Faculty Bibliography

OBJECTIVE:To identify factors associated with distress experienced by physicians during their first COVID-19 triage decisions. METHODS:An online survey was administered to physicians licensed in New York State. RESULTS:Of the 164 physicians studied, 20.7% experienced severe distress during their first COVID-19 triage decisions. The mean distress score was not significantly different between physicians who received just-in-time training and those who did not (6.0 ± 2.7 vs 6.2 ± 2.8, P=0.550) and between physicians who received clinical guidelines and those who did not (6.0 ± 2.9 vs 6.2 ± 2.7, P=0.820). Substantially increased odds of severe distress were found in physicians who reported that their first COVID-19 triage decisions were inconsistent with their core values (adjusted odds ratio 6.33, 95% confidence interval 2.03-19.76) and who reported having insufficient skills and expertise (adjusted odds ratio 2.99, 95% confidence interval 0.91-9.87). CONCLUSION/CONCLUSIONS:About 1 in 5 physicians in New York experienced severe distress during their first COVID-19 triage decisions. Physicians with insufficient skills and expertise, and core values misaligned to triage decisions are at heightened risk of severe distress. Just-in-time training and clinical guidelines do not appear to alleviate distress experienced by physicians during their first COVID-19 triage decisions.

BACKGROUND:Alcohol and other drugs (AOD) increase the risk of traumatic injury occurring, but data suggest a protective benefit in preventing trauma-related mortality. The objective of this study is to describe the epidemiology of AOD-related traumatic injury in the US over a recent 7 year period and assess the interaction of traumatic injury and AOD on pre-admission fatality on both an additive scale using incidence contrasts and on a statistical multiplicative scale using survey-adjusted logistic regression. METHODS:Using the National Emergency Department Sample (NEDS), we describe the epidemiology of alcohol and substance-related emergency department traumatic injury over a recent period. AOD-related injury was assessed using survey-adjusted counts and means. Ratio estimates and differences were calculated using simulations based on survey-adjusted counts and standard errors. Differences in trends over time were evaluated by comparing the slopes of linear regression equations with year as the predictor variable. RESULTS:Alcohol and substance-related emergency department injury discharges increased 9.8 % during the study period. There was a statistically significant interaction between traumatic injury death and AOD on both an additive scale and multiplicative scale. (Odds Ratio for interaction term = 1.76, 95 % CI = 1.53, 2.03). CONCLUSIONS:AOD use does not provide a protective benefit in the setting of trauma, but rather is an important contributor to traumatic injury mortality.

BACKGROUND:Pickleball is growing rapidly with a passionate senior following. Understanding and comparing players' injury experience through analysis of a nationally representative hospital emergency department sample helps inform senior injury prevention and fitness goals. METHODS:A cross-sectional descriptive study was performed using 2010 to 2019 data from the U.S. Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS). Tennis was selected for comparison purposes because of the similarity of play, occasional competition for the same court space, and because many seniors play both sports. Non-fatal pickleball and tennis-related cases were identified, examined, recoded, and separated by injury versus non-injury conditions. Since over 85% of the pickleball injury-related cases were to players ≥60 years of age, we mostly focused on this older age group. Analyses consisted of descriptive statistics, injury frequency, type and trends over time, and comparative measures of risk. RESULTS:Among players ≥60 years of age, non-injuries (i.e., cardiovascular events) accounted for 11.1 and 21.5% of the pickleball and tennis-related cases, respectively. With non-injuries removed for seniors (≥60 years), the NEISS contained a weighted total of 28,984 pickleball injuries (95% confidence interval [CI] = 19,463-43,163) and 58,836 tennis injuries (95% CI = 44,861-77,164). Pickleball-related injuries grew rapidly over the study period, and by 2018 the annual number of senior pickleball injuries reached parity with senior tennis-related injuries. Pickleball-related Slip/Trip/Fall/Dive injury mechanisms predominated (63.3, 95% CI = 57.7-69.5%). The leading pickleball-related diagnoses were strains/sprains (33.2, 95% CI = 27.8-39.5%), fractures (28.1, 95% CI = 24.3-32.4%) and contusions (10.6, 95% CI = 8.0-14.1%). Senior males were three-and-a-half times more likely than females to suffer a pickleball-related strain or sprain (Odds Ratio [OR] 3.5, 95% CI = 2.2-5.6) whereas women were over three-and-a-half times more likely to suffer a fracture (OR 3.7, 95% CI = 2.3-5.7) compared to men and nine times more likely to suffer a wrist fracture (OR 9.3 95% CI = 3.6-23.9). Patterns of senior tennis and pickleball injuries were mostly similar. CONCLUSIONS:NEISS is a valuable data source for describing the epidemiology of recreational injuries. However, careful case definitions are necessary when examining records involving older populations as non-injury conditions related to the activity/product codes of interest are frequent. As pickleball gains in popularity among active seniors, it is becoming an increasingly important cause of injury. Identifying and describing the most common types of injuries may can help inform prevention and safety measures.

INTRODUCTION/BACKGROUND:Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures. METHODS:The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management. RESULTS:A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001). CONCLUSIONS:Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.

BACKGROUND:Aortic occlusion (AO) is utilized for patients in extremis, with resuscitative endovascular balloon occlusion of the aorta (REBOA) use increasing. Our objective was to examine changes in AO practices and outcomes over time. The primary outcome was the temporal variation in AO mortality, while secondary outcomes included changes in technique, utilization, and complications. STUDY DESIGN/METHODS:This study examined the AORTA registry over a 5-year period (2014-2018). AO outcomes and utilization were analyzed using year of procedure as an independent variable. A multivariable model adjusting for year of procedure, signs of life (SOL), SBP at AO initiation, operator level, timing of AO, and hemodynamic response to AO was created to analyze AO mortality. RESULTS:1458 AO were included. Mean age (39.1 ± 16.7) and Median ISS (34[25,49]) were comparable between REBOA and Open AO. Open AO patients were more likely: male (84% vs. 77%, p = 0.001), s/p penetrating trauma (61% vs. 19%, p < 0.001), and arrived without SOL (60% vs. 40%, p = 0.001). REBOA use increased significantly and adjusted mortality decreased 22%/year while open AO survival was unchanged. REBOA initiation SBP increased significantly over the study period (52.2 vs. 65, p = 0.04). Compared with patients undergoing AO with CPR, each decile increase in SBP improved survival 12% (AOR 1.12, adj p = 0.001). The use of 7F REBOA (2.9% to 54.8%) and Zone III deployment increased significantly (14.7% vs 40.6%), with Zone III placement having decreased associated mortality (AOR 0.33, adj p = 0.001). Overall REBOA complication rate was 4.5% and did not increase over time (p = 0.575). CONCLUSIONS:REBOA survival has increased significantly while open AO survival remained unchanged. This may be related to lower thresholds for REBOA insertion at higher blood pressures, increased operator experience and improved catheter technology leading to earlier deployment.

INTRODUCTION: The COVID-19 pandemic overwhelmed New York City hospitals. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. The objective of this study was to determine the impact of percutaneous dilational tracheostomy (PDT) in COVID-19 patients on critical care capacity.
METHOD(S): This is a single-institution prospective case series of SARS-CoV-2 infected patients undergoing PDT from April 1-June 4, 2020 with follow-up through June 25, 2020 at a public tertiary care center. Clinical data were obtained through medical record review. Mechanically ventilated COVID-19 patients were screened for intervention based on the following criteria: >= 6 days of intubation with further need for mechanical ventilation, a fractional inspired oxygen concentration of <= 60%, positive end expiratory pressure <=12, no significant organ dysfunction except acute kidney injury, and minimal pressor requirements. The main outcomes measured were change in 48-hour periprocedural sedative/analgesia requirements, liberation from the ventilator, rate of transfer from the ICU, decannulation, PDT-related complications, and in-hospital survival.
RESULT(S): Fifty-five patients met PDT criteria and underwent PDT a median of 13 days from intubation. Patient characteristics are found in Table 1. Intravenous midazolam equivalents, fentanyl equivalents and cisatracurium equivalents were significantly reduced post- PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 and 12 days respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care. Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30).
CONCLUSION(S): Mechanically ventilated COVID-19 patients undergoing PDT using standard criteria improves ventilator and medication utilization in areas strained by the SARS-CoV-2 pandemic. Long term outcomes after PDT in this population deserve further study

BACKGROUND:Powered, two-wheeled transportation devices like electric bicycles (E-bikes) and scooters are increasingly popular, but little is known about their relative injury risk compared to pedal operated bicycles. METHODS:Descriptive and comparative analysis of injury patterns and trends associated with E-bikes, powered scooters and pedal bicycles from 2000 to 2017 using the US National Electronic Injury Surveillance System. RESULTS:While persons injured using E-bikes were more likely to suffer internal injuries (17.1%; 95% CI 5.6 to 28.6) and require hospital admission (OR=2.8, 95% CI 1.3 to 6.1), powered scooter injuries were nearly three times more likely to result in a diagnosis of concussion (3% of scooter injuries vs 0.5% of E-bike injuries). E-bike-related injuries were also more than three times more likely to involve a collision with a pedestrian than either pedal bicycles (OR=3.3, 95% CI 0.5 to 23.6) or powered scooters (OR=3.3, 95% CI 0.3 to 32.9), but there was no evidence that powered scooters were more likely than bicycles to be involved in a collision with a pedestrian (OR=1.0, 95% CI 0.3 to 3.1). While population-based rates of pedal bicycle-related injuries have been decreasing, particularly among children, reported E-bike injuries have been increasing dramatically particularly among older persons. CONCLUSIONS:E-bike and powered scooter use and injury patterns differ from more traditional pedal operated bicycles. Efforts to address injury prevention and control are warranted, and further studies examining demographics and hospital resource utilisation are necessary.

While the incidence of geriatric trauma continues to increase, outcomes following severe blunt liver injury (BLI) are unknown. We sought to investigate independent predictors of mortality among elderly trauma patients with severe BLI. A retrospective study of the NTDB (2014-15) identified patients with isolated, high-grade BLI. Patients were stratified into two groups, non-elderly (<65 years) and elderly (≥65 years), and then two management groups: operative within 24 h of admission and non-operative. Demographics and outcomes were compared. Multivariable logistic regression was used to estimate association with mortality. A total of 1133 patients met our inclusion criteria. 107 patients required surgery and 1011 patients were managed non-operatively. Age was independently associated with mortality (AOR 1.04, p < .001). For patients <65 years, need for operative intervention was associated with a 55 times greater likelihood of death (AOR 55.1, p < .001). In patients ≥65 years, operative intervention was associated with a 122 times greater likelihood of death (AOR 122.09, p = .005). Age is independently associated with mortality in patients with high grade BLI.

INTRODUCTION/BACKGROUND:The population and spatial characteristics of COVID-19 infections are poorly understood, but there is increasing evidence that in addition to individual clinical factors, demographic, socioeconomic and racial characteristics play an important role. METHODS:We analyzed positive COVID-19 testing results counts within New York City ZIP Code Tabulation Areas (ZCTA) with Bayesian hierarchical Poisson spatial models using integrated nested Laplace approximations. RESULTS:Spatial clustering accounted for approximately 32% of the variation in the data. There was a nearly five-fold increase in the risk of a positive COVID-19 test. (IDR = 4.8, 95% Cr I 2.4, 9.7) associated with the proportion of Black / African American residents. Increases in the proportion of residents older than 65 years, housing density and the proportion of residents with heart disease were each associated with an approximate doubling of risk. In a multivariable model including estimates for age, COPD, heart disease, housing density and Black/African American race, the only variables that remained associated with positive COVID-19 testing with a probability greater than chance were the proportion of Black/African American residents and proportion of older persons. CONCLUSIONS:Areas with large proportions of Black/African American residents are at markedly higher risk that is not fully explained by characteristics of the environment and pre-existing conditions in the population.