Faculty Bibliography

BACKGROUND: Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate. METHODS: This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute. RESULTS: Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30 degrees of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. CONCLUSIONS: Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

BACKGROUND: While the efficacy of helmet use in the prevention of head injury is well described, helmet use as it relates to bicyclists' behaviors and hospital resource use following injury is less defined. The objective of this study was to compare the demographics, behaviors, hospital workups, and outcomes of bicyclists based on helmet use. METHODS: This study was a subset analysis of a 2.5-year prospective cohort study of vulnerable roadway users conducted at Bellevue Hospital Center, a New York City Level 1 trauma center. All bicyclists with known helmet status were included. Demographics, insurance type, traffic law compliance, alcohol use, Glasgow Coma Scale (GCS) score, initial imaging studies, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), admission status, length of stay, disposition, and mortality were assessed. Information was obtained primarily from patients; witnesses and first responders provided additional information. RESULTS: Of 374 patients, 113 (30.2%) were wearing helmets. White bicyclists were more likely to wear helmets; black bicyclists were less likely (p = 0.037). Patients with private insurance were more likely to wear helmets, those with Medicaid or no insurance were less likely (p = 0.027). Helmeted bicyclists were more likely to ride with the flow of traffic (97.2%) and within bike lanes (83.7%) (p < 0.001 and p = 0.013, respectively). Nonhelmeted bicyclists were more likely to ride against traffic flow (p = 0.003). There were no statistically significant differences in mean GCS score, AIS score, and mean ISS for helmeted versus nonhelmeted bicyclists. Nonhelmeted patients were more likely to have head computed tomographic scans (p = 0.049) and to be admitted (p = 0.030). CONCLUSION: Helmet use is an indicator of safe riding practices, although most injured bicyclists do not wear them. In this study, helmet use was associated with lower likelihood of head CTs and admission, leading to less hospital resource use. Injured riders failing to wear helmets should be targeted for educational programs. LEVEL OF EVIDENCE: Epidemiologic study, level III.

BACKGROUND: Road safety constitutes an international crisis. In 2010, 11,000 pedestrians and 3,500 bicyclists were injured by motor vehicles in New York City. This study aims to identify the demographics, behaviors, injuries, and outcomes of vulnerable roadway users struck by motor vehicles in New York City's congested central business district and surrounding periphery. METHODS: A prospective, descriptive study of pedestrians and bicyclists struck by motor vehicles and treated at a Level I regional trauma center was performed. Data were collected between December 2008 and June 2011 by interviewing patients and first responders supplemented with imaging and outcomes variables. Main outcome measures included patient demographics, behavior patterns, scene-related data, Injury Severity Score (ISS), and outcomes including mortality. Multivariate ordinal logistic regression modeling was performed to isolate effects of predictor variables on outcome of ISS categories. RESULTS: Injured pedestrians (n = 1,075) and bicyclists (n = 382) differ by age (p < 0.001), sex (p < 0.001), ethnicity/race (p < 0.001), and involved motor vehicle type (p < 0.001). Pedestrians sustain more severe/critical injuries (p < 0.001) and hospital admissions (p < 0.001). Bicyclists are more commonly struck by taxis (p < 0.001) and infrequently wear helmets (29.6%). Variables associated with low ISS include bicycling (adjusted odds ratio [AOR], 0.43; 95% confidence interval [CI], 0.29-0.63), above normal body mass index (AOR, 0.73; 95% CI, 0.54-0.99), Latino (AOR, 0.65; 95% CI, 0.46-0.94) or black (AOR, 0.63; 95% CI, 0.41-0.96) ethnicity/race, and struck by a taxicab (AOR, 0.50; 95% CI, 0.33-0.76) or turning vehicle (AOR,0.49; 95% CI, 0.34-0.70). Variables associated with high ISS include alcohol (AOR, 2.71; 95% CI, 1.81-4.05), age less than 18 years (AOR, 1.73; 95% CI, 1.05-2.86), hearing impairment (AOR, 2.24; 95% CI, 1.24-4.03), and struck by a truck or bus (AOR, 1.91; 95% CI, 1.18-3.10). Mortality was 1.2%. CONCLUSION: Injured pedestrians and bicyclists represent distinct entities. Prevention modalities must be tailored accordingly with a focus on high-risk subgroups and compliance with traffic laws. Studying fatality or admissions data fail to capture the extent of the epidemic. LEVEL OF EVIDENCE: Prospective epidemiologic study, level II.

BACKGROUND: : Injuries to pedestrians struck by motor vehicles represent a significant public health hazard in large cities. The purpose of this study is to investigate the demographics of alcohol users who are struck by motor vehicles and to assess the effects of alcohol on pedestrian crossing patterns, medical management, and outcomes. METHODS: : Data were prospectively collected between December 2008 to September 2010 on all pedestrians who presented to a Level I trauma center after being struck by a motor vehicle. Variables were obtained by interviewing patients, scene witnesses, first responders, and medical records. RESULTS: : Pedestrians who used alcohol were less likely to cross the street in the crosswalk with the signal (22.6% vs. 64.7%) and more likely to cross either in the crosswalk against the signal (22.6% vs. 12.4%) or midblock (54.8% vs. 22.8%). Alcohol use was associated with more initial computed tomography imaging studies compared with no alcohol involvement. Alcohol use was associated with a higher Injury Severity Score (8.82 vs. 4.85; p < 0.001) and hospital length of stay (3.89 days vs. 1.82 days; p < 0.001) compared with those with no alcohol involvement. Patients who used alcohol had a lower average Glasgow Coma Scale score (13.80 vs. 14.76; p < 0.001) and a higher rate of head and neck, face, chest, abdomen, and extremity/pelvic girdle injuries (based on Abbreviated Injury Scale) than those with no alcohol involvement. CONCLUSION: : Alcohol use is a significant risk factor for pedestrians who are struck by motor vehicles. These patients are more likely to cross the street in an unsafe manner and sustain more serious injuries. Traffic safety and injury prevention programs must address irresponsible alcohol use by pedestrians

Risk of thermal injury to the bowel when utilizing electrocautery at the bladder dome has been reported anecdotally. This is a case report of a 64-year-old man with urothelial carcinoma in situ of the bladder who underwent transurethral resection of bladder tumor at the posterior bladder wall near the dome without evidence of perforation. The postoperative course was complicated by delayed small bowel perforation likely secondary to transmission of thermal energy during fulguration of the resection bed. This injury highlights the need for particular prudence when resecting and fulgurating bladder tumors using monopolar electrocautery, specifically in the regions adjacent to bowel

BACKGROUND:Several studies in the literature have examined the volume-outcome relationship for trauma, but the findings have been mixed, and the associated impact of the trauma center level has not been examined to date. The purposes of this study are to (1) determine whether there is a significant relationship between the annual volume of trauma inpatients treated in a trauma center (with "patients" defined in multiple ways) and short-term mortality of those patients, and (2) examine the impact on the volume-mortality relationship of being a Level I versus Level II trauma center. METHODS:Data from New York's Trauma Registry in 2003 to 2006 were used to examine the impact of total trauma patient volume and volume of patients with Injury Severity Score (ISS) of at least 16 on in-hospital mortality rates after adjusting for numerous risk factors that have been demonstrated to be associated with mortality. RESULTS:The adjusted odds of in-hospital mortality patients in centers with a mean annual volume of less than 2,000 patients was significantly higher (adjusted odds ratio = 1.46, 95% confidence interval, 1.25-1.71) than the odds for patients in higher volume centers. The adjusted odds of mortality for patients in centers with an American College of Surgeons-recommended annual volume of less than 240 patients with an ISS of at least 16 was 1.41 times as high (95% confidence interval, 1.17-1.69) as the odds for patients in higher volume centers. However, for both volume cohorts analyzed, the variation in risk-adjusted in-hospital mortality rate was greater among centers within each volume subset than between these volume subsets. CONCLUSION/CONCLUSIONS:When considering the trauma system as a whole, higher total annual trauma center volume (2,000 or higher) and higher volume of patients with ISS ≥16 (240 and higher) are significant predictors of lower in-hospital mortality. Although the American College of Surgeons-recommended 1,200 total volume is not a significant predictor, hospitals in New York with ISS ≥16 volumes in excess of 240 also have total volumes in excess of 2,000. However, when considering individual trauma centers, high volume centers do not consistently perform better than low volume centers. Thus, despite the association between volume and mortality, we believe that the most accurate way to assess trauma center performance is through the use of an accurate, complete, comprehensive database for computing center-specific risk-adjusted mortality rates, rather than volume per se.

Background: In NYC, pediatric pedestrians struck by motor vehicles account for thousands of visits to pediatric emergency departments. In 2007, approximately 60 children were killed due to this mechanism of injury. Currently, NY State collects retrospective information of admitted pediatric pedestrians injured. Objectives: Our goal is to collect comprehensive information prospectively of all children injured as a pedestrian or cyclist vs. motor vehicle. This novel project will allow better delineation of risk factors to target injury prevention. Methods: We have developed a prospective database of all pedestrians/cyclists injured or killed by motor vehicles from December 22, 2008 until present. A pediatric patient is defined as age < 18 years. Information regarding circumstances of incident, injury information, and hospital course were obtained from patient, guardian, emergency responders (paramedics, police, fire officers), and other sources (witnesses and medical record). Results: of 1000 patients, 116 (12%) were pediatric patients. The mean age was 11 years, with 40% of patients in the 6-12 age range. There was a male predominance. Eighty-five percent were pedestrians. One quarter of the cyclists were wearing a helmet. Fifty-two percent did not have adult supervision at the time of the incident. Five percent of incidents occurred within two blocks of school. Forty-two percent of patients were struck mid-block, 25% were darting out into the street, and two patients were boarding a bus. Eleven percent of patients were using an electronic device at time of injury. One patient reported cocaine and one patient was ethanol intoxicated. Twenty percent of patients had loss of consciousness and 6% had a GCS < 15 upon arrival. The injury severity score was greater than 10 in 9% of patients. Twenty-eight percent of patients were admitted. There were no mortalities. Conclusion: Pediatric pedestrians and cyclists struck by motor vehicles are a public health hazard. The majority of injuries are low acuity and result in few hospitalizations. Injury prevention strategies should focus on improving traffic safety knowledge and safety gear wearing in children. (Table Presented)

BACKGROUND: There is an intuitive belief that in-house trauma attendings benefit patient outcome, although multiple studies have failed to prove this. However, no studies investigate the financial advantage for hospitals by having the attendings also perform urgent general surgery cases (GSC) during nights and weekends. The purpose of this study is to identify how an in-house attending program was used for urgent GSC and to see if it provided a financial benefit to the hospital. METHODS: The in-house program began in October 2007. A retrospective study reviewed all cholecystectomies performed from October 2006 to September 2007 and October 2007 to September 2008. Total length of stay (LOS) was calculated. Total LOS for each group was multiplied by the daily cost for a medical-surgical bed ($2,530.00). The cost difference was calculated for the pre- and post-in-house groups. RESULTS: Two hundred sixty-four cholecystectomies were performed before instituting an in-house attending program compared with 291 cases in the period after a 9% increase. Total LOS for cholecystectomies performed before the program was 6.4 days translating to $16,192.00 in room costs versus 5.24 days after and $13,257.20 in room costs. This translated to a savings of $2,934.80 per patient and $854,026.80 savings in total because of reduced LOS, which subsidized the cost of the program, which was $750,000.00. CONCLUSION: In-house attendings are beneficial in decreasing overall LOS for urgent GSC. This study demonstrates that in-house attendings can perform urgent GSCs and realize a savings for a hospital that can be used to fully subsidize the cost of the program