EMS systems: Opening the 'Black Box'

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/30851/1/0000513.pd

Injury Type, Injury Severity, and Repeat Occurrence of Alcohol-Related Trauma in Adolescents

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66113/1/j.1530-0277.1994.tb00011.x.pd

A Comparison of Data Sources for Motor Vehicle Crash Characteristic Accuracy

Objective: To determine the accuracy of police reports (PRs), ambulance reports (ARs), and emergency department records (EDRs) in describing motor vehicle crash (MVC) characteristics when compared with an investigation performed by an experienced crash investigator trained in impact biomechanics. Methods: This was a cross-sectional, observational study. Ninety-one patients transported by ambulance to a university emergency department (ED) directly from the scene of an MVC from August 1997 to April 1998 were enrolled. Potential patients were identified from the ED log and consent was obtained to investigate the crash vehicle. Data describing MVC characteristics were abstracted from the PR, AR, and medical record. Variables of interest included restraint use (RU), air bag deployment (AD), and type of impact (TI). Agreements between the variables and the independent crash investigation were compared using kappa. Interrater reliability was determined using kappa by comparing a random sample of 20 abstracted reports for each data source with the originally abstracted data. Results: Agreement using kappa between the crash investigation and each data source was 0.588 (95% CI = 0.508 to 0.667) for the PR, 0.330 (95% CI = 0.252 to 0.407) for the AR, and 0.492 (95% CI = 0.413 to 0.572) for the EDR. Variable agreement was 0.239 (95% CI = 0.164 to 0.314) for RU, 0.350 (95% CI = 0.268 to 0.432) for AD, and 0.631 (95%= 0.563 to 0.698) for TI. Interrater reliability was excellent (kappa > 0.8) for all data sources. Conclusions: The strength of the agreement between the independent crash investigation and the data sources that were measured by kappa was fair to moderate, indicating inaccuracies. This presents ramifications for researchers and necessitates consideration of the validity and accuracy of crash characteristics contained in these data sources.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75653/1/j.1553-2712.2000.tb02067.x.pd

Guidelines for the Management of Severe Head Injury: Are Emergency Physicians Following Them?

The Brain Trauma Foundation published “Guidelines for the Management of Severe Head Injury” in 1995. These evidence-based clinical guidelines (CGs) recommended against prophylactic hyperventilation and glucocorticoid use and advocated for aggressive blood pressure (BP) resuscitation, and the careful use of mannitol. Objective: To survey Michigan emergency physicians (MEPs) to test their adherence to these guidelines. Methods: An anonymous mail survey was sent to all 566 MEPs who are members of the American College of Emergency Physicians. Three clinical scenarios involving severe head injury were presented, all with Glasgow Coma Scale (GCS) scores of 8 or less. The physicians were asked to choose from 15 diagnostic and treatment options, which included: intubation and hyperventilation, BP resuscitation, intravenous (IV) mannitol administration, and IV glucocorticoid administration. Results: Three hundred nineteen (56%) surveys were returned. Forty-six percent [95% confidence interval (95% CI) = 40% to 51%] of the MEPs elected to use prophylactic hyperventilation; very few administered IV glucocorticoids. Seventy-eight percent (95% CI = 75% to 81%) corrected hypotension with systolic BP < 90 mm Hg; 83% (95% CI = 80% to 86%) also administered mannitol appropriately. Conclusions: A majority of MEPs are managing severe head injury patients in accordance with the “Guidelines for the Management of Severe Head Injury,” with the exception of avoiding prophylactic hyperventilation. More education and/or exposure to the evidence regarding prophylactic hyperventilation of severely head injured patients may improve adherence to the guidelines.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74731/1/aemj.9.8.806.pd

Alcohol Abuse/Dependence in Motor Vehicle Crash Victims Presenting to the Emergency Department

Objective: 1) To determine the prevalence of current alcohol abuse/alcohol dependence (AA/AD) among the full injury range of ED motor vehicle crash (MVC) patients; and 2) compare AA/AD and non-AA/AD patient characteristics. Methods: This was a prospective cohort study using a stratified random sample of MVC patients aged ≥18 years presenting to a university hospital and university-affiliated community hospital ED from May 1, 1992, to August 30, 1994. A diagnosis of current AA/AD was based on the alcohol section of the Diagnostic Interview Survey (DIS). Other measurements included the presence of blood alcohol (BAC +), Injury Severity Score (ISS-85), occupant status (driver/passenger), age, gender, seat belt use, culpability for crash, and ED disposition (admitted vs released). A weighted prevalence was determined; subgroups were compared using t-tests, Χ 2 . 2-factor analysis, and logistic regression modeling; Α = 0.05. Results: 1,161 patients were studied. The weighted prevalence of current AA/AD was 22.5%; 53% of these patients were released from the ED. Almost 45% of the patients with current AA/AD were BAC —. When controlling for BAC and AA/AD, greater injury severity and culpability were associated with a BAC +, but not with current AA/AD. Conclusion: Almost 23% of ED MVC patients have current AA/AD; BAC testing does not accurately identify these patients. Intervention strategies must be directed to both admitted and released patients.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73408/1/j.1553-2712.1997.tb03545.x.pd

Characteristics of Cocaine Users Presenting to an Emergency Department Chest Pain Observation Unit

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73770/1/j.aem.2004.11.021.pd

Rates of At-risk Drinking among Patients Presenting to the Emergency Department with Occupational and Nonoccupational Injury

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/71604/1/S1069-6563_03_00538-4.pd

Trauma scores, accident deformity codes, and car restraints in children

The importance and effectiveness of the appropriate use of automobile restraints by young children has been emphasized in several studies. Once the child has entered the emergency care system, however, restraint use may not be the best predictor of injury severity. This study was undertaken to investigate the relationship of restraint status to morbidity and mortality in children examined in a hospital emergency facility following involvment in a motor vehicle crash (MVC). The emergency room charts of 101 children under 18 years of age, who were victims of MVCs, were reviewed and the following trauma scores were calculated: Glascow Coma Scale, Pediatric Trauma Score, Revised Trauma Score, Injury Severity Score, and Maximum Abbreviated Injury Score. In addition, the Traffic Accident Damage (TAD) score, an estimate of crash severity determined by the police at the accident scene, was recorded. The patients were age stratified as follows: 0 to 4 years (n = 24), 5 to 11 years (n = 29), and 12 to 17 years (n = 48). Fifty patients were appropriately restrained at the time of the crash. There was a significant correlation between mean trauma scores and mean TAD codes (P P &gt; .05) across all age groups, and these children were grouped together as "unrestrained" in further analyses. In the 0 to 4 age group, there were no significant differences in mean trauma scores between restrained and improperly restrained or unrestrained children in contrast to the 5 to 11 and the 12 to 17 age groups. There were no significant difference between the distribution of restrained and unrestrained victims with regard to mean TAD scores (P = .5224) in the 0 to 4 age group. This study demonstrates a close correlation between mean trauma scores and vehicle deformity in all age groups, and shows that mean trauma scores appear to be independent of restraint use for the 0 to 4-year-old age subset. Therefore, a police-assigned crash severity score, such as the TAD, may be useful in the initial traige of pediatric trauma victims to an appropriate hospital or trauma center.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/31099/1/0000777.pd

Rural motor vehicle crash mortality: The role of crash severity and medical resources

We did a retrospective case control study to examine the relationship between the risk of dying for Michigan motor vehicle crash (MVC) drivers and the type of county (rural/nonrural) of crash occurrence, while adjusting for crash characteristics, age, sex, and the medical resources in the county of crash occurrence. The 1987 Michigan Accident Census was used to obtain data regarding all MVC driver nonsurvivors (733) and a random sample of all surviving drivers (2,483). County of crash occurrence was defined as rural or nonrural. The crash characteristics analyzed were vehicle deformity, seat belt use, and drivability of the vehicle from the scene. Age and sex of the driver were also analyzed. Medical resource characteristics for the county of crash occurrence were measured as the number of resources per square mile for each of the following: ambulances, emergency medical technicians (EMT), acute care hospital beds, and operating rooms, surgeons and emergency physicians. Also considered were the number and level of emergency rooms in the county of crash occurrence along with the maximum level of prehospital care available (basic life support versus advanced life support) in a county. Before adjusting, the relative risk (RR) for rural MVC drivers dying, compared to their nonrural counterparts, was 1.96. Adjustment for crash characteristics, age, and sex (using logistic regression) decreased the RR to 1.51. An attempt to add medical resource variables to the model resulted in high correlation with the rural/nonrural variable, as well as with each other. This multi-collinearity prevented us from providing a simple explanation of the role of medical resource variables as predictors of survival. We conclude that almost 50% of excess rural MVC mortality, as measured by the RR, can be accounted for by difference in crash characteristics and age. Delineation of the role of medical resources will require further investigation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29706/1/0000038.pd

Risk Adjustment and Outcome Measures for Out-of-hospital Respiratory Distress

: The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work, this group delineated the priority conditions, described conceptual models, suggested core and risk adjustment measures potentially useful to emergency medical services research, and summarized out-of-hospital pain measurement. In this fifth article in the EMSOP series, the authors recommend specific risk-adjustment measures and outcome measures for use in out-of-hospital research on patients presenting with respiratory distress. The methodology included systematic literature searches and a structured review by an expert panel. The EMSOP group recommends use of pulse oximetry, peak expiratory flow rate, and the visual analog dyspnea scale as potential risk-adjustment measures and outcome measures for out-of-hospital research in patients with respiratory distress. Furthermore, using mortality as an outcome measure is also recommended. Future research is needed to alleviate the paucity of validated tools for out-of-hospital outcomes research.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73779/1/j.aem.2004.03.010.pd