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Biomedical subjects

L M Jacobs

Publications and source records attributed to L M Jacobs.

At least 19 recordsLinked to original sources
PubMed1998

Emergency medicine in France.

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.

Ambulances↗
PubMed1996

Hypercoagulability following multiple trauma.

We sought evidence of hypercoagulability in 59 seriously injured trauma patients. An extended coagulation profile (consisting of tissue plasminogen activator antigen concentration, plasminogen activator inhibitor, serum antithrombin III, protein C antigen, functional protein C, protein S antigen, D-dimer, and prothrombin fragment 1.2) was compared to control values. Laboratory evidence of hypercoagulability was seen in 85% (n = 50) of the patients. Patients with an Injury Severity Score (ISS) > or = 16 (n = 36) had significantly elevated levels of D-dimer and decreased levels of functional protein C compared to patients with an ISS < or = 15 (n = 23). Functional protein C had a negative correlation (r = -0.44; p < 0.001) with the ISS. A hypercoagulable state exists immediately following severe trauma. Greater injury severity may increase this hypercoagulable state. Decreased levels of functional protein C best correlated with increased injury severity.

Adult↗
PubMed1995

The quantity of cause-of-injury information documented on the medical record: an appeal for injury prevention.

OBJECTIVE: To determine how much information about the cause of injury (available at the time of ED treatment) is documented on the medical record. This information is used by medical records coders to assign e-codes. METHODS: Quantitative "stages of information" were defined: stage 1 = the maximum amount of information available from the patient, as collected by a trained research assistant; stage 2 = the amount of information obtained by the care provider during the patient interview; and stage 3 = the amount of information the care provider documented in the medical record. Comparisons were made between the three stages; subgroup analyses compared amounts of information loss between the stages for levels of care provider and cause-of-injury information categories. RESULTS: Information was obtained from 109 patients. Only 46% of the cause-of-injury information available during the ED visit was recorded on the medical record. Incomplete history taking (obtaining 68% of the available information) and failure to document (writing 67% of the information obtained during the patient interview) contributed equally to the loss of information. The most information was obtained about who had received the injury (72%) and the least amount of information was in the category of where the injury had occurred (14%). Attending physicians collected the most information (74%) but documented significantly less (65%) than did physician assistants (70%) or medical students (81%). Medical students collected the least (65%) but documented the most, resulting in the students' medical records' being the most complete (52%) for cause-of-injury information. CONCLUSION: Emergency providers obtain significantly less cause-of-injury information than is available from the patient. Also, these providers' handwritten medical records contain significantly less cause-of-injury information than was obtained during the patient interview.

Connecticut↗
PubMed1995

Accuracy of e-codes assigned to emergency department records.

OBJECTIVE: To determine the accuracy of ICD-9-CM external-cause-of-injury codes (e-codes) assigned to the medical records of injured patients treated in an ED and released. METHODS: A comparison was made of routine coding and expert recoding of medical records generated in the ED for a convenience sample of patients treated for injuries within 24 hours of injury occurrence and subsequently released from the ED. The medical record was handwritten and subsequently coded by three medical records coders (MRCs). The e-coded charts were sent to an external medical record consultant (expert), who was blinded to the codes previously assigned. The expert reading was used as the criterion standard. Accuracy was measured using a kappa statistic, and errors were described. RESULTS: Of 126 available patient charts, 108 (85.7%) were assigned e-codes by MRCs. The expert assigned two codes to (double-coded) 67 patients, while the MRCs double-coded only one patient. The additional code was usually a "place of occurrence code." In 60 cases (55.6%), the expert code exactly matched the MRC code; kappa = 0.462. Of the 48 mismatches (44.4%), 20 (41.7%) were e-coded in the wrong category, 20 (41.7%) were e-coded in the correct category but with incorrect specificity of information, either too specific or not specific enough, and eight (16.6%) had combined coding errors. CONCLUSION: The accuracy of e-codes assigned to ED records was moderate in this single institution analysis. Errors were predominantly related to the specificity of the code, but some e-codes were in the wrong category. There are implications for injury surveillance and research. E-code assignment must be standardized and applied uniformly to obtain accurate codes. Automation of e-coding could improve accuracy and consistency of codes. National and international epidemiologic studies of cause of injury among ED patients will be severely hampered until e-code assignment can be better standardized.

Emergency Service, Hospital↗
PubMed1995

Emergency management of blunt testicular trauma.

OBJECTIVE: Severe blunt testicular trauma is an infrequently reported consequence of injury, yet it is associated with significant sequelae. This case series evaluates the characteristics of patients with severe blunt testicular trauma, assesses the role of ultrasonography in their management, and offers an evaluation algorithm for use by both emergency and urology personnel. METHODS: A retrospective review was conducted of ten patients who had severe blunt testicular injuries referred for urologic evaluation over a seven-year period at a level 1 trauma center. Attention was focused on ultrasonographic results, operative findings, and testicular salvage rates. RESULTS: With the exception of two motorcycle crash victims, patients presented in a delayed fashion (mean 3.5 days; range 1-5 days). Most (6/10) patients had true testicular rupture, all were explored urgently, and there was a 100% testicular salvage rate. Of the eight patients who had preoperative ultrasonographic examination, two were reported to show testicular rupture, but on exploration only one in fact had a tunica albuginea tear. Six patients had ultrasonographic examinations that revealed nonspecific abnormalities but failed to show testicular rupture; three had testicular rupture. CONCLUSIONS: Ultrasonography cannot be relied on to accurately diagnose rupture of the testis in high-risk patients. However, testicular rupture is universally associated with an abnormal ultrasonography scan, albeit commonly yielding nonspecific findings. A high level of suspicion is mandatory with high-energy transfer mechanisms. Since a significant delay in presentation is not unusual, early exploration is warranted in the setting of high risk and provides an excellent chance of testicular salvage. Injuries associated with normal testicular ultrasonography may be managed conservatively.

Adolescent↗
PubMed1995

Mesenteric injury from blunt abdominal trauma.

Mesenteric injury from blunt abdominal trauma is rare and can be difficult to diagnose. Twenty-seven cases were admitted over the past 5 years to our Level I trauma center. These cases have been retrospectively reviewed to better define the experience of patients with blunt mesenteric injury for the physician faced with making this diagnosis. It was found that the diagnosis of mesenteric injuries tends to be delayed in a certain subset of patients. Patients with a devascularizing, isolated injury or patients who are evaluated by abdominal CT scan (as opposed to DPL) tended to be more likely to experience a diagnostic delay. It was also found that motor vehicle accidents are the most common, though not the only, mechanism of injury and that the mesentery of the small bowel is injured approximately five times more frequently than the colonic mesenteries. These factors, however, did not result in earlier diagnostic decision making. To decrease the likelihood of a missed diagnosis, physicians should entertain the possibility of mesenteric injury in all patients presenting with blunt abdominal trauma, even if few clinical findings are initially present and/or an abdominal CT scan demonstrates no definitive intraabdominal injury.

Abdominal Injuries↗
PubMed1994

Personality types of flight crew members in a hospital-based helicopter program.

PURPOSE: To determine the personality preferences of flight crew members in a hospital-based helicopter emergency medical service (HEMS) using the Myers-Briggs Type Indicator (MBTI), and to differentiate and compare these preferences between crew specialties and a historical control population. METHODS: A prospective cohort study was conducted of all active crew members (nurses, respiratory therapists and pilots) in a hospital-based flight program. Data collected included the results of the MBTI, gender, age and years of flight experience. RESULTS: Crew members were represented by 14 of 16 possible MBTI personality types, with three types predominating. For each crew specialty, extroversion preferences predominated over introversion, and perceiving characteristics predominated over judging characteristics. Differences existed by crew specialty for the sensing-intuition and thinking-feeling dimensions. CONCLUSIONS: A personality typology has been established for individual and group preferences within one hospital-based HEMS program. This data begins to develop a data base and an investigative protocol for understanding some of the human factors regarding flight programs. Future research should focus on expanding the data base and exploring specific crew interactions based on additional diagnostic and evaluative methodologies.

Adult↗
PubMed1994

Prospective evaluation of craniofacial pressure in four different cervical orthoses.

INTRODUCTION: Cervical collars play a role in the long-term treatment of cervical spine injuries. Pressure ulcers are one of the potential complications. We previously reported on three patients who developed pressure ulcers of the scalp while wearing cervical collars. The pressure exerted by different collars was measured to determine whether this was a significant factor in the clinical problem we observed. METHODS: Four brands of cervical collars (Stifneck, Philadelphia, Newport, and Miami J) were tested in 20 normal volunteers. Pressure was measured at the occiput, mandible, and chin. Opinions on comfort were also collected. RESULTS: The Stifneck collar exceeds capillary closing pressure (CCP) for most contact points. The Philadelphia collar exposes the wearer to high pressures when supine compared with the upright position (p < 0.001). The Newport and Miami J collars exerted pressure well below CCP. The subjective comfort (scale from 0 (poor) to 5 (best)) ratings were: Stifneck = 0.85, Philadelphia = 3.00, Newport = 3.80, and Miami J = 3.45. CONCLUSIONS: We recommend use of "patient-friendly" collars such as the Newport or Miami J because of their favorable skin pressure patterns and superior patient comfort. These collars should potentially reduce the incidence of soft-tissue complications and improve patient compliance.

Adult↗
PubMed1994

Isolated free fluid on abdominal computerized tomographic scan: an indication for surgery in blunt trauma patients?

A retrospective study of 792 patients who sustained blunt traumatic injury and underwent abdominopelvic computerized tomographic scan (CT) evaluation was performed. Patients who had free intraperitoneal fluid without evidence of solid visceral organ damage served as the study population. Sixty-six (8.3%) of patients were identified as having free fluid without evidence of solid organ injury. Pelvic fractures occurred in 14 of the 66 (21.2%) patients. Splenic injuries requiring laparotomy were not diagnosed initially on CT scan of the abdomen in four (6%) patients. Mesenteric or small bowel injuries occurred in six (9%) patients. Nine (13.6%) of the patients expired. Thirty-five patients (53%) had no sequelae of intra-abdominal injuries and required no surgical intervention. If patients with pelvic fractures are excluded, 10 (19.2%) of the patients required operative intervention for their injuries. It is our conclusion that free fluid as the only significant finding on CT scan in blunt trauma patients may be a harbinger of significant intra-abdominal injury, and that these patients need to be closely observed to decrease morbidity associated with these potential injuries.

Abdominal Injuries↗
PubMed1994

An efficient system for controlled distal colorectal irrigation.

We have found this setup to be most useful. For those surgeons who incorporate rectal irrigation as part of their treatment plan for patients with rectal injuries, we would recommend trial of this simple yet effective technique. The more senior anesthesia and nursing staff who have suffered through the vagaries of widespread fecal contamination from the beginning to the end of the operation rapidly become advocates of this procedure.

Anal Canal↗
PubMed1993

The response of scene call volume to prehospital education.

INTRODUCTION: Transport of injured patients directly from a scene to a trauma center improves survival of patients and shortens their length of stay in the hospital. This paper studies the relationship between education presentations to prehospital personnel and scene call volume. The education sessions emphasize safety issues and how, when, and why to call for air medical transport. METHODS: The town and date of scene flights were compared to the town and date of flight nurse presentations and aircraft demonstrations. The length of time from a presentation to a scene call for each town was determined, and a cumulative frequency graph was drawn. Epidemiologic curves of presentations and calls were drawn for each town. Based on these graphs, observations of a relationship were obtained. RESULTS: There were 65 scene calls to 27 towns that had no education programs. There were 880 scene calls to 90 towns that had 235 education programs. There were 21 towns that received a total of 41 presentations and never initiated a scene call. The results show that scene call requests are more likely to occur within three months of a presentation. Individual town analysis shows variability of response to education programs. CONCLUSION: Prehospital provider education programs increase scene call volume, but this effect seems to last for three months. On a town-by-town basis there are many other determinants of scene call volume.

Air Ambulances↗
PubMed1993

Continuous quality improvement applied to a scientific assembly: the history of the Eastern Association for the Surgery of Trauma.

INTRODUCTION: The purpose of this study was to measure the quality of the research presented at the Eastern Association for the Surgery of Trauma (EAST) for the first 5 years. METHODS: Abstracts from the scientific assemblies of EAST, 1988-1992, were reviewed. Five elements were identified for each abstract, the research question, the research design, the sampling method, the validity of the conclusions, and if the research question was answered. These were identified because of their significant impact on the quality of the research presented in the abstract format. RESULTS: Two hundred two abstracts were reviewed. There was a significant improvement in research design, in the sampling method, in the validity of the conclusions, and in the proportion of research questions answered. There was an initial improvement in the presence of a research question, but it was not sustained. CONCLUSION: The results clearly demonstrate an improvement in the quality of the abstracts chosen for presentation at the scientific assembly of the Eastern Association for the Surgery of Trauma. Further improvements can be made by adding the category of 'research question' or 'purpose' and requiring a structured abstract.

Abstracting and Indexing↗
PubMed1992

Delayed hemorrhagic pericardial effusion: case reports of a complication from severe blunt chest trauma.

The rare occurrence of delayed hemorrhagic pericardial effusion requiring treatment is reported following significant blunt chest trauma (AIS greater than or equal to 3) in three patients from 12 to 15 days after injury. Cardiomegaly was suspected on serial chest roentgenograms, and the pericardial effusion was confirmed by echocardiography. Two of three patients required systemic anticoagulation early after their admission to the hospital. It is currently unknown whether the number of delayed hemorrhagic pericardial effusions is increasing with the use of certain anticoagulation treatment regimens.

Adult↗
PubMed1992

The effect of the new trauma DRGs on reimbursement.

Reimbursement for trauma care based on prospective payment has not been satisfactory. The Health Care Financing Administration introduced four new Multiple Significant Trauma (MST) DRGs in 1991 with the intention of covering patients who have had at least two body sites injured. To determine the effect if any on reimbursement, a sample of patients who were assigned the new DRGs over a 5-month period were analyzed. The analysis compared the calculated reimbursement for these 49 patients based on their total accumulated charges, DRG weights, and the average Medicare dollar blend along with the additional weight factor specific for the study facility. This analysis was compared with an additional analysis determining the reimbursement performed on the same patient sample but with DRG weights determined from DRGs derived from the 1989 DRG GROUPER/FINDER. During the 5-month study period, 5.5% of the patients discharged from the hospital has sustained at least one injury covered by ICD-9-CM codes. Of these, 49 (3.9%) were classified into one of the four new MST DRGs. The majority of patients were male (75.5%), the mean age was 31.8 years, and the total charges accumulated were $1,809,192.23. The calculated DRG-based reimbursement was $1,183,495.40, or 65.5% of the total charges. In the second part of the study, using the DRGs available in 1989 for the same sample of patients, the DRG-based reimbursement was $691,437.72, or only 38.2% of the accumulated charges.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis-Related Groups↗
PubMed1992

Factors associated with outcome in blunt aortic injury: a population-based study.

A population-based study was conducted for two contiguous states representing a population of 9.1 million to determine whether age, injury severity score, major complications, and preexisting conditions contribute to the outcome of patients diagnosed with blunt traumatic aortic injury. A secondary analysis reviewed patients with blunt aortic injury admitted over a six-year period to a trauma center located in one of the states to examine other more detailed factors related to mortality. Age was the only variable that correlated statistically with mortality in both populations analyzed. (Region P = .004; trauma center P = .0012) The severity of injury showed a tendency for decreased survival with increasing injury severity score. The elderly (age > or = 55) in both data sets sustained higher mortality from blunt aortic injury. In the trauma center population, the elderly had more delay in diagnosis than the younger patient population.

Adult↗
PubMed1992

The changing perspectives of trauma care. The Sinkler Memorial Lecture.

Trauma and the management of injuries have changed considerably over the past century. A sound understanding of the factors that generate injuries and sophisticated systems that can be accessed immediately are now in place in most of the United States. The concept of a team approach to the management of multiple system injuries using specialists from all disciplines has resulted in the reduction of morbidity and mortality. Although many of the challenges of managing the trauma patient have been overcome, there are still a number of exciting areas that lend themselves to ongoing research. These changing perspectives allow for many exciting challenges for the trauma team.

Emergency Medicine↗