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Hwabejire JO, Kaafarani HMA, Lee J, Yeh DD, Fagenholz P, King DR, de Moya MA, Velmahos GC. Patterns of injury, outcomes, and predictors of in-hospital and 1-year mortality in nonagenarian and centenarian trauma patients. JAMA Surg 2015; 149:1054-9. [PMID: 25133434 DOI: 10.1001/jamasurg.2014.473] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE With the dramatic growth in the very old population and their concomitant heightened exposure to traumatic injury, the trauma burden among this patient population is estimated to be exponentially increasing. OBJECTIVE To determine the clinical outcomes and predictors of in-hospital and 1-year mortality in nonagenarian and centenarian trauma patients (NCTPs). DESIGN, SETTING, AND PARTICIPANTS All patients 90 years or older admitted to a level 1 academic trauma center between January 1, 2006, and December 31, 2010, with a primary diagnosis of trauma were included. Standard trauma registry data variables were supplemented by systematic medical record review. Cumulative mortality rates at 1, 3, 6, and 12 months after discharge were investigated using the Social Security Death Index. Univariate and multivariable analyses were performed to identify the predictors of in-hospital and 1-year postdischarge cumulative mortalities. MAIN OUTCOMES AND MEASURES Length of hospital stay, in-hospital mortality, and cumulative mortalities at 1, 3, 6, and 12 months after discharge. RESULTS Four hundred seventy-four NCTPs were included; 71.7% were female, and a fall was the predominant mechanism of injury (96.4%). The mean patient age was 93 years, the mean Injury Severity Score was 12, and the mean number of comorbidities per patient was 4.4. The in-hospital mortality was 9.5% but cumulatively escalated at 1, 3, 6, and 12 months after discharge to 18.5%, 26.4%, 31.3%, and 40.5%, respectively. Independent predictors of in-hospital mortality were the Injury Severity Score (odds ratio [OR], 1.09; 95% CI, 1.02-1.16; P = .01), mechanical ventilation (OR, 6.23; 95% CI, 1.42-27.27; P = .02), and cervical spine injury (OR, 4.37; 95% CI, 1.41-13.50; P = .01). Independent predictors of cumulative 1-year mortality were head injury (OR, 2.65; 95% CI, 1.24-5.67; P = .03) and length of hospital stay (OR, 1.06; 95% CI, 1.02-1.11; P = .005). Cumulative 1-year mortality in NCTPs with a head injury was 51.1% and increased to 73.2% if the Injury Severity Score was 25 or higher and to 78.7% if mechanical ventilation was required. Most NCTPs required rehabilitation; only 8.9% were discharged to home. CONCLUSIONS AND RELEVANCE Despite low in-hospital mortality, the cumulative mortality rate among NCTPs at 1 year after discharge is significant, particularly in the presence of head injury, spine injury, mechanical ventilation, high injury severity, or prolonged length of hospital stay. These considerations can help guide clinical decisions and family discussions.
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Rago AP, Sharma U, Sims K, King DR. Conceptualized Use of Self-Expanding Foam to Rescue Special Operators From Abdominal Exsanguination: Percutaneous Damage Control for the Forward Deployed. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2015; 15:39-45. [PMID: 26360352 DOI: 10.55460/x2ll-7jps] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Noncompressible hemorrhage is the leading cause of potentially survivable death on the battlefield. In Special Operations Forces (SOF), 50% of potentially survivable deaths have been related to noncompressible hemorrhage. Currently, there are no widely available presurgical interventions that can slow abdominal bleeding. Consequently, many of the preventable deaths occur en route to definitive care as a failure to rescue from exsanguination. A self-expanding polyurethane foam has been developed as a percutaneous damage control intervention to rescue casualties who would otherwise die of noncompressible hemorrhage, and allow them to survive long enough to reach surgical intervention. The purpose of this paper is to summarize the existing preclinical data, describe the role of SOF personnel in foam delivery-system development, and to integrate these together to conceptualize how foam could be incorporated into SOF medical care. METHODS All existing publications on self-expanding foam are reviewed. Additionally, eight SOF medical providers with combat experience provided end-user input to delivery-device design through an interactive human-factors testing process. RESULTS Ten preclinical publications described efficacy, safety, dose translation, and risk-benefit analysis of exsanguination rescue with percutaneous-foam damage control. SOF medical providers guided weight, cubic, operational requirements, and limits for the foam delivery device. CONCLUSION Presurgical exsanguination rescue with percutaneous foam damage control is safe and effective with a favorable risk-benefit profile in preclinical studies. Battlefield, presurgical use by SOF medical providers is conceptually possible. Adoption of the technology on the battlefield should proceed with SOF medical provider input.
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van der Wilden GM, Yeh DD, Hwabejire JO, Klein EN, Fagenholz PJ, King DR, de Moya MA, Chang Y, Velmahos GC. Trauma Whipple: do or don’t after severe pancreaticoduodenal injuries? An analysis of the National Trauma Data Bank (NTDB). World J Surg 2014; 38:335-40. [PMID: 24121363 DOI: 10.1007/s00268-013-2257-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy for trauma (PDT) is a rare procedure, reserved for severe pancreaticoduodenal injuries. Using the National Trauma Data Bank (NTDB), our aim was to compare outcomes of PDT patients to similarly injured patients who did not undergo a PDT. METHODS Patients with pancreatic or duodenal injuries treated with PDT (ICD-9-CM 52.7) were identified in the NTDB 2008–2010 Research Data Sets. We excluded those who underwent delayed PDT (>4 days). The PDT group (n = 39) was compared to patients with severe combined pancreaticoduodenal injuries (grade 4 or 5) who did not undergo PDT (non-PDT group, n = 38). Patients who died in the emergency department or did not undergo a laparotomy were excluded. Our primary outcome was death. Secondary outcomes were intensive care unit length of stay (LOS), hospital LOS, and total ventilator days. A multivariate model was used to determine predictors of in-hospital mortality within each group and in the overall cohort. RESULTS The non-PDT group had a significantly lower systolic blood pressure and Glasgow Coma Scale values at baseline and more severe duodenal, pancreatic, and liver injuries. There were no significant differences in outcomes between the two groups. The Injury Severity Score was the only independent predictor of mortality among PDT patients [odds ratio (OR) 1.12, 95 % confidence interval (CI) 1.01–1.24] and in the entire cohort (OR 1.06, 95 % CI 1.01–1.12). The operative technique did not influence any of the outcomes. CONCLUSIONS Compared to non-PDT, PDT did not result in improved outcomes despite a lower physiologic burden among PDT patients. More conservative procedures for high-grade injuries of the pancreaticoduodenal complex may be appropriate.
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Mavros M, Velmahos GC, Larentzakis A, Yeh DD, Fagenholz PJ, DeMoya M, King DR, Lee J, Kaafarani HM. Benchmarking the Quality of Intraoperative Surgical Care: Risk-Adjustment for Procedure Complexity and Previous Surgery is Crucial. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Naraghi L, Peev MP, Esteve R, Chang Y, Berger DL, Thayer SP, Rattner DW, Lillemoe KD, Kaafarani H, Yeh DD, de Moya MA, Fagenholz PJ, Velmahos GS, King DR. The influence of anesthesia on heart rate complexity during elective and urgent surgery in 128 patients. J Crit Care 2014; 30:145-9. [PMID: 25239820 DOI: 10.1016/j.jcrc.2014.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Revised: 08/15/2014] [Accepted: 08/18/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND As an emerging "new vital sign," heart rate complexity (by sample entropy [SampEn]) has been shown to be a useful trauma triage tool by predicting occult physiologic compromise and need for life-saving interventions. Sample entropy may be confounded by anesthesia possibly limiting its value intraoperatively. We investigated the effects of anesthesia on SampEn during elective and urgent surgical procedures. We hypothesized that SampEn is reduced by general anesthesia. METHODS With institutional review board-approved waiver of informed consent, 128 patients undergoing elective or urgent general surgery were prospectively enrolled. Real-time heart rate complexity was calculated using SampEn through electrocardiogram recordings of 200 consecutive beats in a continuous sliding-window fashion. We recorded SampEn starting 10 minutes before induction until 10 minutes after emergence from anesthesia. The time before induction of anesthesia was categorized as period 1, the time after induction and before emergence as period 2 (intraoperative), and the time after emergence as period 3. We analyzed SampEn changes as patients moved between the different periods and made 3 comparisons: from period 1 with period 2 (comparison A), from period 2 with period 3 (comparison B). We also compared period 1 with period 3 SampEn (comparison C). RESULTS The mean SampEn value for all patients before induction of anesthesia was 1.55 ± 0.58. In each 1 of the 3, comparisons there was a decline in SampEn. Comparison A had a mean decrease of 0.53 ± 0.55 (P < .0001), comparison B had a decrease of 0.13 ± 0.52 (P < .0051), and the mean SampEn difference for comparison C was 0.66 ± 0.53 (P < .0001). Certain pharmacologics had significant effect on SampEn as did need for urgent surgery and American Society of Anesthesiologists class. CONCLUSION Sample entropy decreases after induction of anesthesia and continues to decrease even immediately after emergence in patients without any immediately life-threatening conditions. This finding may complicate interpretation low complexity as a predictor of life-saving interventions in patients in the perioperative period.
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Dowling MB, Smith W, Balogh P, Duggan MJ, MacIntire IC, Harris E, Mesar T, Raghavan SR, King DR. Hydrophobically-modified chitosan foam: description and hemostatic efficacy. J Surg Res 2014; 193:316-23. [PMID: 25016441 DOI: 10.1016/j.jss.2014.06.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/06/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40% of deaths within the first 24 h after injury. Noncompressible hemorrhage accounts for the majority of hemorrhage-related deaths. Thus, materials which can arrest bleeding rapidly are necessary for improved clinical outcomes. This preliminary study evaluated several self-expanding hydrophobically modified chitosan (HM-CS) foams to determine their efficacy on a noncompressible severe liver injury under resuscitation. METHODS Six HM-CS foam formulations (HM-CS1, HM-CS2, HM-CS3, HM-CS4, HM-CS5, and HM-CS6) of different graft types and densities were synthesized, characterized, and packaged into spray canisters using dimethyl ether as the propellant. Expansion profiles of the foams were evaluated in bench testing. Foams were then evaluated in vitro, interaction with blood cells was determined via microscopy, and cytotoxicity was assessed via live-dead cell assay on MCF7 breast cancer cells. For in vivo evaluation, rats underwent a 14 ± 3% hepatectomy. The animals were treated with either: (1) an HM-CS foam formulation, (2) CS foam, and (3) no treatment (NT). All animals were resuscitated with lactated Ringer solution. Survival, total blood loss, mean arterial pressures (MAP), and resuscitation volume were recorded for 60 min. RESULTS Microscopy showed blood cells immobilizing into colonies within tight groups of adjacent foam bubbles. HM-CS foam did not display any toxic effects in vitro on MCF7 cells over a 72 h period studied. Application of HM-CS foam after hepatectomy decreased total blood loss (29.3 ± 7.8 mL/kg in HM-CS5 group versus 90.9 ± 20.3 mL/kg in the control group; P <0.001) and improved survival from 0% in controls to 100% in the HM-CS5 group (P <0.001). CONCLUSIONS In this model of severe liver injury, spraying HM-CS foams directly on the injured liver surface decreased blood loss and increased survival. HM-CS formulations with the highest levels of hydrophobic modification (HM-CS4 and HM-CS5) resulted in the lowest total blood loss and highest survival rates. This pilot study suggests HM-CS foam may be useful as a hemostatic adjunct or solitary hemostatic intervention.
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Sheridan RL, Shumaker PR, King DR, Wright CD, Itani KMF, Cancio LC. Case records of the Massachusetts General Hospital. Case 15-2014. A man in the military who was injured by an improvised explosive device in Afghanistan. N Engl J Med 2014; 370:1931-40. [PMID: 24827038 DOI: 10.1056/nejmcpc1310008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mavros MN, Velmahos GC, Larentzakis A, Yeh DD, Fagenholz P, de Moya M, King DR, Lee J, Kaafarani HMA. Opening Pandora's box: understanding the nature, patterns, and 30-day outcomes of intraoperative adverse events. Am J Surg 2014; 208:626-31. [PMID: 24953016 DOI: 10.1016/j.amjsurg.2014.02.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 12/27/2013] [Accepted: 02/27/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little evidence exists regarding the characteristics of intraoperative adverse events (iAEs). METHODS Administrative data, the American College of Surgeons - National Surgical Quality Improvement Project, and systematic review of operative reports were used to confirm iAEs in abdominal surgery patients. Standard American College of Surgeons - National Surgical Quality Improvement Project data were supplemented with variables including injury type/organ, phase of operation, adhesions, repair type, and intraoperative consultations. RESULTS Two hundred twenty-seven iAEs (187 patients) were confirmed in 9,292 patients. Most common injuries were enterotomies during intestinal surgery (68%) and vessel injuries during hepatopancreaticobiliary surgery (61%); 108 iAEs (48%) specifically occurred during adhesiolysis. A third of the iAEs required organ/tissue resection or complex reconstruction. Because of iAEs, 20 intraoperative consults (11%) were requested and 9 of the 66 (16%) laparoscopic cases were converted to open. Thirty-day mortality and morbidity were 6% and 58%, respectively. The complications included perioperative transfusions (36%), surgical site infection (19%), systemic sepsis (13%), and failure to wean off the ventilator (12%). CONCLUSIONS iAEs commonly occur in reoperative cases requiring lysis of adhesions and possibly lead to increased patient morbidity. Understanding iAEs is essential to prevent their occurrence and mitigate their adverse effects.
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King DR, Larentzakis A. Treatment of sea urchin injuries. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2014; 14:56-59. [PMID: 24952041 DOI: 10.55460/m5u1-2y40] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2014] [Indexed: 06/03/2023]
Abstract
Sea urchin injuries can be sustained in a variety of environments in which U.S. Forces are operating, and familiarity with this uncommon injury can be useful. Injuries by sea urchin spines can occur during military activities close to rocky salt aquatic ecosystems via three mechanisms. The author describes these mechanisms and discusses the diagnosis, management, and treatment of sea urchin injuries.
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Duggan MJ, Rago A, Marini J, Beagle J, Peev M, Velmahos G, Sharma U, King DR. Development of a lethal, closed-abdomen, arterial hemorrhage model in noncoagulopathic swine. J Surg Res 2013; 187:536-41. [PMID: 24398305 DOI: 10.1016/j.jss.2013.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/19/2013] [Accepted: 12/06/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prehospital treatment for noncompressible abdominal bleeding, particularly due to large vascular injury, represents a significant unmet medical need on the battlefield and in civilian trauma. To date, few large animal models are available to assess new therapeutic interventions and hemostatic agents for prehospital hemorrhage control. METHODS We developed a novel, lethal, closed-abdomen injury model in noncoagulopathic swine by strategic placement of a cutting wire around the external iliac artery. The wire was externalized, such that percutaneous distraction would result in vessel transection leading to severe uncontrolled abdominal hemorrhage. Resuscitation boluses were administered at 5 and 12 min. RESULTS We demonstrated 86% mortality (12/14 animals) at 60 min, with a median survival time of 32 min. The injury resulted in rapid and massive hypotension and exsanguinating blood loss. The noncoagulopathic animal model incorporated clinically significant resuscitation and ventilation protocols based on best evidenced-based prehospital practices. CONCLUSION A new injury model is presented that enables screening of prehospital interventions designed to control noncompressible arterial hemorrhage.
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Abstract
Necrotizing skin and soft tissue infections are severe bacterial infections resulting in rapid and life-threatening soft tissue destruction and necrosis along soft tissue planes.
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Peev MP, Naraghi L, Chang Y, Demoya M, Fagenholz P, Yeh D, Velmahos G, King DR. Real-time sample entropy predicts life-saving interventions after the Boston Marathon bombing. J Crit Care 2013; 28:1109.e1-4. [PMID: 24120576 DOI: 10.1016/j.jcrc.2013.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 08/23/2013] [Accepted: 08/25/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE Identifying patients in need of a life-saving intervention (LSI) during a mass casualty event is a priority. We hypothesized that real-time, instantaneous sample entropy (SampEn) could predict the need for LSI in the Boston Marathon bombing victims. MATERIALS AND METHODS Severely injured Boston Marathon bombing victims (n = 10) had sample entropy (SampEn) recorded upon presentation using a continuous 200-beat rolling average in real time. Treating clinicians were blinded to real-time results. The correlation between SampEn, injury severity, number, and type of LSI was examined. RESULTS Victims were males (60%) with a mean age of 39.1 years. Injuries involved lower extremities (50.0%), head and neck (24.2%), or upper extremities (9.7%). Sample entropy negatively correlated with Injury Severity Score (r = -0.70; P = .023), number of injuries (r = -0.70; P = .026), and the number and need for LSI (r = -0.82; P = .004). Sample entropy was reduced under a variety of conditions. (Table see text). CONCLUSIONS Sample entropy strongly correlates with injury severity and predicts LSI after blast injuries sustained in the Boston Marathon bombings. Sample entropy may be a useful triage tool after blast injury.
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Kasotakis G, Duggan M, Li Y, O'Dowd D, Baldwin K, de Moya MA, King DR, Alam HB, Velmahos G. Optimal pressure of abdominal gas insufflation for bleeding control in a severe swine splenic injury model. J Surg Res 2013; 184:931-6. [DOI: 10.1016/j.jss.2013.03.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/01/2013] [Accepted: 03/07/2013] [Indexed: 10/27/2022]
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van der Wilden GM, Janjua S, Wedel SK, Agarwal S, Shapiro ML, Andersen ND, Odom SR, Gates JD, Frakes MA, Chang Y, Velmahos GC, Alam HB, King DR, De Moya MA. Multi-institutional comparison of helicopter transfers directly to the operating room versus the pit stop in the emergency department. Am Surg 2013; 79:939-943. [PMID: 24069995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Van Der Wilden GM, Janjua S, Wedel SK, Agarwal S, Shapiro ML, Andersen ND, Odom SR, Gates JD, Frakes MA, Chang Y, Velmahos GC, Alam HB, King DR, Moya MAD. Multi-institutional Comparison of Helicopter Transfers Directly to the Operating Room versus the Pit Stop in the Emergency Department. Am Surg 2013. [DOI: 10.1177/000313481307900934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Presented September 24, 2011, at the 92nd annual meeting of the New England Surgical Society, September 23–25, 2011, Mt. Washington, New Hampshire.
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King DR. Managing uncertainty: lessons from Xenophon's retreat. JOURNAL OF MANAGEMENT HISTORY 2013. [DOI: 10.1108/jmh-10-2011-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe article's purpose is to address complementary perspectives for managing uncertainty by looking at a historical example.Design/methodology/approachThis is done using a case study of the experience of ancient Greek mercenaries that fought in and out of Persia over two years and approximately 2,000 miles.FindingsAn unexpected finding is that the size of an organization can be instrumental to its environment fit.Research limitations/implicationsAn implication is that the application of existing models to the historical example suggests existing perspectives of change do not appear adequate individually in explaining or preparing organizations for change.Practical implicationsA wider implication of the study involves confirming the need for research and society to better understand the role of organization politics in outcomes.Originality/valueThe study uses a unique historical example to examine organizational responses to uncertainty that range between rational and haphazard explanations and it offers insights for management thought and practice today.
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King DR, Kragh JF, Blackbourne LH. Quality of care assessment in forward detection of extremity compartment syndrome in war. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2013; 13:20-24. [PMID: 23817874 DOI: 10.55460/dmc9-73id] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Recent efforts to improve the quality of care in the Afghanistan theater have focused on extremity compartment syndrome, a common, disabling, and costly problem. To identify opportunities to improve care, the present survey was undertaken to observe the use of two standard methods?the traditional, improvised method and the common, off-the-shelf method?for determining intracompartmental pressures in the lower extremities of combat casualties. METHODS As part of a quality of care improvement effort during Operation Enduring Freedom, all combat casualties presenting to a forward surgical team at Forward Operating Base Shank from August to November 2011 with lower-extremity major trauma were evaluated for signs and symptoms of compartment syndrome. RESULTS Ten casualties had pressure measurement surveyed simultaneously using both methods. A two one-sided test analysis demonstrated a mean difference of ?0.13 (90% confidence interval, ?0.36 to 0.096), which indicated that the methods were similar. A repeated-measures analysis yielded a p value of .72, indicating no statistical difference between the methods. The receiver operating characteristic curve demonstrated excellent agreement within the prespecified limits (?2mm Hg, area under the curve 1.0), which indicated that the methods were similar. CONCLUSION The main finding of the quality of care effort was that clinicians received similar information from use of two standard methods for far forward measurement of pressures to detect extremity compartment syndrome. This finding may help clinicians improve the quality of care in the theater in detecting, diagnosing, and monitoring compartment syndrome.
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Ndao S, Jensen KF, Velmahos GC, King DR. Design and demonstration of a battery-less fluid warmer for combat. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2013; 13:31-36. [PMID: 24048986 DOI: 10.55460/09eb-z83o] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2013] [Indexed: 06/02/2023]
Abstract
BACKGROUND Prehospital battlefield hypothermia remains an issue, with cold fluid resuscitation likely being a significant contributor. Currently, no prehospital battlefield technology exists to warm intravenous resuscitation fluids. Existing commercial fluid-warming technologies are either inadequate or unreliable or have an unacceptable weight and size, making them inappropriate for the austere combat environment. We propose the creation of a battery-less, flameless, portable, lowweight, small, chemically powered fluid warmer for the battlefield. METHODS A magnesium-based exothermic chemical reaction was used as the sole heating source. A low-weight, small insulated container was created to contain the reaction. The chemical reaction was manipulated to sustain fluid heating as long as required. RESULTS The exothermic reaction was used to boil a Fluorinert ™ liquid within an insulated container that heats resuscitation fluid passing through the heat exchanger. A working prototype device, 9 inches in length and 4 inches in diameter, was engineered and tested. Warming was maintained over a variety of clinically relevant flow rates. CONCLUSION A chemically based, safe, battery-less, flameless, lightweight fluid warmer was created. This technology could represent a significant remote capability currently unavailable on the battlefield.
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Mejaddam AY, van der Wilden GM, Chang Y, Cropano CM, Sideris AC, Hwabejire JO, Velmahos GC, Alam HB, de Moya MA, King DR. Development of a rugged handheld device for real-time analysis of heart rate: entropy in critically ill patients. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2013; 13:29-33. [PMID: 23526319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 06/02/2023]
Abstract
INTRODUCTION The usefulness of heart rate variability (HRV) and heart rate complexity (HRC) analysis as a potential triage tool has been limited by the inability to perform real-time analysis on a portable, handheld monitoring platform. Through a multidisciplinary effort of academia and industry, we report on the development of a rugged, handheld and noninvasive device that provides HRV and HRC analysis in real-time in critically ill patients. METHODS After extensive re-engineering, real-time HRV and HRC analyses were incorporated into an existing, rugged, handheld monitoring platform. Following IRB approval, the prototype device was used to monitor 20 critically ill patients and 20 healthy controls to demonstrate real-world discriminatory potential. Patients were compared to healthy controls using a Student?s t test as well as repeated measures analysis. Receiver operator characteristic (ROC) curves were generated for HRV and HRC. RESULTS Critically ill patients had a mean APACHE-2 score of 15, and over 50% were mechanically ventilated and requiring vasopressor support. HRV and HRC were both lower in the critically ill patients compared to healthy controls (p < 0.0001) and remained so after repeated measures analysis. The area under the ROC for HRV and HRC was 0.95 and 0.93, respectively. CONCLUSIONS This is the first demonstration of real-time, handheld HRV and HRC analysis. This prototype device successfully discriminates critically ill patients from healthy controls. This may open up possibilities for real-world use as a trauma triage tool, particularly on the battlefield.
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Ryan ML, Thorson CM, King DR, Van Haren RM, Manning RJ, Andrews DM, Livingstone AS, Proctor KG. Insertion of central venous catheters induces a hypercoagulable state. J Trauma Acute Care Surg 2012; 73:385-90. [PMID: 22846944 DOI: 10.1097/ta.0b013e31825a0519] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Central venous catheters (CVCs) increase the risk of venous thromboembolism. We have previously demonstrated that pulmonary artery catheters are associated with a hypercoagulable state in an animal model and in patients. The purpose of this study is to determine whether the insertion of a CVC is associated with a similar response. METHODS ANIMAL 7F femoral artery catheters were placed in healthy anesthetized swine (N = 16). Serial arterial blood samples were drawn immediately before and after an 8.5F jugular vein CVC and then for 3 hours after CVC removal. Samples were analyzed using kaolin-activated thromboelastography (TEG) at precisely 2 minutes. Human: An institutional review board-approved prospective observational trial was conducted, with informed consent, in patients with critical illness (N = 8) at a Level I trauma center. Blood was drawn from indwelling arterial catheters immediately before and 60 minutes after CVC insertion. Samples were stored in sodium citrate for 15 minutes before TEG. Routine and special coagulation tests were performed on stored samples in the hospital pathology laboratory. RESULTS Insertion of a CVC decreased TEG clotting time (R) by 55% in swine and by 29% in humans (p < 0.001 and 0.019, respectively). Initial clot formation time (K) was reduced by 41% in swine and by 36% in humans (p = 0.003 and 0.019). Fibrin cross-linking (α) was accelerated by 28% in swine and by 17% in humans (p = 0.007 and 0.896), but overall clot strength (maximum amplitude) was not affected. There was no change in routine or special coagulation factors, including von Willebrand factor, antithrombin III, prothrombin time, international normalized ratio, or activated partial thromboplastin time. In animals, the hypercoagulable TEG response was persistent for 3 hours after CVC removal and was prevented by pretreatment with enoxaparin (n = 4) but not heparin (n = 2). CONCLUSION In healthy swine and patients with critical illness, a systemic hypercoagulable state occurred after CVC insertion, and this may partially account for an increased risk of venous thromboembolism. However, because the sample size was small and not powered to detect changes in coagulation proteins, no inferences can be made about the mechanism for the hypercoagulable response.
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Duggan MJ, Mejaddam AY, Beagle J, Demoya MA, Velmahosa GC, Alam HB, Rago A, Zugates G, Busold R, Freyman T, Sharma U, King DR. Development of a lethal, closed-abdomen grade V hepato-portal injury model in non-coagulopathic swine. J Surg Res 2012; 182:101-7. [PMID: 22921917 DOI: 10.1016/j.jss.2012.07.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 07/05/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hemorrhage within an intact abdominal cavity remains a leading cause of preventable death on the battlefield. Despite this need, there is no existing closed-cavity animal model to assess new hemostatic agents for the preoperative control of intra-abdominal hemorrhage. METHODS We developed a novel, lethal liver injury model in non-coagulopathic swine by strategic placement of two wire loops in the medial liver lobes including the hepatic and portal veins. Distraction resulted in grade V liver laceration with hepato-portal injury, massive bleeding, and severe hypotension. Crystalloid resuscitation was started once mean arterial pressure (MAP) fell below 65 mm Hg. Monitoring continued for up to 180 min. RESULTS We demonstrated 90% lethality (9/10) in swine receiving injury and fluid resuscitation, with a mean survival time of 43 min. Previous efforts in our laboratory to develop a consistently lethal swine model of abdominal solid organs, including preemptive anticoagulation, a two-hit injury with controlled hemorrhage prior to liver trauma, and the injury described above without resuscitation, consistently failed to result in lethal injury. CONCLUSION This model can be used to screen other interventions for pre hospital control of noncompressible.
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Cannon JW, Chung KK, King DR. Advanced technologies in trauma critical care management. Surg Clin North Am 2012; 92:903-23, viii. [PMID: 22850154 DOI: 10.1016/j.suc.2012.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.
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King DR. Editorial critique. J Trauma Acute Care Surg 2012; 72:1011-1012. [PMID: 22590751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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King DR, van der Wilden GM, Kragh JF, Blackbourne LH. Forward assessment of 79 prehospital battlefield tourniquets used in the current war. JOURNAL OF SPECIAL OPERATIONS MEDICINE : A PEER REVIEWED JOURNAL FOR SOF MEDICAL PROFESSIONALS 2012; 12:33-38. [PMID: 23536455 DOI: 10.55460/bv5c-t9ig] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2012] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance. METHODS War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics. RESULTS Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied. DISCUSSION Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow ? convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.
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King DR, Ogilvie MP, Velmahos G, Alam HB, Demoya MA, Wilcox SR, Mejaddam AY, Van Der Wilden GM, Birkhan OA, Fikry K. Emergent cricothyroidotomies for trauma: training considerations. Am J Emerg Med 2011; 30:1429-32. [PMID: 22205011 DOI: 10.1016/j.ajem.2011.10.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 10/28/2011] [Accepted: 10/29/2011] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons. METHODS We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined. RESULTS Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001). CONCLUSIONS (1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.
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