Search

Gogh, Vincent Van (1853-1890). The Starry Night. Saint Rémy, June 1889. Oil on canvas, 29 × 36 1/4″ (73.7 × 92.1 cm). Acquired through the Lillie P. Bliss Bequest. The Museum of Modern Art. Digital Image © The Museum of Modern Art/Licensed by SCALA/Art Resource, NY.

If statesmanship can be characterized as a bed rock of principles, a strong moral compass, a vision, and an ability to articulate and effect that vision, then the fortitude, tenacity, imperturbability, and resilience of William Crawford Gorgas cannot be overestimated. As Chief Sanitary Officer in Cuba and as Chief Medical Officer in Panama, he actualized strategies to eradicate the vectors of yellow fever and malaria. His superiors initially pigeonholed his requisitions, refused to provide him with any authority, and clamored for his dismissal. Nevertheless, with dogged persistence he created a coalition of the willing, who eventually implemented those reforms. As Surgeon General in the United States Army, he organized and expanded the Active Duty and Medical Reserve Corps in anticipation of World War I. Skilled university affiliated surgeons and personnel from throughout North America, manned base hospitals in Europe. Those lessons impacted upon subsequent military and civilian surgical care—organizationally, logistically, and clinically. He was universally recognized for his bonhomie, savoir-faire, modesty, discretion, decorum, courtesy, and graciousness. To those attributes must be added his devotion to duty, discipline, integrity, and authenticity, which characterized his leadership and statesmanship. Those attributes are most worthy of emulation and perpetuation by clinicians, academicians, educators, and investigators.

Many members of the medical profession in Mobile, Alabama, have exemplified a strong commitment to the education of their colleagues and successors, a tradition (L., traditio, “to hand over”) that dates from the early 18th century. The Mobile General (city/county) Hospital (1830 to 1970) and its successor, the Medical Center, University of South Alabama (1971 to the present), were the institutional foci of those endeavors. Because it is individuals who create, design, and vitalize institutions, this monograph is an acknowledgment of the accomplishments of those who gave that endeavor purpose, direction, and meaning, particularly with reference to the evolution of surgical education. Numerous clinical and societal forces—cultural, economic, political, and social—influenced that evolution. This compilation gives attribution to a legacy of commitment to health and medical/surgical care, education, and research within southern Alabama.

Physician clinical clearance of the cervical spine after blunt trauma is practiced in many trauma centers. Prehospital clinical clearance of the cervical spine (c-spine) performed by emergency medical services (EMS) personnel can decrease cost, improve patient comfort, decrease complications, and decrease prehospital time. The purpose of this study was to assess whether EMS personnel can effectively clinically clear the c-spine of injury in the prehospital setting. All paramedics from a single urban fire department were trained in clinical clearance of the c-spine. During the 14-month period from January 2008 through March 2009, clinical examination of the c-spine was performed by paramedics on blunt trauma patients in the prehospital setting. Paramedics immobilized the c-spine and delivered the patients to the University of South Alabama Medical Center. After trauma center arrival, paramedics documented their clinical examination of the c-spine in a computerized data collection form. Paramedic clinical findings were compared with trauma surgeon clinical examination findings and computed tomographic findings of the c-spine. All patients had prehospital Glasgow Coma Score 14 or greater. Patients were not excluded for distracting injuries. One hundred ninety-three blunt trauma patients were entered. Sixty-five (34%) c-spines were clinically cleared by EMS. There were no known missed injuries in this patient group. Eight (6%) patients who were not clinically cleared by EMS were diagnosed with c-spine injury. Trauma surgeons clinically cleared 135 (70%) of the patients with no known missed injury. EMS personnel in the prehospital setting may reliably and effectively perform clinical clearance of the c-spine. Further prospective study for prehospital c-spine clinical clearance is warranted.

Helicopter transport for trauma remains controversial because its appropriate utilization and efficacy with regard to improved survival is unproven. The purpose of this study was to assess rural trauma helicopter transport utilization and effect on patient survival. A retrospective chart review over a 2-year period (2007–2008) was performed of all rural helicopter and ground ambulance trauma patient transports to an urban Level I trauma center. Data was collected with regard to patient mortality and Injury Severity Score (ISS). Miles to the Level I trauma center were calculated from the point where helicopter or ground ambulance transport services initiated contact with the patient to the Level I trauma center. During the 2-year period, 1443 rural trauma patients were transported by ground ambulance and 1028 rural trauma patients were transported by helicopter. Of the patients with ISS of 0 to 10, 471 patients were transported by helicopter and 1039 transported by ground. There were 465 (99%) survivors with ISS 0 to 10 transported by helicopter with an average transport distance of 34.6 miles versus 1034 (99.5%) survivors with ISS 0 to 10 who were transported by ground an average of 41.0 miles. Four hundred and twenty-one patients with ISS 11 to 30 were transported by helicopter an average of 33.3 miles with 367 (87%) survivors versus a 95 per cent survival in 352 patients with ISS 11 to 30 who were transported by ground an average of 39.9 miles. One hundred and thirty-six patients with ISS >30 were transported by helicopter an average of 32.8 miles with 78 (57%) survivors versus a 69 per cent survival in 52 patients with ISS > 30 who were transported by ground an average of 33.0 miles. Helicopter transport does not seem to improve survival in severely injured (ISS > 30) patients. Helicopter transport does not improve survival and is associated with shorter travel distances in less severely injured (ISS < 10) patients in rural areas. This data questions effective helicopter utilization for trauma patients in rural areas. Further study with regard to helicopter transport effect on patient survival and cost-effective utilization is warranted.

OBJECTIVE: : To assess whether repositioning of ambulance stations in a rural county of Alabama can improve emergency medical services (EMS) response time to motor vehicle crashes (MVCs) without adversely affecting response time to non-MVC-related emergencies. METHODS: : Using geographical information system software, locations of MVCs during a 9-month period in a rural county of Alabama were plotted on a map. A single ambulance station provided EMS for the entire county. Based on the number of ambulances serving the county and concentrated areas of MVCs, the county was geographically divided into two regions. A new ambulance station was assigned to each region based on high MVC concentrations and access to a major thoroughfare. The number of ambulances in-service did not change. Following establishment of both ambulance stations (redeployment), data were prospectively collected for EMS miles to scene, EMS time to scene, fatalities, and type of call (MVC vs. non-MVC) during a 9-month period (January 2006 to September 2006). The prospective data were compared with historical data (non-redeployment) from a similar time period (January 2005 to September 2005). RESULTS: : During the redeployment period, 597 EMS calls were documented, 106 (17.8%) of which were MVCs. In all, 764 EMS calls were documented before the redeployment period, 62 (8.1%) of which were MVCs. During the redeployment period, the mean miles EMS traveled to an MVC scene was 8.6 miles versus 10.7 miles before redeployment (p = 0.038). The mean time to an MVC scene was 8.0 minutes during redeployment versus 9.5 minutes before redeployment (p = 0.03). During the redeployment period, the mean time to non-MVC emergencies was 8.6 minutes versus 9.2 minutes during the period before redeployment (p = 0.27). CONCLUSIONS: : Utilizing geographical information system software, EMS response time to MVCs could be improved in rural areas by optimal location of ambulance stations based on geographical highest concentration of MVCs and vicinity of major thoroughfares. This can be accomplished without adversely affecting response time to non-MVC-related emergencies. Language: en

Objective: The purpose of this study was to prospectively evaluate a protocol that assesses the efficacy and sensitivity of clinical examination in complement with computed tomographic (CT) scan in screening for cervical spine (c-spine) injury. Methods: During the 26-month period from March 2005 to May 2007, blunt trauma patients older than 13 years were prospectively entered into a study protocol. If patients were awake and alert with Glasgow Coma Score (GCS) ≥14, clinical examination of the neck was performed. Clinical examination was performed regardless of distracting injuries. If the patient had no complaints of pain or tenderness, the cervical collar was removed. Patients with complaints of c-spine pain or tenderness and patients with GCS score

Fatality rates from rural vehicular trauma are almost double those found in urban settings. Increased emergency medical services (EMS) prehospital time has been implicated as one of the causative factors for higher rural fatality rates. Advanced Trauma Life Support guidelines suggest scene time should not be extended to insert an intravenous catheter (IV). The purpose of this study was to assess the association between intravenous line placement and motor vehicle crash (MVC) scene time in rural and urban settings. An imputational methodology using the National Highway Traffic Safety Administration Crash Outcome Data Evaluation System permitted linkage of data from police motor vehicle crash and EMS records. Intergraph GeoMedia software permitted this linked data to be plotted on digital maps for segregation into rural and urban groups. MVCs were defined as rural or urban by location of the accident using the U.S. Bureau of Census Criteria. Linked data were analyzed to assess for EMS time on-scene, on-scene IV insertion, on-scene IV insertion attempts, and patient mortality. Over a 2-year period from January 2001 through December 2002, data were collected from Alabama EMS patient care reports (PCRs) and police crash reports. A total of 45,763 police crash reports were linked to EMS PCRs. Of these linked crash records, 34,341 (75%) and 11,422 (25%) were injured in rural and urban settings, respectively. Six hundred eleven (1.78%) mortalities occurred in rural settings and 103 (0.90%) in urban settings (P < 0.005). There were 6,273 (18.3%) on-scene IV insertions in the rural setting and 1,290 (11.3%) in the urban setting (P < 0.005). Mean EMS time on-scene when single IV insertion attempts occurred was 16.9 minutes in the rural setting and 14.5 minutes in the urban setting (P < 0.0001). When two attempts of on-scene IV insertion were made, mean EMS time on-scene in the rural setting (n = 891 [2.6%]) was 18.4 minutes and 15.7 minutes in the urban setting (n = 142 [1.2%; P < 0.005). Excluding dead on-scene patients, mean EMS time on-scene when mortalities occurred in rural and urban settings was 18.9 minutes and 10.8 minutes, respectively (P < 0.005). On-scene IV insertion occurred with significantly greater frequency in rural than urban settings. This incurs greater EMS time on-scene and prehospital time that may be associated with increased vehicular fatality rates in rural settings.

OBJECTIVE: The purpose of this study was to assess whether higher roadway speed limits and excessive vehicular speed were contributing factors to increased rural vehicular mortality rates in the State of Alabama. METHODS: During a 2-year period from January 2001 through December 2002, data were collected from Alabama police crash reports and EMS patient care reports. Police crash reports and EMS patient care reports were linked utilizing an imputational methodology. Vehicular speeds were estimated speeds extracted from police crash reports. Vehicular speeding was defined as estimated speeds greater than posted speed limits. RESULTS: A total of 38,117 reports were linked. Of those, 30,260 (79%) and 7,857 (21%) were injured in rural and urban settings, respectively. The frequency of vehicular speeding was significantly higher in rural (18.8%) than in urban settings (9.4%) (p < 0.0001). At vehicular speeds less than 26 mph, mortality rates for occupants of speeding and nonspeeding vehicles were not significantly different in rural (1.68%, 0.82%) and urban (1.44%, 0.59%) settings (p = 0.78,1.0), respectively. On roads with posted speeds of 26 to 50 mph, mortality rates for occupants in speeding vehicles were not significantly different in rural (3.75%) and urban (2.23%) settings (p = 0.1360). For occupants of nonspeeding vehicles on roads with posted speeds of 26 to 50 mph, mortality rates were significantly greater in rural (0.72%) than in urban (0.35%) settings (p < 0.0032). On roads with posted speeds of 51 to 70 mph, mortality rates for occupants in speeding vehicles were not significantly different in rural (5.80%) and urban (4.95%) settings (p = 1.0). For occupants of nonspeeding vehicles on roads with posted speeds of 51 to 70 mph, mortality rates were significantly greater in rural (1.92%) than in urban (0.94%) settings (p = 0.01). CONCLUSIONS: Vehicular speeding occurs with significantly higher frequency in rural settings. This imparts a greater overall vehicular mortality rate. At higher rates of speed, mortality rates for travel above the posted speed limit are similar in rural and urban settings; however, mortality rates for travel within the posted speed limit are greater in rural settings. This suggests factors beyond higher and excessive vehicular speed impart higher rates in rural settings. Language: en

Background Deep sternal wound infections are a rare but serious complication after median sternotomy. We evaluated the incidence of deep sternal wound infection associated with two techniques for sternal closure. Methods In this retrospective case series, we recorded the method of sternal closure in consecutive patients undergoing a variety of cardiothoracic surgical procedures. Sternal closure in the historical control group was performed using trans-sternal, stainless-steel wire sutures; subsequent patients were closed using wire sutures in conjunction with a novel, peristernal cable-tie closure system to reinforce the corpus sterni. Perioperative care was standardized between groups. Demographics, risk factors, and postoperative outcomes were analyzed. Results Between July 2010 and July 2014, 609 consecutive adult patients underwent sternal closure following open median sternotomy at a single hospital in Mobile, Alabama. Sternal closure was accomplished with wire sutures in the first 309 patients and with cable-tie reinforcement in the subsequent 300 patients. Baseline characteristics were comparable between groups, except that the cable-tie group exhibited greater preoperative comorbidity. Mean body mass index was comparable between groups (30.2 ± 6.6 kg/m2 wire suture versus 30.5 ± 7.7 cable-tie, p = 0.568). Deep sternal wound infection occurred in 2.6 % (8/309) patients in the wire-suture group, whereas no deep sternal wound infections were observed in the cable tie group (p = 0.008). Conclusions The peristernal cable-tie system was a simple and reliable method for sternal closure after open median sternotomy, and was associated with a reduced risk of deep sternal wound infection, even in an obese and comorbid population.

The frequency of insertion of prophylactic inferior vena cava filters (IVCF) among traumatized patients has increased nationally. That has placed a substantial operational and economic burden upon trauma centers. The purpose of this study was to compare and contrast successful implantation, morbidity, and cost-effectiveness of prophylactic IVCF insertion in a surgical-trauma intensive care unit (STICU) versus an operating room (OR). A retrospective chart review was conducted of all trauma patients who received a prophylactic IVCF at an urban Level I trauma center between January 1999 and December 2003. Data were collected to identify patient demographics, indications, anatomical site of insertion, hospital location of insertion, hospital days before insertion, and complications associated with insertion. One hundred thirty-four patients underwent prophylactic IVCF during the study period: seventy-eight (58%) in the OR and fifty-six (42%) in the STICU. The average age of patients for the OR and STICU groups were 38.6 years and 39.6 years, respectively. The average number of days to IVCF insertion was 6.5 days and 7.0 days in the OR and STICU groups, respectively. Indications for IVCF among patients who had placement in the OR were orthopedic injury (60%), spinal cord injury (25%), and head injury (15%). Indications for IVCF among patients who had placement in the STICU were head injury (38%), orthopedic injuries (34%), and spinal cord injury (25%). Three (3.8%) patients in the OR group and two (3.6%) patients in the STICU group required a change of anatomic insertion site from the femoral to the internal jugular vein. There were two (2.6%) complications associated with IVCF insertion in the OR and two (3.5%) complications associated with IVCF insertion in the STICU (P > 0.05). Insertion of IVCF in the STICU decreased patient-cost by an average of $1636 per patient. Prophylactic IVCF insertion in an STICU is cost-effective and can be performed with similar success and complication rates to IVCF insertion in an OR.

Purpose How can the surgical disciplines (1) attract and recruit students of the highest capabilities and ideals; (2) ensure professional competency; and (3) maximize efficacy and safety of biotechnology translated to patient care? Methods Critique of the occidental humanistic literature. Results The imperative of mentorship is grounded in the philosophical traditions of occidental society dating from antiquity. Conclusion This essay affirms that imperative in relationship to the surgical disciplines from an historical perspective.

Honored graduates, you chose a stunning day, a stunning year, a stunning century, and a stunning millennium for your graduation from medical school. We are delighted that family and friends have assembled in your honor. They are justly proud of your accomplishments. Express your appreciation of and gratitude for each of them. I have composed a poem for you in honor of your graduation. It is of the haiku genre of Oriental poetry (17 or fewer English syllables in length). Haiku poets strive for attributes of awareness, perceptivity, brevity, concision, and simplicity. The intent of this poetic style is to capture the essence of a moment in the continuum of time.

Background This study is a qualitative assessment of the effect of clinical encounter documentation cards on medical student-surgical resident interaction during the core surgical clerkship, junior medical school year. Methodology The implementation of a clinical encounter documentation card system occurred during academic year 2009–2010. The results were compared with historical control medical student cohorts from antecedent academic years. The perceptions of overall quality of the clerkship and effectiveness of residents as teachers were assessed using a psychometric Likert scale. Results Ninety percent of the medical students and surgical residents “agreed” or “strongly agreed” that the educational value of clinical encounters was enhanced by the documentation card system. Discussion Junior medical students receive a substantial and valuable portion of their formal surgical education from surgical residents. We argue that this documentation card system tangibly increased the educational value of clinical encounters and improved the cognitive, technical, and rhetorical skills of both medical students and surgical residents. Conclusion We submit that this clinical encounter documentation card system: improved each student's educational experience and each resident's teaching ability; provided valuable information about residents as teachers; facilitated more refined assessment of their performance in relationship to the core competencies; provided timely information permitting adjustments of clinical service assignments during each rotation; and “clinical context teaching moments” were perceived as a valuable element of the core surgical clerkship.

The concept of core competencies in graduate medical education was introduced by the Accreditation Council for Graduate Medical Education of the American Medical Association to semiquantitatively assess the professional performance of students, residents, practitioners, and faculty. Many aspects of the career of J. Marion Sims, MD, are exemplary of those core competencies: MEDICAL KNOWLEDGE: Author of the first American textbook related to gynecology. MEDICAL CARE: Innovator of the Sims' Vaginal Speculum, Sims' Position, Sims' Test, and vesico-/rectovaginal fistulorrhaphy; advocated abdominal exploration for penetrating wounds; performed the first cholecystostomy. PROFESSIONALISM: Served as President of the New York Academy of Medicine, the American Medical Association, and the American Gynecologic Society. INTERPERSONAL RELATIONSHIPS/COMMUNICATION: Cared for the indigent, hearthless, indentured, disenfranchised; served as consulting surgeon to the Empress Eugenie (France), the Duchess of Hamilton (Scotland), the Empress of Austria, and other royalty of the aristocratic Houses of Europe; accorded the National Order of the Legion of Honor. PRACTICE-BASED LEARNING: Introduction of silver wire sutures; adoption of the principles of asepsis/antisepsis; adoption of the principles of general anesthesia. SYSTEMS-BASED PRACTICE: Established the Woman's Hospital, New York City, New York, the predecessor of the Memorial Sloan-Kettering Center for the Treatment of Cancer and Allied Diseases; organized the Anglo-American Ambulance Corps under the patronage of Napoleon III. What led him to a life of clinical and humanitarian service? First, he was determined to succeed. His formal medical/surgical education was perhaps the best available to North Americans during that era. Second, he was courageous in experimentation and innovation, applying new developments in operative technique, asepsis/antisepsis, and general anesthesia. Third, his curiosity was not burdened by rigid adherence to old doctrines or antiquated theories. Fourth, he broadened his professional experience and knowledge by travels to renowned intellectual centers in Western Europe. Fifth, he was perceived as cautiously optimistic and judiciously positive as he interacted with patients, students, and colleagues. Courage, confidence, creativity, compassion, charisma, character, and controversy marked his career. His legacy is illustrative and exemplary of the core competencies fostered contemporaneously in graduate medical educational programs.

Objectives To review and assess educational strategies and formats regarding communication with families/survivors in the aftermath of unexpected and untimely patient death. To propose an integrated curriculum designed and intended to foster proficiency, competence, confidence, and composure in relaying catastrophic information in the context of the professional experience of a cohort of seasoned surgeons. Background Unexpected and untimely patient death is emotionally and psychologically wrenching for families, surgeons, and healthcare providers. We have previously proffered that 2 distinct, but interactive, phases of response are relevant when communicating with a family before and after the event: a proactive phase intended to establish a positive therapeutic relationship with the family; and a reactive phase intended to respond to the family in a compassionate and respectful manner and to ensure self-care for the physicians and health care providers. Study Design Survey of a cohort of senior surgeons (membership of the Southern Surgical Association) and Surgical Residency Program Directors (membership of the Association of Program Directors in Surgery). Results Sixty percent of the senior surgeons surveyed had experienced unexpected patient death. They advised strategies to cope with that clinical situation commensurate with the core competencies of the Accreditation Council for Graduate Medical Education: Medical Knowledge: maximize objective information/data and minimize subjective opinion; Patient Care: critique the events and conduct postmortem analyses; Interpersonal and Communication Skills: honesty, empathy, and patience; Professionalism: provide emotional and psychological support to family and personnel with privacy and in a nonaccusatory manner; Practice-Based Learning and Improvement: preoperative discussion and documentation in the context of informed consent and advanced directives vis-a-vis risk-benefit, effort-yield, and benefit-burden analyses; and Systems-Based Practice: involve chaplains and hospital personnel. Thirty-six percent of the graduate surgical educational programs surveyed allegedly provided educational venues to enable surgical residents to cope with unexpected patient death, although the formats were not specified. Conclusions Graduate, postgraduate, and continuing educational programs aspire to prepare physicians and surgeons for independent professional practice—scientifically, humanistically, and artistically. Incorporating educational strategies to enable graduates to cope with the emotional and psychological turmoil of unexpected patient death is relevant.

BACKGROUND: Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene. METHODS: A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room. RESULTS: Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route. CONCLUSIONS: EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.

A patient-physician relationship provides a milieu for a patient to achieve healing, solace, and reintegration of personhood. A patient's primary physician assumes a leadership role in that regard, coordinating and facilitating a regimen of analysis and therapy. The quality, quantity, and rapidity of technological advancements in the delivery of medical care, render any individual physician incomplete in terms of his ability to provide total care. Consequently, a succession of professional and paraprofessional personnel must be involved to maximize the care rendered. Nevertheless, a patient's primary physician must fulfill a leadership role as he coordinates consultations and interprets the data they provide, placing it in the appropriate situational context for his patient as part of a collective and mutual decision-making process. A patient's primary physician must be acknowledged to possess the power and authority to effect the care provided, as he must also accept the accountability, duty, obligation, and responsibility for the result of that care. By these means ambiguity and uncertainty are mitigated.

Rural emergency medical services (EMS) often serves expansive areas that many EMS personnel are unfamiliar with. EMS response time is increased in rural areas, which has been suggested as a contributing factor to increased mortality rates from motor vehicle crashes (MVCs) and nontraumatic emergencies. The purpose of this study was to assess the effect of a global positioning system (GPS) on rural EMS response time.GPS units were placed in ambulances of a rural EMS provider. The GPS units were set for fastest route (not shortest distance) to the scene that depends on traffic lights and posted road speed. During a 1-year period from September 2006 to August 2007, EMS response time and mileage to the scene were recorded for MVCs and other emergencies. Response times and mileage to the scene were then compared with data from the same EMS provider during a similar 1-year period when GPS technology was not used. EMS calls less than 1-mile were removed from both data sets because GPS was infrequently used for short travel distances.During the 1-year period before utilization of GPS, 893 EMS calls greater than 1 mile were recorded and 791 calls recorded with GPS. The mean EMS response time for MVCs was 8.5 minutes without GPS and 7.6 minutes with GPS (p0.0001). When MVCs were matched for miles traveled, mean EMS response time without GPS was 13.7 minutes versus 9.9 minutes with GPS (p0.001).GPS technology can significantly improve EMS response time to the scene of MVCs and nontraumatic emergencies.

Background Compartment syndrome of the lower extremity can be a difficult diagnosis to make with serious consequences if diagnosis and intervention is delayed. Identifying patients who are more likely to develop this syndrome can help prevent the associated complications. The purpose of this study was to evaluate whether the anatomic location of the penetrating lower-extremity injuries can predict development of compartment syndrome. Methods A retrospective chart review was performed of all patients admitted for a minimum of 23 hours to the University of South Alabama trauma center for penetrating lower-extremity trauma during the 8-year period from July 1998 through June 2006. Patients were entered in the study if wound trajectory was confined to the lower extremity between the inguinal ligament and the ankle. Injuries were categorized as above knee (AK) or below knee (BK), and whether the injury was in the proximal or distal half of the extremity segment. Clinical examination or compartmental pressures were used to diagnose BK compartment syndrome. Results A total of 321 patients sustained 393 lower-extremity injuries during the study period, of which 255 (65%) were AK and 138 (35%) were BK. Thirty-one (8%) lower extremities developed BK compartment syndrome with 29 (94%) secondary to penetrating injuries of the BK segment. All BK injuries that developed compartment syndrome were located in the proximal half of the BK segment. Eighteen (7%) AK injuries underwent BK 4-compartment fasciotomy, 16 (6%) of which were prophylactic after surgical intervention for AK vascular injury. Two patients (1%) developed postoperative BK compartment syndrome after superficial femoral vein ligation. All AK injuries that underwent fasciotomy sustained vascular injuries requiring surgical intervention. No BK compartment syndromes occurred in any patients with expectantly managed AK or distal BK injuries. Conclusions Injuries to the proximal half of the BK segment are the most common cause for the development of compartment syndrome from penetrating injuries of the lower extremity. Development of BK compartment syndrome because of penetrating AK injury is rare without an associated surgically significant vascular injury. Observational admission for compartment syndrome development in patients with penetrating injury to the AK segment or distal BK segment is unnecessary.

Fatality rates from rural vehicular trauma are almost double those found in urban settings. It has been suggested that increased prehospital time is a factor that adversely affects fatality rates in rural vehicular trauma. By linking and analyzing Alabama's statewide prehospital data, emergency medical services (EMS) prehospital time was assessed for rural and urban vehicular crashes.An imputational methodology permitted linkage of data from police motor vehicle crash (MVC) and EMS records. MVCs were defined as rural or urban by crash location using the United States Census Bureau criteria. Areas within Alabama that fell outside the Census Bureau definition of urban were defined as rural. Prehospital data were analyzed to determine EMS response time, scene time, and transport time in rural and urban settings.Over a 2-year period from January 2001 through December 2002, data were collected from EMS Patient Care Reports and police crash reports for the entire state of Alabama. By using an imputational methodology and join specifications, 45,763 police crash reports were linked to EMS Patient Care Reports. Of these, 34,341 (75%) were injured in rural settings and 11,422 (25%) were injured in urban settings. A total of 714 mortalities were identified, of which 611 (1.78%) occurred in rural settings and 103 (.90%) occurred in urban settings (P.0001). When mortalities occurred, the mean EMS response time in rural settings was 10.67 minutes and 6.50 minutes in urban settings (P.0001). When mortalities occurred, the mean EMS scene time in rural settings was 18.87 minutes and 10.83 minutes in urban settings (patients who were dead on scene and extrication patients were excluded from both settings) (P.0001). When mortalities occurred, the mean EMS transport time in rural settings was 12.45 minutes and 7.43 minutes in urban settings (P.0001). When mortalities occurred, the overall mean prehospital time in rural settings was 42.0 minutes and 24.8 minutes in urban settings (P.0001). The mean EMS response time for rural MVCs with survivors was 8.54 minutes versus a mean of 10.67 minutes with mortalities (P.0001). The mean EMS scene time for rural MVCs with survivors was 14.81 minutes versus 18.87 minutes with mortalities (patients who were dead on scene and extrication patients were excluded) (P = .0014).Based on this statewide analysis of MVCs, increased EMS prehospital time appears to be associated with higher mortality rates in rural settings.

Background: Current management of penetrating extraperitoneal rectal injury includes diversion of the fecal stream. The purpose of this study is to assess whether nondestructive penetrating extraperitoneal rectal injuries can be managed successfully without diversion of the fecal stream. Methods: This study was performed at an urban Level I trauma center during a 28-month period from February 2003 through June 2005. All patients who suffered nondestructive penetrating extraperitoneal rectal injuries were managed with a diagnosis and treatment protocol that excluded fecal stream diversion. Patients were placed in one of two management arms based upon clinical suspicion for intraperitoneal injury. In the first arm, patients with suspicion for rectal injury and a positive clinical examination for intraperitoneal injuries were delivered to the operating room for exploratory laparotomy. Proctoscopy was performed before exploratory laparotomy. Extraperitoneal rectal injuries were left to heal by secondary intention. Intraperitoneal rectal injuries were repaired primarily. Patients did not receive fecal diversion or perineal drainage. In the second management arm, patients with a negative clinical examination for intraperitoneal injury and wounding agent trajectory suspicious for rectal injury underwent diagnostic peritoneal lavage (DPL), cystography, and proctoscopy in the emergency room. Positive DPL or cystography warranted laparotomy as above. Patients with positive proctoscopy alone were admitted and placed on a clear liquid diet. Barium enema was performed 5 to 7 days postinjury for all rectal injuries with diets advanced accordingly. A matched historic control group of rectal injury patients who underwent fecal diversion was compared with the nondiversion protocol group. Patients from both groups were matched for penetrating abdominal trauma index (PATI), age and mechanism of injury. Results: There were 14 consecutive patients diagnosed with penetrating rectal injury placed in the nondiversion management protocol. Of these, 9 (64%) patients in the nondiversion group required laparotomy. The average age in the diversion historical control group was 30.5 years and 29.3 years in the nondiversion group. The average PATI in the diversion group was 15.3 and 16.1 in the nondiversion protocol group. The average length of stay for the diversion and nondiversion groups was 9.8 days (range, 7-15) and 7.2 days (range, 4-10), respectively. There were no complications associated with rectal injuries in either group. Conclusions: Nondestructive penetrating rectal injuries can be managed successfully without fecal diversion. Randomized prospective study will be necessary to assess this management method.

Fatality rates from rural vehicular trauma are almost double those found in urban settings. Causes of this difference in rural and urban trauma fatality rates have yet to be fully explored. The purpose of this study is to identify prehospital causes of the higher rural fatality rates by linking, analyzing, and comparing prehospital data for rural and urban vehicular crashes.A probabilistic algorithm was developed that permitted linkage of data from police motor vehicle crash reports, and from Emergency Medical Service (EMS), and hospital records. Motor vehicle crashes (MVCs) were defined as rural or urban by location of the crash using the United States Bureau of Census criteria. Areas that fell outside that urban definition were defined as rural. Linked data were analyzed to identify factors that were thought to be associated with the higher mortality rates observed in rural settings.During the 20-month period from November 2001 through May 2003, data were collected from police crash reports and EMS Patient Care Reports (PCRs) within seven counties in southwest Alabama. Using high probability match criteria and join specifications, 4,694 police crash reports were linked to EMS PCRs. Of these, 3,068 patients (65.4%) were injured in rural settings, and 1,626 (34.6%) were injured in urban settings. A total of 164 (3.5%) mortalities were identified. A total of 129 (4.2%) mortalities occurred in a rural setting and 35 (2.1%) were urban (p = 0.0001). Of the 129 rural deaths, 91 (70.5%) were dead on scene (DOS) and of 35 urban deaths, 20 (57.1%) were DOS (p0.0001). Mean EMS response time for rural MVCs with survivors was 11.2 minutes versus a mean of 13.9 minutes for rural MVC with survivors (p0.0002). When survivors were involved, mean EMS response time for an urban setting was 6.8 minutes versus 13.9 minutes for a rural setting (p0.0001). In a rural setting, mean EMS distance to the scene when patients were alive was 7.7 miles versus 10.5 miles when patients were DOS (p0.001). For patients who died after transfer from the scene, mean rural EMS time on scene was 16.1 minute versus 11.6 minutes in an urban setting (p0.04).In a setting of rural MVC, increased EMS response time, time on scene and distance to the scene are associated with higher rural trauma mortality rates.

m t w p p o p t t a t A t e h t s n appreciation for the consequences of the shock state as led to a revision of trauma surgery principles over the ast 2 decades. Operations with good technical results ut bad patient outcomes secondary to irreversible metbolic distress prompted surgeons to begin truncating nitial procedures on severely injured patients after chieving hemostasis and controlling spill from the alientary tract. These temporized patients would unergo aggressive correction of their acidosis, coagulopahy, and hypothermia in the intensive care unit, with lans for a return trip to the operating room for definiive management of their injuries if they survived their esuscitation. This technique of quickly and solely conrolling hemorrhage and contamination to expedite restablishing a survivable physiology has come to be nown as “damage-control” operation, and its use has esulted in improved mortality rates. Although its aplication in abdominal trauma is now routine, the conept has also begun to be used in thoracic trauma, albeit ith some modifications. The principle of expediting he operative management of unstable patients still olds in thoracic damage control. In addition to abdomnal damage-control’s emphasis on temporizing injuries, horacic damage control also entails performing definiive techniques that are rapid and relatively simple. Use f damage-control thoracotomy has led to better-thanxpected survival rates for these badly injured patients. ts successful application requires not only specific taiored maneuvers, but a change in the mindset of the perating surgeon as well. This collective review will iscuss both as they apply to various injuries in the chest, ith an emphasis on surgical technique.

A 49-year-old male presented with atypical chest pain. Complete cardiac evaluation was normal except for cardiac catheterization, which revealed a myocardial bridge across the LAD (left anterior descending coronary artery) that caused a 50% systolic stenosis. Abdominal ultrasound revealed cholelithiasis. The patient became asymptomatic and was discharged only to return with biliary pancreatitis, which resolved over 2 weeks and laparoscopic cholecystectomy was attempted. Upon establishment of a pneumoperitoneum, he began to suffer cardiac ischemia, which immediately resolved upon desufflation. The procedure was converted to an uneventful open cholecystectomy. He did well without any further problems. This is the first report of myocardial bridging, a well-known cardiac anomaly, possibly preventing safe laparoscopy. This was possibly due to transmitted intraperitoneal pressure effect on the pericardium pushing closed that myocardial bridge.

Ventral/incisional abdominal hernias following celiotomies continue to be a vexing problem for both patients and general and plastic and reconstructive surgeons, since no universally applicable preventive or reconstructive techniques have evolved. With reference to reconstruction, for example, primary repair is associated with a high incidence of recurrence; utilization of synthetic mesh is susceptible to extrusion, infection, and intestinal fistulization; and employment of truncal or extremity, free or rotational, myofascial flaps is associated with the morbidity of the procedure per se. By contrast, the use of fascial partition/release of the components of the abdominal wall employing bilateral parasagittal relaxing incisions in the obliquus externus abdominis and/or transversus abdominis fascia facilitates coaptation of the linea alba and obviates the aforementioned morbidity. This technique was utilized electively in seven adult patients with large defects of the anterior abdominal wall. In addition, for two patients, synthetic nonabsorbable mesh was applied superficial to the midline fascial closure. During a mean follow-up interval of 18 months (range 6 to 36 months), each patient healed per primum without evidence of eventration or herniation. The theoretic and pragmatic advantages of this technique are discussed. The use of fascial partition/release for reconstruction of abdominal wall defects should be part of the armamentarium of all herniotomists.

Conveying to family members that their loved one has unexpectedly died during an operation is perhaps the most stressful task a surgeon must perform. The loss of a patient's life precipitates enormous personal and professional anxiety and stress on a surgeon: profound grief, damage to self-esteem, loss of self-confidence and reputation, and the specter of litigation. Most surgeons feel unskilled in such a setting, yet how they communicate-what they say and how they say it-is extremely important for everyone involved. Two distinct, but interactive, phases of response are relevant when communicating with a family before and after an unexpected death of their loved one: a proactive phase ("CARE") intended to establish a positive therapeutic relationship, and a reactive phase ("SHARE") intended to respond to the crisis in a compassionate and respectful manner and to ensure self-care for the physician.

To evaluate a semi-standardized protocol for colostomy closure, the cases of 166 consecutive patients from 1974 through 1981 were analyzed retrospectively. There were 17 complications (17/166); overall morbidity rate was 2.4 per cent. A significantly increased incidence of major morbidity and septic complications was associated with colostomies closed at an interval of less than 8.5 weeks from formation (P≤0.001). Simple transverse closure of colostomy versus resection and end-to-end anastomosis did not result in increased morbidity (P≤0.1). The wound infection rate was 1.2 per cent (2/166) with 135/166 wounds closed primarily, or primarily over a subcutaneous drain, thus rendering primary wound closure safe and desirable

From an historical perspective, great intellectual effort and struggle were required to secure the privilege of human postmortem anatomical dissection. It represents one expression of the validity and value of the patient-physician relationship. The latter contributes to the welfare of mankind, if through that involvement the knowledge and wisdom of each is enhanced. “… Death rejoices to come to the aid of life” only if patients and physicians are committed to the educational and functional value of postmortem analysis, organ/tissue donation, and cadaveric anatomical dissection. Physicians must be willing to communicate to the individuals they encounter the usefulness of these opportunities for the continued enhancement of patient care and medical science. I would argue that it should be perceived as an expression of an interdependence among all sentient beings, and as such should be promoted as the zeitgeist of all interpersonal relationships within contemporary society.

The first legislated orthodox medical school within Alabama was founded in Mobile in 1859, a legacy of Dr. Josiah Clark Nott. That it developed later than other Southern medical schools has been attributed to multiple factors, among them rural isolation, restricted communication, limited transportation, sparse population, cultural deprivation, and climatologic enervation. The rationale for a medical school within Alabama was also multifactorial: to supply physicians to rural Alabama, to reverse the economic and cultural drain among Alabamians that out-of-state education implied, and to educate medical students regarding the unique health care requirements of a predominantly rural Alabama populace. A medical school building was constructed east of the Mobile City Hospital, and was equipped with an elegant collection of anatomic models acquired by Nott during his travels in western Europe in 1859. After only two sessions, however, the War Between the States (1861 to 1865) forced the medical school to close, as faculty and students joined the Confederate forces. In 1868, with the continued involvement of Dr. W. H. Anderson as Dean, the institution was reopened. During the succeeding 52 years of its existence, the financially strapped medical school attempted to cope with evolving medical technologies and educational philosophies. Despite the commitment of the administrators and faculty, sociopolitical factors and insufficient economic support militated against the school's continued existence. Nott has been characterized as a physician, anatomist, anthropologist, and ethnologist. His opinions as revealed in his writings were controversial because they addressed sociopolitical and racial issues. Nevertheless, his commitment to the Medical College of Alabama in Mobile was unstinting, and he provided the major leadership role in its establishment.

Intraluminal measurements of distance cephalad to the anal verge in the colorectal region of 40 consecutive adult patients were performed employing rigid and flexible proctosigmoidoscopic techniques. In 2/40 (5%) patients, the measurements were identical. In 32/40 (80%) patients, measurements employing a flexible proctosigmoidoscope exceeded measurements employing a rigid instrument by at least 3 cm. The observations have relevance in the context of assessments of adequate distal margins and preservation of anal continence in patients requiring colorectal surgery via transabdominal, transsacral, transperineal, and/or transanal routes.

P hysicians and medical industrial representatives (pharmaceutical, medical service, medical product, surgical instrument) are strange bedfellows. At one extreme, significant diagnostic and therapeutic contributions to the health care of patients have occurred consequent to the mutual cooperation between these two groups. Medical industry is a vigorous scientific and financial supporter of basic and applied research, a consideration of increased significance in the context of curtailed governmental research support. And at the other extreme, aggressive marketing programs by medical industrial representatives in an atmosphere of a free enterprise system can foster inappropriate and biased utilization of those products. Exemplary of these extremes, the dichotomy of which poses an ethical dilemma, is the relationship between physicians and pharmaceutical representatives. Physicians are constantly confronted with a corpus of rapidly expanding and evolving medical knowledge and with the availability of a plethora of pharmaceutical agents. In that context, continuing medical education is essential to physicians if they want to maintain their expertise. What role should pharmaceutical representatives, occasionally themselves licensed pharmacists, play in the provision of information regarding any specific product? The sale of pharmaceutical products is unique mainly because it is indirect. Pharmaceutical advertising campaigns for prescription compounds are rarely directed toward the consumer (patient), but rather toward the intermediate dispenser (physician). When pharmaceutical companies have directed advertising campaigns toward patients, physicians, governmental agencies, and consumer advo cacy groups have raised a vast hue-and-cry reaching even lay periodicals (Should prescription drugs be advertised to consumers? Consumer Reports 1984; 49; 392-393). How should physicians respond to solicitation by pharmaceutical representatives in the form of “curb side” consultations, “free samples,” professional journal advertising, and invitations to attend and participate in pharmaceutical company-sponsored symposia? How impartial and unbiased are any of these modes of interaction? In answer to the questions just posed, it is imperative for physicians to adopt and employ critical analytic skills when evaluating medical industrial products. Adaptation of a scientific methodologic approach to analyses of refereed journal articles, balanced seminars, and personal empiric observations is essential if the health care needs of patients are to be best served. Medical school educators bear significant responsibility in this regard in fostering, demanding, and exemplifying the use of critical analytic techniques, mitigating partial and biased solicitations. It would be naive for physicians to presume that they are immune to the blandishments of “free” samples, books, meals, trips, symposia, et cetera. Equally naive is the view that medical ir&strial representatives are always pernicious and biased, representing a monolithic enterprise motivated solely for profit. Somewhere be tween the quixotic joust against windmills and an uncritical quotidian embrace lies the ethically responsible and appropriate course for a sentient physician.

Advertisements via multiple media inundate contemporary society, a reflection of an entrepreneurial competiveness and consumerism. In a recent brief article in The New York Times, R.D. Rice, President, Television Bureau of Advertising, stated that “the health care category (of .advertising) is one of the fastest-growing and most important in local television.” According to Mr. Rice, health care companies spent 125.6 million dollars on television advertising in 1985. In the same article, S. Jacobs, President, Healthware Images, attributed the boom in health care commercials to two sources: judicial decisions that granted professionals the legal right to advertise, and an orientation toward private medical care, both of which had increased marketing consciousness. As Ms. Jacobs commented: “physicians, hospitals, dentists-these are all businesses. They have to approach their audiences the same way that QocaCola does” [I]. Advertisements, as distinguished from other forms of communication, imply an advertiser who pays a media representative to deliver a message; and within that context, certain legal constraints (non-deceptive, unrestricted competitiveness), and standards of advertising practice, the advertiser controls the message. Advertisements are intended to elicit a response desired by the advertiser-to influence, convince, or win the suffrage of others. Advertisements by physicians are intended to promote the sale of his or her services.

Deep sternal wound infections (DSWI) are a rare but serious complication after median sternotomy.

A polyethylene catheter inadvertently sheared off during a diagnostic thoracentesis was successfully extracted with a flexible endoscope. Coincidentally, excellent visualization of the entire pleural space was noted. The procedure was performed with the patient under general anesthesia and sterile technique was employed. The patient sustained no untoward consequence. Coelomic analysis with a flexible endoscope may be appropriate in other diagnostic and therapeutic circumstances.