Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost... more Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.
The Journal of Trauma: Injury, Infection, and Critical Care, 1993
To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated pr... more To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty-seven patients during an 8-month period met high-risk criteria for VT including age > 45 years, > 2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies.
As the new leader of the Centers for Disease Control and Prevention (CDC) National Center for Inj... more As the new leader of the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control, I am thrilled by the opportunity to comment on the future direction of the Injury Center, as well as the intersection of policy and injury prevention. As the cost of healthcare continues to rise and greater demands are placed on the healthcare system, the use of public health policy becomes increasingly critical to protect the public’s health and prevent injury and its related morbidities and disabilities. I am committed to advancing the Injury Center’s focus on policy strategies to ensure that each person has the opportunity to live life to its fullest potential through the creation of an environment that decreases injury risks and promotes safety. I recently came to the CDC from Yale University, where I served as research director for the Department of Emergency Medicine at Yale School of Medicine and director of the Yale Center for Public Health Preparednes...
In order to assess the feasibility of emergency department (ED) physician screening of patients w... more In order to assess the feasibility of emergency department (ED) physician screening of patients with minor injuries for alcohol problems, a two-part screening process was implemented in an urban ED. Blood alcohol concentration was measured using either a saliva strip or a serum alcohol test. Questions about alcohol use frequency, and consumption quantity were asked in addition to the CAGE questions. Over a one-year period 2,439 adults (age ≥ 18 years) with non-life-threatening injuries were screened. Multiple strategies were used in order to increase compliance over the course of the study. Over the first six months, the overall screening rate increased from 8% to 45% and remained level for most of the duration of the project. Individual variations in rates ranged from 5% to 70%. Screening for alcohol problems is feasible in the ED setting and may be integrated as part of the role of the ED physician.
Sixty-four patients with cardiac contusion documented by electrocardiographic changes and creatin... more Sixty-four patients with cardiac contusion documented by electrocardiographic changes and creatine kinase MB fraction assay following blunt chest injury were reviewed to assess the impact of cardiac contusion on subsequent management. Fifty-eight patients had elevated creatine kinase MB levels; 35 patients had electrocardiographic abnormalities, including ST-segment and T-wave changes (25), premature ventricular contraction (ten), right bundle-branch block (nine), atrioventricular block (three), atrial fibrillation (three), and premature atrial contraction (two). Thirty patients underwent general anesthesia. There were only four perioperative complications: ventricular ectopy, ventricular fibrillation, nodal rhythm, and pulmonary edema. There were no deaths attributable to cardiac contusion. In summary, patients with blunt trauma who have sustained a cardiac contusion can undergo elective operation with a low incidence of complication. In the emergency setting, however, hemodynamic monitoring for early detection of arrhythmias is indicated.
Academic Emergency Medicine Official Journal of the Society For Academic Emergency Medicine, Aug 1, 2010
The objective was to evaluate the effects of Project Alcohol and Substance Abuse Services Educati... more The objective was to evaluate the effects of Project Alcohol and Substance Abuse Services Education and Referral to Treatment (ASSERT), an emergency department (ED)-based screening, brief intervention, and referral to treatment program for unhealthy alcohol and other drug use. Health promotion advocates (HPAs) screened ED patients for alcohol and/or drug problems 7 days a week using questions embedded in a general health questionnaire. Patients with unhealthy drinking and/or drug use received a brief negotiation interview (BNI), with the goal of reducing alcohol/drug use and/or accepting a referral to a specialized treatment facility (STF), depending on severity of use. Patients referred to an STF were followed up at 1 month by phone or contact with the STF to determine referral completion and enrollment into the treatment program. Over a 5-year period (December 1999 through December 2004), 22,534 adult ED patients were screened. A total of 10,246 (45.5%) reported alcohol consumption in the past 30 days, of whom 5,533 (54%) exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for low-risk drinking. Use of at least one illicit drug was reported by 3,530 patients (15.7%). Over one-fourth of screened patients received BNIs (6,266, or 27.8%). Of these, 3,968 (63%) were referred to an STF. Eighty-three percent of patients were followed at 1 month, and 2,159 (65%) had enrolled in a program. Patients who received a direct admission to an STF were 30 times more likely to enroll than those who were indirectly referred (odds ratio = 30.71; 95% confidence interval = 18.48 to 51.04). After 3 years, funding for Project ASSERT was fully incorporated into the ED budget. Project ASSERT has been successfully integrated into an urban ED. A direct, facilitated referral for patients with alcohol and other drug problems results in a high rate of enrollment in treatment programs.
The Journal of Trauma Injury Infection and Critical Care, 1998
Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, g... more Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, grading of injuries does not reliably predict the need for intervention. Objective reporting is essential to evaluate accuracy and facilitate patient triage. We established and tested a five-point grading system for overall severity of injury. A total of 392 computed tomographic trauma cases were objectively classified according to the type and severity of abdominal injuries, by two experienced radiologists. Interobserver variability between the original interpretation and the consensus of the film reviewers was evaluated. The computed tomographic grading system was measured against rate of admission, exploratory laparotomy, and further imaging. Patients with higher grades of injury on computed tomography were increasingly likely to have surgical management (odds ratio, 3.99; 95% confidence interval, 1.86-8.58; p < 0.0006), with sensitivity 100%, specificity 89.5% for level 2 injuries and higher. Although there was almost perfect agreement between the official interpretation and the reviewers' blinded consensus interpretation (raw agreement 84%, weighted kappa 0.86), indeterminate studies were reduced from 23% (16 of 67) to 12% (8 of 67) on review: these were more likely to have metallic or motion artifacts (5 of 16 vs. 1 of 51 p < 0.002). Standardizing reporting of injuries enhances accuracy, and grading eliminates equivocation. Diagnostic certainty in computed tomography of blunt abdominal trauma is reduced by motion and metallic artifacts.
Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost... more Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.
The Journal of Trauma: Injury, Infection, and Critical Care, 1993
To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated pr... more To determine the incidence of venous thrombosis (VT), high-risk trauma patients were evaluated prospectively biweekly with Doppler ultrasound (US). Fifty-seven patients during an 8-month period met high-risk criteria for VT including age > 45 years, > 2 days bed rest, previous history of thromboembolism, spine fracture, coma, spinal cord injury, pelvic fracture, lower extremity injury, or femoral vein catheter. Doppler ultrasound showed 16 VTs in 12 patients. Venous thrombosis occurred despite prophylaxis (heparin or compression devices) in 9 of 12 patients. Iliac VT was noted in four patients, two of whom had no lower extremity VT. Upper extremity VT occurred in two patients who had received central venous catheters. (1) US surveillance may be valuable in high-risk trauma patients because VT is a common finding (21%), despite prophylactic measures. (2) Examination of the upper extremity and pelvic venous system appears to be important, since 33% (4 of 12) of our patients with VT developed thrombi isolated to these regions. These would not have been identified during routine lower extremity duplex studies.
As the new leader of the Centers for Disease Control and Prevention (CDC) National Center for Inj... more As the new leader of the Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control, I am thrilled by the opportunity to comment on the future direction of the Injury Center, as well as the intersection of policy and injury prevention. As the cost of healthcare continues to rise and greater demands are placed on the healthcare system, the use of public health policy becomes increasingly critical to protect the public’s health and prevent injury and its related morbidities and disabilities. I am committed to advancing the Injury Center’s focus on policy strategies to ensure that each person has the opportunity to live life to its fullest potential through the creation of an environment that decreases injury risks and promotes safety. I recently came to the CDC from Yale University, where I served as research director for the Department of Emergency Medicine at Yale School of Medicine and director of the Yale Center for Public Health Preparednes...
In order to assess the feasibility of emergency department (ED) physician screening of patients w... more In order to assess the feasibility of emergency department (ED) physician screening of patients with minor injuries for alcohol problems, a two-part screening process was implemented in an urban ED. Blood alcohol concentration was measured using either a saliva strip or a serum alcohol test. Questions about alcohol use frequency, and consumption quantity were asked in addition to the CAGE questions. Over a one-year period 2,439 adults (age ≥ 18 years) with non-life-threatening injuries were screened. Multiple strategies were used in order to increase compliance over the course of the study. Over the first six months, the overall screening rate increased from 8% to 45% and remained level for most of the duration of the project. Individual variations in rates ranged from 5% to 70%. Screening for alcohol problems is feasible in the ED setting and may be integrated as part of the role of the ED physician.
Sixty-four patients with cardiac contusion documented by electrocardiographic changes and creatin... more Sixty-four patients with cardiac contusion documented by electrocardiographic changes and creatine kinase MB fraction assay following blunt chest injury were reviewed to assess the impact of cardiac contusion on subsequent management. Fifty-eight patients had elevated creatine kinase MB levels; 35 patients had electrocardiographic abnormalities, including ST-segment and T-wave changes (25), premature ventricular contraction (ten), right bundle-branch block (nine), atrioventricular block (three), atrial fibrillation (three), and premature atrial contraction (two). Thirty patients underwent general anesthesia. There were only four perioperative complications: ventricular ectopy, ventricular fibrillation, nodal rhythm, and pulmonary edema. There were no deaths attributable to cardiac contusion. In summary, patients with blunt trauma who have sustained a cardiac contusion can undergo elective operation with a low incidence of complication. In the emergency setting, however, hemodynamic monitoring for early detection of arrhythmias is indicated.
Academic Emergency Medicine Official Journal of the Society For Academic Emergency Medicine, Aug 1, 2010
The objective was to evaluate the effects of Project Alcohol and Substance Abuse Services Educati... more The objective was to evaluate the effects of Project Alcohol and Substance Abuse Services Education and Referral to Treatment (ASSERT), an emergency department (ED)-based screening, brief intervention, and referral to treatment program for unhealthy alcohol and other drug use. Health promotion advocates (HPAs) screened ED patients for alcohol and/or drug problems 7 days a week using questions embedded in a general health questionnaire. Patients with unhealthy drinking and/or drug use received a brief negotiation interview (BNI), with the goal of reducing alcohol/drug use and/or accepting a referral to a specialized treatment facility (STF), depending on severity of use. Patients referred to an STF were followed up at 1 month by phone or contact with the STF to determine referral completion and enrollment into the treatment program. Over a 5-year period (December 1999 through December 2004), 22,534 adult ED patients were screened. A total of 10,246 (45.5%) reported alcohol consumption in the past 30 days, of whom 5,533 (54%) exceeded the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines for low-risk drinking. Use of at least one illicit drug was reported by 3,530 patients (15.7%). Over one-fourth of screened patients received BNIs (6,266, or 27.8%). Of these, 3,968 (63%) were referred to an STF. Eighty-three percent of patients were followed at 1 month, and 2,159 (65%) had enrolled in a program. Patients who received a direct admission to an STF were 30 times more likely to enroll than those who were indirectly referred (odds ratio = 30.71; 95% confidence interval = 18.48 to 51.04). After 3 years, funding for Project ASSERT was fully incorporated into the ED budget. Project ASSERT has been successfully integrated into an urban ED. A direct, facilitated referral for patients with alcohol and other drug problems results in a high rate of enrollment in treatment programs.
The Journal of Trauma Injury Infection and Critical Care, 1998
Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, g... more Although computed tomography is used widely in evaluating injuries from blunt abdominal trauma, grading of injuries does not reliably predict the need for intervention. Objective reporting is essential to evaluate accuracy and facilitate patient triage. We established and tested a five-point grading system for overall severity of injury. A total of 392 computed tomographic trauma cases were objectively classified according to the type and severity of abdominal injuries, by two experienced radiologists. Interobserver variability between the original interpretation and the consensus of the film reviewers was evaluated. The computed tomographic grading system was measured against rate of admission, exploratory laparotomy, and further imaging. Patients with higher grades of injury on computed tomography were increasingly likely to have surgical management (odds ratio, 3.99; 95% confidence interval, 1.86-8.58; p < 0.0006), with sensitivity 100%, specificity 89.5% for level 2 injuries and higher. Although there was almost perfect agreement between the official interpretation and the reviewers' blinded consensus interpretation (raw agreement 84%, weighted kappa 0.86), indeterminate studies were reduced from 23% (16 of 67) to 12% (8 of 67) on review: these were more likely to have metallic or motion artifacts (5 of 16 vs. 1 of 51 p < 0.002). Standardizing reporting of injuries enhances accuracy, and grading eliminates equivocation. Diagnostic certainty in computed tomography of blunt abdominal trauma is reduced by motion and metallic artifacts.
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