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Biomedical subjects

L M Jacobs

Publications and source records attributed to L M Jacobs.

At least 19 recordsLinked to original sources
PubMed2001

Definitive surgical trauma care live porcine session: a technique for training in trauma surgery.

BACKGROUND: A new Definitive Surgical Trauma Care course was developed to educate surgeons in operative management of injuries. The course consists of an interactive CD-ROM and a live porcine animal laboratory. METHOD: A five-hour session was conducted. Penetrating injuries to stomach, bowel, diaphragm, spleen, pancreas, kidney, ureter, inferior vena cava, liver, and heart were created by the senior surgeon and managed by the junior surgeon. Participants rated their expertise in 26 maneuvers pre- and post-lab. The evaluation scale used was: no prior experience; able to perform skill with assistance; proficient at procedure; able to teach procedure to another surgeon. RESULTS: In 26 procedures, a maximum score of 78 was possible. There was an increase from pre- to post-session scores of 22.6 for PGY-4 residents (n = 3); 23.3 for PGY-5 residents (n = 4); 11.25 for fellows (n = 4); and 0 for attendings (n = 4). CONCLUSION: The operative animal session had the greatest educational benefit among surgeons without formal training in trauma surgery. By exposing them to a range of trauma-induced surgical conditions, the DSTC course develops their operative repertoire and should increase their effectiveness in managing trauma patients.

Animals↗
PubMed2000

Clinical practice guidelines and the cost of care. A growing alliance.

UNLABELLED: Healthcare policy, medical practice, and cost of care are no longer considered distinct entities. Each is an integral factor in determining not only what, but how, patient care will be delivered. Clinical practice guidelines are the lynchpin that connects them. This paper addresses the various components of the clinical practice guideline--cost alliance. OBJECTIVE: To examine the bidirectional influence of choice of care on costs and of cost of care on decision making. METHODS: The literature was used to identify cost-related factors that influence development of guidelines and change in physician practice behavior. In a MEDLINE search with modifiers to the keywords "clinical practice guidelines," particular attention was paid to identifying surveys of practitioners. An analysis, prompted by a recently published guideline, of treating penetrating intraperitoneal colon injuries by different surgical approaches (primary repair versus diverting colostomy) exemplified how implementation of a guideline can affect the cost of care. Inpatient cost estimates, adjusted for medical inflation and cost-to-charge ratios and reported in 1999 U.S. dollars, were developed using data from 1996 and 1997 discharge databases from California and Massachusetts. RESULTS: The results showed that a substantial savings in hospital costs was achieved when a primary repair surgical technique, as advocated by the guideline, was used. The effect of cost influences on the development of clinical practice guidelines was established by demonstrating the cyclical effect between usual and customary practices, guideline implementation, changing practice patterns, and the economic considerations influencing the process. CONCLUSIONS: A growing, albeit uneasy, alliance between costs and clinical practice guidelines is evident.

Colon↗
PubMed1999

Economic effects of managed care.

There have been substantial changes in the way health care has been paid for in the last half of this century. The original contract between a physician and a patient has evolved to insurance companies paying usual and customary costs for physician services. Now, the medical care of a whole population is bid to organizations willing to insure the risk for managing the care of the population for a prospectively determined fee. The rising cost of health care has imposed new strategies to manage these escalating costs for physician, facilities, and patients. Despite the changes that have radically altered health care delivery, costs continue to rise. This fact ensures that there will be continuing evolution of strategies to decrease the rising rate of health care. Trauma care management traditionally has involved looking at the entire spectrum of the patient's disease process from the prehospital phase to his or her rehabilitation. The discipline that was necessary to identify each component of the system and quantify the cost associated with it has made trauma care a potential model for managed care. There are now systems of care in place that are fully dedicated to trauma. The facilities in them are verified by the American College of Surgeons or a similar professional body. These facilities are designated by a regulatory body, such as the state. It will become more common for payors to require that patients be enrolled in some trauma system of care because this will provide the most cost-effective management, especially for severely injured patients. Surgeons should clearly understand the historic and present strategies for cost-management and how they have evolved. A clear understanding of these forces will allow rational plans to be developed that will deliver the best, most cost effective care to trauma victims.

Certification↗
PubMed1999

Violence in America: a public health crisis--domestic violence.

Domestic violence is a major public health problem. It is important that physicians are aware of the extent and pervasiveness of this disease. It is important to identify potential victims of domestic violence when they are encountered in the hospital or office environment. A few, short, carefully asked questions can serve an important surveillance and diagnostic function. Once domestic violence is identified, a well thought out, sensitive, safe plan of action should be discussed with the victim. In this way, not only will the current event be well managed, but also the potential for mitigating further domestic violence events will be initiated. Through this document, EAST hopes to add its voice to that of other physician groups to serve as a catalyst for broad education on the subject of domestic violence as well as activating victim advocacy among physicians and others who come into contact with this problem in their patients.

Adolescent↗
PubMed1999

Helicopter air medical transport: ten-year outcomes for trauma patients in a New England program.

BACKGROUND: Twenty-five years have passed since the introduction of the first civilian hospital-based air medical helicopter service. This study reviews the impact of a single air medical service during a decade of service on the survival of severely injured trauma patients. METHODS: A retrospective database analysis was performed to determine program demographics and obtain outcome data. The outcomes of trauma patients were compared to mortality derived from a national database utilizing physiologic indices of severity. RESULTS: Outcome analysis demonstrated an overall 13% reduction in mortality for air transported patients when compared to controls. Stratification based upon Trauma Score demonstrated a 35% reduction in mortality for victims transported directly from the scene with scene scores between four and 13, and essentially no difference in outcome for patients at Trauma Score extremes. CONCLUSIONS: Rapid utilization of helicopter air medical transport can have a dramatic impact upon patient outcome, especially within a select group of scene transported trauma patients with Trauma Scores ranging from four to 13.

Adult↗
PubMed1998

Emergency medicine in France.

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.

Ambulances↗
PubMed1996

Hypercoagulability following multiple trauma.

We sought evidence of hypercoagulability in 59 seriously injured trauma patients. An extended coagulation profile (consisting of tissue plasminogen activator antigen concentration, plasminogen activator inhibitor, serum antithrombin III, protein C antigen, functional protein C, protein S antigen, D-dimer, and prothrombin fragment 1.2) was compared to control values. Laboratory evidence of hypercoagulability was seen in 85% (n = 50) of the patients. Patients with an Injury Severity Score (ISS) > or = 16 (n = 36) had significantly elevated levels of D-dimer and decreased levels of functional protein C compared to patients with an ISS < or = 15 (n = 23). Functional protein C had a negative correlation (r = -0.44; p < 0.001) with the ISS. A hypercoagulable state exists immediately following severe trauma. Greater injury severity may increase this hypercoagulable state. Decreased levels of functional protein C best correlated with increased injury severity.

Adult↗
PubMed1995

The quantity of cause-of-injury information documented on the medical record: an appeal for injury prevention.

OBJECTIVE: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e-codes. METHODS: Quantitative "stages of information" were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause-of-injury information categories. RESULTS: Information was obtained from 109 patients. Only 46% of the cause-of-injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause-of-injury information. CONCLUSION: Emergency providers obtain significantly less cause-of-injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause-of-injury information than was obtained during the patient interview.

Connecticut↗
PubMed1995

Accuracy of e-codes assigned to emergency department records.

OBJECTIVE: To determine the accuracy of ICD-9-CM external-cause-of-injury codes (e-codes) assigned to the medical records of injured patients treated in an ED and released. METHODS: A comparison was made of routine coding and expert recoding of medical records generated in the ED for a convenience sample of patients treated for injuries within 24 hours of injury occurrence and subsequently released from the ED. The medical record was handwritten and subsequently coded by three medical records coders (MRCs). The e-coded charts were sent to an external medical record consultant (expert), who was blinded to the codes previously assigned. The expert reading was used as the criterion standard. Accuracy was measured using a kappa statistic, and errors were described. RESULTS: Of 126 available patient charts, 108 (85.7%) were assigned e-codes by MRCs. The expert assigned two codes to (double-coded) 67 patients, while the MRCs double-coded only one patient. The additional code was usually a "place of occurrence code." In 60 cases (55.6%), the expert code exactly matched the MRC code; kappa = 0.462. Of the 48 mismatches (44.4%), 20 (41.7%) were e-coded in the wrong category, 20 (41.7%) were e-coded in the correct category but with incorrect specificity of information, either too specific or not specific enough, and eight (16.6%) had combined coding errors. CONCLUSION: The accuracy of e-codes assigned to ED records was moderate in this single institution analysis. Errors were predominantly related to the specificity of the code, but some e-codes were in the wrong category. There are implications for injury surveillance and research. E-code assignment must be standardized and applied uniformly to obtain accurate codes. Automation of e-coding could improve accuracy and consistency of codes. National and international epidemiologic studies of cause of injury among ED patients will be severely hampered until e-code assignment can be better standardized.

Emergency Service, Hospital↗
PubMed1995

Emergency management of blunt testicular trauma.

OBJECTIVE: Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel. METHODS: A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven-year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates. RESULTS: With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1-5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture. CONCLUSIONS: Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high-risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high-energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.

Adolescent↗
PubMed1995

Mesenteric injury from blunt abdominal trauma.

Mesenteric injury from blunt abdominal trauma is rare and can be difficult to diagnose. Twenty-seven cases were admitted over the past 5 years to our Level I trauma center. These cases have been retrospectively reviewed to better define the experience of patients with blunt mesenteric injury for the physician faced with making this diagnosis. It was found that the diagnosis of mesenteric injuries tends to be delayed in a certain subset of patients. Patients with a devascularizing, isolated injury or patients who are evaluated by abdominal CT scan (as opposed to DPL) tended to be more likely to experience a diagnostic delay. It was also found that motor vehicle accidents are the most common, though not the only, mechanism of injury and that the mesentery of the small bowel is injured approximately five times more frequently than the colonic mesenteries. These factors, however, did not result in earlier diagnostic decision making. To decrease the likelihood of a missed diagnosis, physicians should entertain the possibility of mesenteric injury in all patients presenting with blunt abdominal trauma, even if few clinical findings are initially present and/or an abdominal CT scan demonstrates no definitive intraabdominal injury.

Abdominal Injuries↗
PubMed1994

Personality types of flight crew members in a hospital-based helicopter program.

PURPOSE: To determine the personality preferences of flight crew members in a hospital-based helicopter emergency medical service (HEMS) using the Myers-Briggs Type Indicator (MBTI), and to differentiate and compare these preferences between crew specialties and a historical control population. METHODS: A prospective cohort study was conducted of all active crew members (nurses, respiratory therapists and pilots) in a hospital-based flight program. Data collected included the results of the MBTI, gender, age and years of flight experience. RESULTS: Crew members were represented by 14 of 16 possible MBTI personality types, with three types predominating. For each crew specialty, extroversion preferences predominated over introversion, and perceiving characteristics predominated over judging characteristics. Differences existed by crew specialty for the sensing-intuition and thinking-feeling dimensions. CONCLUSIONS: A personality typology has been established for individual and group preferences within one hospital-based HEMS program. This data begins to develop a data base and an investigative protocol for understanding some of the human factors regarding flight programs. Future research should focus on expanding the data base and exploring specific crew interactions based on additional diagnostic and evaluative methodologies.

Adult↗
PubMed1994

Measuring factors that influence the response of medical practitioners and social workers to problem drinkers: a pilot study.

It is increasingly recognized that factors such as professionals' empathy, willingness to intervene, self-efficacy and role legitimacy influence the initial engagement of clients into treatment and the nature of any subsequent therapeutic relationship. These factors are difficult to measure using questionnaires, and for this reason qualitative research techniques are frequently used in this field of inquiry. The present methodological study is based on in-depth interviews conducted with 16 medical practitioners and 12 social workers, and attempts to overcome one of the main limitations associated with qualitative data-that is, the difficulty of reducing such complex material to a numerical value suitable for quantitative analysis. The interview technique and rating system described were most successful in achieving this in the case of self-efficacy and least successful in the case of empathy. Possible reasons for this are discussed. It is concluded that the technique described has the potential to elicit detailed data concerning the interactions of medical practitioners and social workers with problem drinkers, and that this material can be reliably rated in a manner that is not unduly time-consuming and burdensome to researchers.

Journal Article↗
PubMed1994

Prospective evaluation of craniofacial pressure in four different cervical orthoses.

INTRODUCTION: Cervical collars play a role in the long-term treatment of cervical spine injuries. Pressure ulcers are one of the potential complications. We previously reported on three patients who developed pressure ulcers of the scalp while wearing cervical collars. The pressure exerted by different collars was measured to determine whether this was a significant factor in the clinical problem we observed. METHODS: Four brands of cervical collars (Stifneck, Philadelphia, Newport, and Miami J) were tested in 20 normal volunteers. Pressure was measured at the occiput, mandible, and chin. Opinions on comfort were also collected. RESULTS: The Stifneck collar exceeds capillary closing pressure (CCP) for most contact points. The Philadelphia collar exposes the wearer to high pressures when supine compared with the upright position (p < 0.001). The Newport and Miami J collars exerted pressure well below CCP. The subjective comfort (scale from 0 (poor) to 5 (best)) ratings were: Stifneck = 0.85, Philadelphia = 3.00, Newport = 3.80, and Miami J = 3.45. CONCLUSIONS: We recommend use of "patient-friendly" collars such as the Newport or Miami J because of their favorable skin pressure patterns and superior patient comfort. These collars should potentially reduce the incidence of soft-tissue complications and improve patient compliance.

Adult↗
PubMed1994

Isolated free fluid on abdominal computerized tomographic scan: an indication for surgery in blunt trauma patients?

A retrospective study of 792 patients who sustained blunt traumatic injury and underwent abdominopelvic computerized tomographic scan (CT) evaluation was performed. Patients who had free intraperitoneal fluid without evidence of solid visceral organ damage served as the study population. Sixty-six (8.3%) of patients were identified as having free fluid without evidence of solid organ injury. Pelvic fractures occurred in 14 of the 66 (21.2%) patients. Splenic injuries requiring laparotomy were not diagnosed initially on CT scan of the abdomen in four (6%) patients. Mesenteric or small bowel injuries occurred in six (9%) patients. Nine (13.6%) of the patients expired. Thirty-five patients (53%) had no sequelae of intra-abdominal injuries and required no surgical intervention. If patients with pelvic fractures are excluded, 10 (19.2%) of the patients required operative intervention for their injuries. It is our conclusion that free fluid as the only significant finding on CT scan in blunt trauma patients may be a harbinger of significant intra-abdominal injury, and that these patients need to be closely observed to decrease morbidity associated with these potential injuries.

Abdominal Injuries↗
PubMed1994

An efficient system for controlled distal colorectal irrigation.

We have found this setup to be most useful. For those surgeons who incorporate rectal irrigation as part of their treatment plan for patients with rectal injuries, we would recommend trial of this simple yet effective technique. The more senior anesthesia and nursing staff who have suffered through the vagaries of widespread fecal contamination from the beginning to the end of the operation rapidly become advocates of this procedure.

Anal Canal↗