Faculty Bibliography

BACKGROUND: New York State's Trauma System has been in place since 1990. At it's inception, 36 trauma centers were designated by the state. As of 2002 there were 50, with more centers applying for designation. The state designation process looks at various criteria that include volume and manpower standards. There is no review of the impact of a new center on neighboring centers. This impact can include issues of residency training, research, and the maintenance of provider skills. If provider skills deteriorate, there is a risk for increased mortality. This study examines how a new trauma center, in the Bronx, impacted a near-by trauma center. METHODS: Data were collected from the trauma and operating room registries during the 12-month period before and after the designation of a near-by trauma center. Data included number of trauma admissions, Injury Severity Score (ISS), mechanism of injury, mortality, number of laparotomies and thoracotomies, and the type of ambulance used for transport (private vs. municipal). RESULTS: There was a 30% reduction in 'major' trauma admissions (ISS >8) and a 14% reduction in admissions with an ISS >15. This reduction included a 22% to 29% reduction in the numbers of severe head injury patients, laparotomies, and thoracotomies. Mortality rates for patients with ISS 16 to 24 and >24 increased after the designation. CONCLUSION: The addition of a new trauma center in the Bronx had a negative impact on a near-by trauma center. Significant reductions in the volume of severely injured patients had a negative impact on factors not routinely measured like resident education, staff competency, and research. It is possible that these factors are at least partially responsible for the increased mortality rates seen after designation. These considerations are not routinely considered during the designation of new trauma centers and may actually adversely affect the very population it is trying to serve. As trauma systems mature, consideration of the impact the new center will have on the existing centers must be included in the designation process

BACKGROUND: Nearly 100,000 people await an organ transplant in the U.S. Improved utilization of potential organ donors may reduce the organ shortage. Physician attitudes toward organ donation may influence donation rates; however, the attitudes of U.S. physicians have not been formally evaluated. METHODS: Anonymous questionnaires were distributed to surgical attendings, surgical residents, and medical students at two academic medical centers. Willingness to donate one's own organs and family member's organs was examined, as well as experience with transplant procedures and religious views regarding organ donation. RESULTS: A total of 106 surveys were returned. Sixty-four percent of responders were willing to donate their own organs, and 49% had signed an organ donor card. Willingness to donate inversely correlated with professional experience. Eighty-four percent of those surveyed would agree to donate the organs of a family member, including 55% of those who refused to donate their own organs. Experience on the transplant service influenced 16% of those refusing donation, with the procurement procedure cited by 83% of this group. Sixteen percent refused organ donation on the basis of religious beliefs. CONCLUSIONS: The surveyed U.S. physicians are less willing to donate their organs compared with the general public. Despite understanding the critical need for organs, less than half of physicians surveyed had signed organ donor cards. Previous experiences with the procurement procedure influenced several responders to refuse organ donation. As the lay public traditionally looks to physicians for guidance, efforts must be made to improve physician attitudes toward organ donation with the hope of increasing donation rates

BACKGROUND: Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS: Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS: There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION: An aggressive laparoscopic program can improve patient management after PAT

BACKGROUND: It has been shown previously that the adverse cardiopulmonary sequelae of increased intra-abdominal pressure (IAP) are worsened by hemorrhage and resuscitation. Bacterial translocation (BT) to the mesenteric lymph nodes (MLNs), liver, and spleen has also been shown to occur with increased IAP. OBJECTIVE: To investigate the hypothesis that BT associated with elevated IAP would be significantly increased after hemorrhage and resuscitation. MATERIALS AND METHODS: Anesthetized adult male rats had femoral artery and vein catheters placed, and an intra-abdominal catheter placed to measure IAP. Group 1 underwent surgery only and served as controls. Group 2 had IAP raised to 10 mm Hg by infused lactated Ringer's solution for 40 minutes. Group 3 had a 25% hemorrhage, followed by resuscitation by infused lactated Ringer's solution and shed blood. Group 4 first had a 25% hemorrhage, resuscitated using infused lactated Ringer's solution and shed blood, and then had IAP raised to 10 mm Hg by infused lactated Ringer's solution for 40 minutes. All groups were killed after 2 hours, and had MLNs, liver, and spleen harvested for quantitative cultures. RESULTS: Hemorrhage and resuscitation alone did not increase BT to the MLNs, liver, or spleen. An increase in IAP to 10 mm Hg resulted in a significant level of BT to the MLNs and liver on MacConkey II agar (P<.05), and a significant increase in the level of BT only to the liver on trypticase soy agar with 5% sheep's blood (P<.05). Hemorrhage and resuscitation did increase the level of BT to the liver and spleen when IAP was increased to 10 mm Hg (P<.05). CONCLUSIONS: In this model, hemorrhage and resuscitation alone did not increase BT to the MLNs, liver, or spleen. However, hemorrhage and resuscitation increased BT to the liver and spleen when IAP was increased to 10 mm Hg. This supports the concept that prior hemorrhage and resuscitation exacerbates the effects of increased IAP

BACKGROUND: Elevations in intra-abdominal pressure (IAP) adversely affect organ function. Prior hemorrhage and resuscitation exacerbates the cardiac and pulmonary effects of IAP. We have recently shown that superior mesenteric artery flow (SMAF) is reduced with increasing IAP. This study was designed to determine whether and how hemorrhage and resuscitation affects SMAF with increasing IAP. METHODS: Ten pigs were divided into two groups after placement of a Doppler flow probe around the proximal SMA and insertion of a pulmonary artery (PA) catheter. Group 1 underwent intraperitoneal infusion of fluid to increase IAP to 10, 20, 30, and 40 mm Hg followed by a 20-minute equilibration period at each IAP. Group 2 was hemorrhaged 20% of circulating volume followed by standard resuscitation. After equilibration, this group had IAP increased in the same manner as group 1. Cardiac output (CO), PA pressures, and SMAF were recorded 1 hour after laparotomy and after equilibration at each IAP. Comparisons were made using repeated measures of analysis of variance, Student's t test, and linear regression analysis. RESULTS: In group 2, a reduction in SMAF was noted at 30 and 40 mm Hg of IAP when compared with baseline (p = 0.009). This reduction was not seen in group 1. There was also a significant (p = 0.001) reduction in CO between baseline and all levels of increased IAP in group 2. This decrease was again not seen in group 1. The correlation between CO and SMAF in group 2 was r = 0.74, r2 = 0.55, p = 0.0001. There was no significant correlation between CO and SMAF in group 1. CONCLUSION: SMAF and CO are reduced with increasing IAP to a greater degree when preceded by hemorrhage and resuscitation. Although there is a strong correlation between the reductions in CO and SMAF, the reduction in SMAF is greater than the reduction in CO. This finding suggests that optimizing cardiac function alone during periods of even moderate levels of increased IAP may be inadequate to normalize SMAF. This lends further support for early abdominal decompression in the treatment of trauma patients with increased IAP

OBJECTIVE: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). METHODS: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H2O) was treated by bedside or operating room laparotomy. RESULTS: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11 patients, eight patients (72.7%) had acidotic pHi (7.10 +/- 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. CONCLUSIONS: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications