- Acute Care Surgeon, Caldwell, Idaho, Clinical Professor of Surgery, University of Washington School of Medicine, WWAMI Program Idahoedit
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Research Interests: Medicine and Flail chest
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Thoracic trauma is common and causes a variety of injuries, ranging from simple abrasions and contusions to life-threatening insults to the thoracic viscera. Thoracic trauma also is associated with a high morbidity. Twenty percent of all... more
Thoracic trauma is common and causes a variety of injuries, ranging from simple abrasions and contusions to life-threatening insults to the thoracic viscera. Thoracic trauma also is associated with a high morbidity. Twenty percent of all trauma deaths involve chest injury, making it second only to head and spinal cord injuries (1). Fortunately, most thoracic injuries do not require major
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Research Interests: Chronic Pain, Adolescent, Activities of Daily Living, Safety, Humans, and 19 moreChild, Female, Animals, Male, Young Adult, Horses, Risk factors, Registries, Clinical Sciences, Aged, Middle Aged, Questionnaires, Adult, Retrospective Studies, Health surveys, Oregon, Risk Factors, Injury Severity Score, and Child preschool
Research Interests: Nursing, Wound Healing, Treatment Outcome, Risk assessment, Humans, and 19 moreFemale, Male, Fascia, Follow-up studies, The, Registries, Clinical Sciences, Aged, Middle Aged, Adult, Survival Rate, Retrospective Studies, Risk Assessment, Abdominal Wall Hernias, Sensitivity and Specificity, Critical Illness, Postoperative Complications, Trauma Centers, and Injury Severity Score
Research Interests: Nursing, Risk assessment, Adolescent, Humans, Female, and 20 moreMale, Follow-up studies, The, Incidence, Cervical Vertebrae, Registries, Clinical Sciences, Aged, Middle Aged, Adult, Survival Rate, Retrospective Studies, Tracheostomy, Risk Assessment, Cervical Spine, Spinal Cord Injuries, Spinal Fusion, Spinal fractures, Trauma Centers, and Injury Severity Score
The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. To determine the necessity of cervical spine clearance and neck extension in trauma patients... more
The lack of cervical spine clearance and inability to extend the neck are assumed to be relative contraindications for percutaneous tracheostomy. To determine the necessity of cervical spine clearance and neck extension in trauma patients receiving percutaneous tracheostomy. Prospective analysis of case series from August 1, 1995 to August 31, 1998. A university-based Level I trauma center. A total of 88 consecutive trauma patients receiving percutaneous tracheostomy. Patients were divided into two groups based on the radiographic or clinical status of their cervical spine: cleared and noncleared. The overall success and complication rate were 99% (87/88) and 11% (10/88), respectively. There were no procedure-related deaths. The cleared group consisted of 60 patients; three patients in this group who had "bull" or "thick" necks did not have full neck extension during percutaneous tracheostomy. The noncleared group consisted of 28 patients, 13 of which had known cervical spine fractures; 27 noncleared patients were maintained in the neutral position (no extension) during percutaneous tracheostomy, whereas one patient with low suspicion of spinal injury was partially extended. Of the 13 patients with cervical spine fractures, six patients had been stabilized with a halo or operative fixation, and seven patients were stabilized with a cervical collar at the time of percutaneous tracheostomy. The success rate was 100% (60/60) for the cleared group compared with 96% (27/28) for the noncleared group (p > .05). The complication rate was 13% (8/60) for the cleared group compared with 7.1% (2/28) for the noncleared group (p > .05). We had a 100% success rate and no complications in the seven patients with cervical spine injury who were stabilized with a cervical collar. No patient had spinal cord injury caused by percutaneous tracheostomy. Percutaneous tracheostomy can be safely performed in trauma patients without cervical spine clearance and neck extension, including patients with stabilized cervical spine or spinal cord injury.
Research Interests: Nursing, Surgery, Treatment Outcome, Adolescent, Critical Care Medicine, and 19 moreProspective studies, Complication, Humans, Female, Male, Technique, Cervical Vertebrae, Posture, Clearance, Clinical Sciences, Aged, Middle Aged, Adult, Public health systems and services research, Tracheostomy, Cervical Spine, X ray Computed Tomography, Spinal Cord Injuries, and Injury Severity Score
Research Interests: Magnetic Resonance Imaging, Treatment Outcome, Adolescent, Prospective studies, Humans, and 16 moreFemale, Male, Young Adult, Follow-up studies, Clinical Sciences, Aged, Middle Aged, Questionnaires, Adult, Time Factors, X ray Computed Tomography, Chest Pain, Pain Measurement, Bone Plates, Bone screws, and Trauma Severity Indices
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Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the... more
Abdominal pathology in the critically ill or injured patient frequently leads to the use of open abdominal techniques or the actual performance of abdominal surgery in the ICU. All individuals responsible for the care of patients in the ICU should be familiar with the concepts and techniques of open abdomen wound management. ICU bedside abdominal surgery may be indicated if the patient is too unstable for transport to the operating room and the surgeon believes a limited procedure, such as a decompression of IAH, will be life-saving. Smaller procedures are also feasible, such as intra-abdominal packing changes for which the operating room is unnecessary. Development of a successful Surgery Outside the Operating Room program depends on mature cooperation between the surgeons and other professional ICU staff. Logistic details of such a program should be discussed and a scheduling protocol should be prepared before an emergent need for bedside surgery.
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... Hart, Robert A; Mayberry, John C*; Herzberg, Alex M. ... Air bags have been shown to reduce the overall incidence of motor vehicle crashrelated injuries and deaths and to decrease the cost of health-care resources expended for... more
... Hart, Robert A; Mayberry, John C*; Herzberg, Alex M. ... Air bags have been shown to reduce the overall incidence of motor vehicle crashrelated injuries and deaths and to decrease the cost of health-care resources expended for collision-related injuries (11,12,21) . ...
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In many critical care units percutaneous dilational tracheotomy (PDT) has become an alternative to open tracheotomy. Although significant tracheal stenosis after PDT has been reported, the exact incidence is unknown. We report our... more
In many critical care units percutaneous dilational tracheotomy (PDT) has become an alternative to open tracheotomy. Although significant tracheal stenosis after PDT has been reported, the exact incidence is unknown. We report our findings on endoscopic laryngotracheoscopy for a group of patients who had undergone PDT more than 6 months before their examination. We did a retrospective review of 108 trauma patients who underwent PDT at least 6 months before enrollment in the study. Twenty-eight patients were either deceased or ineligible. Participation requests were mailed to the last recorded address of 80 patients. Thirty-four of those patients were contacted by phone, and 14 indicated their willingness to participate. Only 10 patients were able to make it to the clinic for examination. After transorally anesthetizing the hypopharynx and larynx with 4% lidocaine, each patient underwent flexible laryngotracheoscopy. Findings were categorized as normal or tracheal stenosis (<25%, 25% to 50%, or >50%). The tracheotomy site was virtually undetectable in 5 patients. In 4 patients, a scar was visible at the tracheotomy site, but there was no decrease in cross-sectional area. In 1 patient there was a 25% to 50% stenosis. All patients were completely asymptomatic with regard to airway and voice quality. One out of 10 patients in our series had a significant but asymptomatic stenosis after PDT. The risk of tracheal stenosis in PDT appears to be the same as that of open tracheotomy.
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The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications... more
The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications (DRC). We conducted a retrospective review of all patients with full-thickness DL surviving more than 72 hours in the years 1989 to 2009. Forty-one patients with a median duodenal organ injury scale of 3 and a mean abdominal trauma index (ATI) of 45 ± 24 underwent laparotomy. Twenty-five patients (61%) were treated with DC and 16 (39%) with fascial closure (FC). Although the ATI of the patients treated with DC was greater than the ATI of the patients treated with FC (56 ± 23 vs 28 ± 17, P < 0.001), DRCs were equivalent (two vs three, nonsignificant). Twenty-one patients were treated in the first decade and 20 in the second decade. Between the first and second decades, there were trends toward an increased use of DC (52 to 70%, nonsignificant) and a decreased use of DDE (52 to 35%, nonsignificant) with a significant reduction in DRC (5 vs 0, P = 0.04). Among the 18 patients (44%) who underwent DDE procedures there were 2 DRCs (11%) related to DDE. Among the 23 patients who did not have DDE, there were three DRCs (13%), including two obstructions, one partial and one complete. When DC is used after DL, DDE may be unnecessary. Diversion is recommended, however, when the duodenum is at risk for obstruction after primary repair.
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Research Interests: Nursing, Surgery, Attention, Risk, Treatment, and 15 moreInjury Prevention, Adolescent, Prevention, Humans, Child, Female, Animals, Male, Anesthesia, The, Horses, Clinical Sciences, Aged, Middle Aged, and Adult
Research Interests: Surgery, Fracture, Treatment, Adolescent, Medicine, and 6 moreHumans, Technique, Clinical Sciences, Fixation, Adult, and Fracture Fixation
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We performed a prospective clinical trial of resection with or without plate fixation for symptomatic rib fracture nonunion three or more months postinjury with 6-month postoperative followup. The McGill Pain Questionnaire (MPQ) and RAND... more
We performed a prospective clinical trial of resection with or without plate fixation for symptomatic rib fracture nonunion three or more months postinjury with 6-month postoperative followup. The McGill Pain Questionnaire (MPQ) and RAND 36 Health Survey were administered and activity level (sedentary, ambulatory, moderately active, vigorous), functional status (disabled, nonphysical labor, physical labor), and work status (employed, unemployed, retired, student) were queried pre- and postoperatively. Twenty-four patients 4 to 197 months (median, 16 months) postinjury underwent surgical intervention for one to four rib fracture nonunions (median, two nonunions). Evidence of intercostal nerve entrapment was present in nine patients (38%). MPQ Present Pain Intensity and Pain Rating Index and RAND 36 Physical Functioning, Role Physical, Social Functioning, Role Social, Bodily Pain, Vitality, Mental Health, and General Health were significantly improved at six months compared with study...
Research Interests: Magnetic Resonance Imaging, Treatment Outcome, Adolescent, Prospective studies, Humans, and 16 moreFemale, Male, Young Adult, Follow-up studies, Clinical Sciences, Aged, Middle Aged, Questionnaires, Adult, Time Factors, X ray Computed Tomography, Chest Pain, Pain Measurement, Bone Plates, Bone screws, and Trauma Severity Indices
The contribution of rib fractures to prolonged pain and disability may be underappreciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures resolves in 6 to 8 weeks. This study was a... more
The contribution of rib fractures to prolonged pain and disability may be underappreciated and undertreated. Clinicians are traditionally taught that the pain and disability of rib fractures resolves in 6 to 8 weeks. This study was a prospective observation of 203 patients with rib fractures at a level 1 trauma center. Chest wall pain was evaluated by the McGill Pain Questionnaire (MPQ) pain rating index (PRI) and present pain intensity (PPI). Prolonged pain was defined as a PRI of 8 or more at 2 months after injury. Prolonged disability was defined as a decrease in 1 or more levels of work or functional status at 2 months after injury. Predictors of prolonged pain and disability were determined by multivariate analysis. One hundred forty-five male patients and 58 female patients with a mean injury severity score (ISS) of 20 (range, 1 to 59) had a mean of 5.4 rib fractures (range, 1 to 29). Forty-four (22%) patients had bilateral fractures, 15 (7%) had flail chest, and 92 (45%) had ...
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Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients' health status with the general population. We... more
Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients' health status with the general population. We performed a retrospective medical record review supplemented with a postal survey of long-term outcomes including the McGill Pain Questionnaire (MPQ) and RAND-36 Health Survey. RAND-36 outcomes were compared with reference values from the Medical Outcomes Study and from the general population. Forty-six patients underwent acute chest wall repair between September 1996 and September 2005. Indications included flail chest with failure to wean from the ventilator (18 patients), acute, intractable pain associated with severely displaced rib fractures (15 patients), acute chest wall defect/deformity (5 patients), acute pulmonary herniation (3 patients), and thoracotomy for other traumatic indications (5 patients). Three patients had a concomitant sternal fr...
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Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown. To determine the current preferences of American... more
Primary repair or resection and anastomosis of colon wounds have been advocated in many recent studies, but the proportion of trauma surgeons accepting these recommendations is unknown. To determine the current preferences of American trauma surgeons for colon injury management. Four hundred forty-nine members of the American Association for the Surgery of Trauma were surveyed regarding their preferred management of eight types of colon wounds among three options: diverting colostomy (DC), primary repair (PR), or resection and anastomosis (RA). The influence of selected patient factors and surgeons&amp;amp;amp;amp;amp;amp;#39; characteristics on the choice of management was also surveyed. Seventy-three percent of surgeons completed the survey. Ninety-eight percent chose PR for at least one type of injury. Thirty percent never selected DC. High-velocity gunshot wound was the only injury for which the majority (54%) would perform DC. More than 55% of the surgeons favored RA when the isolated colon injury was a contusion with possible devascularization, laceration greater than 50% of the diameter, or transection. Surgeons who managed five or fewer colon wounds per year chose DC more frequently (p &amp;amp;amp;amp;amp;amp;lt; 0.001) and PR less frequently (p &amp;amp;amp;amp;amp;amp;lt; 0.001) than surgeons who managed six or more colon wounds per year. The prevailing opinion of trauma surgeons favors primary repair or resection of colon injuries, including anastomosis of unprepared bowel. Surgeons who manage fewer colon wounds prefer colostomy more frequently.
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The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications... more
The management of duodenal laceration (DL) is controversial. We sought to determine the influence of damage control (DC) on the use of decompression/diversion/exclusion (DDE) techniques and the risk of duodenal-related complications (DRC). We conducted a retrospective review of all patients with full-thickness DL surviving more than 72 hours in the years 1989 to 2009. Forty-one patients with a median duodenal organ injury scale of 3 and a mean abdominal trauma index (ATI) of 45 ± 24 underwent laparotomy. Twenty-five patients (61%) were treated with DC and 16 (39%) with fascial closure (FC). Although the ATI of the patients treated with DC was greater than the ATI of the patients treated with FC (56 ± 23 vs 28 ± 17, P < 0.001), DRCs were equivalent (two vs three, nonsignificant). Twenty-one patients were treated in the first decade and 20 in the second decade. Between the first and second decades, there were trends toward an increased use of DC (52 to 70%, nonsignificant) and a de...
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Research Interests: Complication, Humans, Liver, Female, Male, and 6 moreClinical Sciences, Adult, Time Factors, The American, Bile, and Laparotomy
To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS). On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing... more
To determine the current opinion of American trauma surgeons on the use of the open abdomen to prevent the abdominal compartment syndrome (ACS). On a questionnaire survey of expert trauma surgeons regarding 12 clinical factors influencing fascial closure at trauma celiotomy, surgeons graded their willingness to close the fascia in various scenarios on a scale of 1 to 5. The impact of six signs of clinical deterioration on willingness to perform abdominal decompression in a patient with postceliotomy elevated intra-abdominal pressure (IAP) was also queried. Of 292 members of the American Association for the Surgery of Trauma active in abdominal trauma management, 248 members (85%) had experience with ACS one or more times in the previous year. Surgeons&amp;amp;amp;amp;amp;amp;#39; responses to factors found at trauma celiotomy were divided into two distinct categories: factors decreasing willingness to close the fascia, and factors not changing or increasing willingness to close the fascia (p &amp;amp;amp;amp;amp;amp;lt; 0.001). Factors disfavoring fascial closure were pulmonary or hemodynamic deterioration with closure, massive bowel edema, subjectively tight closure, planned reoperation, and packing. Factors not changing or favoring fascial closure were fecal contamination/peritonitis, massive transfusion, hypothermia, multiple abdominal injuries, acidosis, and coagulopathy. Five of the six signs of clinical deterioration increased surgeons&amp;amp;amp;amp;amp;amp;#39; willingness to decompress a patient with elevated IAP (increased O2 requirement, decreased cardiac output, increased acidosis, increased airway pressures, and oliguria). Lowered gastric mucosal pH did not affect willingness. Seventy-one percent of surgeons indicated they would decompress elevated IAP in postceliotomy patient if one or two signs of clinical deterioration were present, but only 14% would decompress a patient for elevated IAP alone. A majority of expert American trauma surgeons have experience with ACS and would leave the abdomen open if ACS occurred. A majority would reopen a closed abdomen in cases of elevated IAP with signs of clinical deterioration. A minority would leave the abdomen open when there was only a risk of developing ACS.
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... Hart, Robert A; Mayberry, John C*; Herzberg, Alex M. ... Air bags have been shown to reduce the overall incidence of motor vehicle crashrelated injuries and deaths and to decrease the cost of health-care resources expended for... more
... Hart, Robert A; Mayberry, John C*; Herzberg, Alex M. ... Air bags have been shown to reduce the overall incidence of motor vehicle crashrelated injuries and deaths and to decrease the cost of health-care resources expended for collision-related injuries (11,12,21) . ...
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Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as... more
Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.