Biomedical subjects
Publications and source records attributed to L M Jacobs.
Emergency medical helicopter services have grown exponentially over the past seventeen years. These services offer rapid transport by flight crews to tertiary care centers with a higher level of medical capabilities. An impact because of helicopters on survival has been well-documented for trauma patients. Assessing usage for other critical care patients remains to be delineated further.
We reviewed the patterns of injuries sustained by 12 consecutive fallers and jumpers in whom primary impact was onto the feet. The fall heights ranged from 20 to 100 ft. The 12 patients sustained 49 significant injuries. Skeletal injuries were most frequent and included 15 lower extremity fractures, four pelvic fractures, and nine spinal fractures. In two patients, paraplegia resulted. Genitourinary tract injuries included bladder hematoma, renal artery transection, and renal contusion. Thoracic injuries included rib fractures, pneumothorax, and hemothorax. Secondary impact resulted in several craniofacial and upper extremity injuries. Chronic neurologic disability and prolonged morbidity were common. One patient died; the patient who fell 100 ft survived. After initial stabilization, survival is possible after falls or jumps from heights as great as 100 feet It is important to recognize the skeletal and internal organs at risk from high-magnitude vertical forces.
A 3-year prospective study was conducted to establish the incidence of traumatic brain injury (TBI) and related characteristics of age, sex, length of stay (LOS), intensive care unit LOS (ICU/LOS), direct hospital charges, and reimbursement using a prospective DRG-based reimbursement system. The study identified TBI patients using ICD-9-Codes. The mean LOS for the two groups of patients with intracranial injury differed (p less than 0.05). Those with such an injury accompanied by a fracture stayed 1.8 days less in the ICU and 6.0 days less overall. Direct hospital charges for all TBI patients were $14,138,036 (mean, $11,645). Using Medicare weights and hospital-specific rates/DRG, the DRG reimbursement was $6,689,293. Thirty-day outliers (those who stayed ten times the geometric mean length of stay) provided an additional $526,389 leaving a total non-reimbursable figure of $6,922,354, or 49% of total charges. Of the 71 DRGs assigned to the study population, 15 reimbursed more than the actual charges. The severity of TBI victims and the complexity of caring for them in a Level I trauma center generates hospital charges of which only half are reimbursed through an all-payor DRG system. Strategies to correct what could be a financial disincentive are: documenting the uniqueness of this population to justify additional reimbursement, calculating a more precise mean LOS for TBI-related DRGs to more accurately identify outliers, and calculating DRG rates for TBI diagnoses derived from a representative sample at varying severity levels and hospitalized in facilities with and without rehabilitation services.
The purpose of this paper is to identify factors associated with improved utilization of health care resources in the treatment of patients with injury. A prospective cohort study was conducted of all trauma patients admitted to a trauma center from April 15, 1987 to February 28, 1988. Altogether, 877 patients were entered into the study: 673 (76.7%) scene patients, and 204 (23.3%) interhospital transfers. The mean length of stay (LOS) for scene patients was 12 days, with mean charges of $8,781, whereas the mean LOS of interhospital transfers was 18 days, with mean charges of $16,734. When controlled for confounding variables, the scene patients had significantly shorter LOS and charges than matched interhospital transfers. This difference was more pronounced for the air-transported patients than for ground-transported patients. The elderly utilize more resources than young patients when matched for severity of injury. It is beneficial to the patients and the health care system to have severely injured trauma patients transported directly to a trauma center from the scene of an injury. Helicopter emergency medical services can enhance the ability of a trauma care system to decrease health care costs.
Over 63% of the patients transported by the LIFE STAR crew are the victims of trauma. The system has transported 2,215 ill and/or injured patients, the majority of whom are critical, either from the scene of an injury or from a medical facility to another of greater specialization. With the audit procedure indicating a 95% positive predictive value for summoning this service, LIFE STAR has contributed to the care of critically ill or injured persons in Connecticut and surrounding areas.
Trauma patients requiring intubation at the scene of the accident were entered into a study from June 1985 to June 1987 to determine: 1) the success rate of intubation by flight crews and 2) factors important in managing the difficult airway at the scene. One hundred thirty-six patients were reviewed. The success rate of trauma patients intubated in the field was 92.6%. The success rate of each procedure was, orotracheal 87%, and nasotracheal 77.6%. Six out of the 10 patients unsuccessfully intubated had vomiting or blood in the oropharynx which was cited as the reason for failure of intubation. All 24 patients requiring medications (paralytics and sedatives) for intubation were successfully intubated. Trismus and combativeness were the indications for medication usage. An aeromedical crew (MD, RN, RT) can successfully intubate trauma patients at the scene of the accident. Severe facial injuries with vomiting and blood in the oropharynx are factors in intubation failure. The use of muscle relaxants and sedatives facilitates difficult intubations.
Civilian helicopters and emergency medical services in the United States have been in existence for approximately 15 years. The rapid growth of this type of health care delivery coupled with an increasing number of accidents has prompted professional and lay scrutiny of these programs. Although they have a demonstrated history of benefit to patients, the type and severity of injuries to patients who are eligible for helicopter transportation need further definition. The composition of the medical crews and the benefits that particular crew members bring to the patients require ongoing evaluation. Significant questions regarding the number of pilots in a helicopter and in a program remain to be answered. This article reviews the role of emergency medical air transport services in providing care to trauma patients, staff training and evaluation, and safety criteria and offers recommendations to minimize risks to patients and crews.
The airway is the most important priority in the management of the severely injured patient. It is essential to open and clear the airway to allow free access of air to the distal endobronchial tree. Manual methods of opening the airway are described. Numerous methods for establishing definitive control of the airway as well as the associated devices currently available to maintain control are described. Once the airway is maintained, it is important to ensure adequate oxygenation and ventilation through the airway. Modern portable devices that monitor the carbon dioxide in the expired air at the end of each breath are currently available. These devices allow the physician to verify the position of the tube in the airway as well as to continuously monitor the efficacy of ventilation.
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Trauma is the fourth leading cause of death for all Americans, with a mortality rate of 61 deaths per 100,000 people. Although the definitive place for the management of major abdominal or thoracic hemorrhage, as well as neurological or orthopedic problems, is the operating room in a tertiary care hospital, trauma is a time-related disease, and the more quickly hemorrhage is controlled and appropriate management initiated, the better the outcome.The author outlines a systematic approach to prehospital management of the trauma patient that includes a primary survey and a secondary survey. The primary survey (Part 1) focuses on life-threatening conditions that affect the airway and methods to clear the airway immediately. Once the airway is cleared, any anatomical or physiologic compromise that limits ventilation is identified and corrected, hemorrhage is controlled, and the cervical spine, if injury is suspected, is protected. The secondary survey (Part 2) is a comprehensive examination.
Trauma is the fourth leading cause of death for all Americans, with a mortality rate of 61 deaths per 100,000 people. Although the definitive place for the management of major abdominal or thoracic hemorrhage, as well as neurologic or orthopedic problems, is the operating room in a tertiary care hospital, trauma is a time-related disease, and the more quickly hemorrhage is controlled and appropriate management initiated, the better the outcome.The author outlines a systematic approach to prehospital management of the trauma patient that includes a primary survey and a secondary survey. The primary survey (Part 1) focuses on life-threatening conditions that affect the airway and methods to clear the airway immediately. Once the airway is cleared, any anatomical or physiologic compromise that limits ventilation is identified and corrected, hemorrhage is controlled, and the cervical spine, if injury is suspected, is protected. The secondary survey (Part 2) is a comprehensive examination.
We studied 1,526 patients entered into the Trauma Registry by demographic, physiologic, anatomic, investigational, and clinical data. Severely injured patients consumed more resources, had longer hospital stays, and were prospectively reimbursed less than the cost of their hospitalization. Age was not related to severity of injury or cost. The hospital was reimbursed approximately $12,000 less per patient than the cost. A financial projection of reimbursement of trauma patients compared with that of all inpatients revealed that trauma patients were reimbursed less than all patients combined (reimbursement, 77% vs 93%, respectively). Updated reimbursement weighting codes for 1985 increased the losses to the hospital. Trauma patients were reimbursed for 56% of their total bill, a financial loss of $1,800 per patient, and all inpatients were reimbursed 80%, a financial loss of +507 per patient. We suggest an alternative reimbursement system, based on voluntary national norms, objective national outcome criteria, and appropriate trauma management.
We developed a prospective study to evaluate the clinician's ability to predict and diagnose cervical spine injury. Of 233 patients evaluated, 24 (10.4%) sustained cervical spine injury confirmed by radiography. The physician was able to predict injury with only 50% accuracy. The incidence of injury was 10.3% (24 of 233). Twenty percent (5 of 24) of cervical spine injuries would have been missed if physicians had used physical examination and mechanism of injury as criteria. Ten elements were identified as being associated statistically with cervical spine injury. Physicians cannot accurately predict the presence of cervical spine injury. Radiographs are ordered for many patients who have no evidence of injury. We used a logistic regression analysis to produce a system for predicting cervical spine injury. This methodology is easily adaptable for use in the emergency department.
The management of impaled foreign objects is always a challenge. Stabilization of the object, control of hemorrhage, and adherence to the basic principles of airway and breathing control are hallmarks of prehospital management. Once the patient is in the hospital, a careful assessment of the involved vital structures is essential before removal is attempted. A penetrating injury to the left hemisphere of the brain with a crowbar is presented. This case demonstrates the characteristics of these injuries in terms of extrication, assessment, management of complications, and neurologic sequelae.
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Explore the source record for details and available documents.
The application of a computer model to evaluate ambulance deployment configurations in an urban ambulance service is described. A planned expansion of the Boston Emergency Ambulance Service was accomplished using computer projections. The use of analytic models in the planning and implementation of an Emergency Medical Services (EMS) system allows for greater understanding of the interactions between various performance measures, facilitating the effective and cost-efficient allocation of resources.