate on the 50th anniversary of the American Association for the Surgery of Trauma to recall the most influential trauma surgeon in 19th century America: Samuel D. Gross. Gross was an innovative surgeon whose 50-year career as a surgeon caring for injured patients encompassed orthopedics, thoracic surgery, abdominal surgery, and ophthalmology. ⋯ Gross was a teacher, occupying for 42 years Chairs of Surgery at three medical schools. Gross wore the mantle of political leadership, founding medical societies that continue today as forums for the presentation and review of new treatments for injured patients. Modern academic trauma surgeons could do no better than to emulate the career of Samuel David Gross, the Patriarch of American trauma surgeons.
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Of 29 blunt trauma victims with a diagnostic peritoneal lavage white blood cell count (DPL:WBC) greater than or equal to 500/mm3 as the sole positive lavage criterion, only four underwent laparotomy at admission, and only one of these had sustained intestinal perforation. Two of the remaining 25 succumbed to extra-abdominal injuries within 24 hours, leaving 23 patients, who were followed clinically for an average of 34.7 days. None was ever discovered to have sustained intestinal perforation. ⋯ The remaining 18 underwent DPL: 17 demonstrated gross blood, and only one patient was diagnosed solely by an elevated DPL:WBC. We conclude that DPL:WBC is a nonspecific indicator of intestinal perforation from blunt abdominal trauma, and prospective studies are needed to properly define its role. Sequential determinations of DPL:WBC may be useful in the diagnosis of intestinal perforation.