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Spinal cord injury remains one of the most devastating forms of traumatic injury. The purpose of this study was to characterize the clinical characteristics of spinal cord injury patients and the geographic location where the injury occurred in the state of Hawai'i. Spinal cord injury cases from 2009-2017 were identified using the State Trauma Registry, which included demographics, mechanism of injury, and outcomes. In 1170 spinal cord injury cases, the second most frequent etiology was an ocean-wave related incident. Over half of wave related spinal cord injury occurred on ten beaches on four islands. Compared to other mechanisms, patients with wave related spinal cord injury were significantly less likely to be Hawai'i residents (15%), screen positive for alcohol (4%), or have an injury in the lower thoracic or lumbar region (4%). These patients were also less likely to die (1%) and more likely to be discharged to home (66%). Wave related incidents are a major cause of spinal cord injury in Hawai'i, disproportionately affecting visitors. Education focused toward middle-aged male visitors at beaches with moderate to severe shorebreak may reduce the incidence of injury., Competing Interests: None of the authors identify any conflict of interest. The views expressed are those of the authors and do not necessarily represent the official views of the Queen's Medical Center or the Hawai‘i State Department of Health., (©Copyright 2019 by University Health Partners of Hawai‘i (UHP Hawai‘i).)

Background: Development of Level III trauma centers in a regionalized system facilitates early stabilization and prompt transfer to a higher level center. The resources to care for patients at Level III centers could also reduce the burden of interfacility transfers. We hypothesized that the development and designation of Level III centers in an inclusive trauma system resulted in lower rates of transfer, with no increase in morbidity or mortality among the non-transferred patients., Methods: State trauma registry data from January 2009 through September 2015 were examined from five rural hospitals that transfer patients to our highest (Level II) trauma center and resource hospital. These five rural hospitals began receiving state support in 2010 to develop their trauma programs and were subsequently verified and designated Level III centers (three in 2011, two in 2013). Multivariate logistic regression was used to examine the adjusted odds of patient transfers and adverse outcomes, while controlling for age, gender, penetrating mechanism, presence of a traumatic brain injury, arrival by ambulance, and category of Injury Severity Score. The study period was divided into "Before" Level III center designation (2009-2010) and "After" (2011-2015)., Results: 7,481 patient records were reviewed. There was a decrease in the proportion of patients who were transferred After (1,281/5,737) compared to Before (516/1,744) periods (22% vs. 30%, respectively). After controlling for the various covariates, the odds of patient transfer were reduced by 32% (p < 0.0001) during the After period. Among non-transferred patients, there were no significant increases in adjusted odds of mortality, or hospitalizations of seven days or more, Before versus After., Conclusions: Development of rural Level III trauma centers in a regionalized system can significantly reduce the need for transfer to a remote, higher level trauma center. This may benefit the patient, family, and trauma system, with no adverse effect upon patient outcome., Level of Evidence: Epidemiological, level III.

Background: Half of the US states have legalized medical cannabis (marijuana), some allow recreational use. The economic and public health effects of these policies are still being evaluated. We hypothesized that cannabis legalization was associated with an increase in the proportion of motor vehicle crash fatalities involving cannabis-positive drivers, and that cannabis use is associated with high-risk behavior and poor insurance status., Methods: Hawaii legalized cannabis in 2000. Fatality Analysis Reporting System data were analyzed before (1993-2000) and after (2001-2015) legalization. The presence of cannabis (THC), methamphetamine, and alcohol in fatally injured drivers was compared. Data from the state's highest level trauma center were reviewed for THC status from 1997 to 2013. State Trauma Registry data from 2011 to 2015 were reviewed to evaluate association between cannabis, helmet/seatbelt use, and payor mix., Results: THC positivity among driver fatalities increased since legalization, with a threefold increase from 1993-2000 to 2001-2015. Methamphetamine, which has remained illegal, and alcohol positivity were not significantly different before versus after 2000. THC-positive fatalities were younger, and more likely, single-vehicle accidents, nighttime crashes, and speeding. They were less likely to have used a seatbelt or helmet. THC positivity among all injured patients tested at our highest level trauma center increased from 11% before to 20% after legalization. From 2011 to 2015, THC-positive patients were significantly less likely to wear a seatbelt or helmet (33% vs 56%). They were twice as likely to have Medicaid insurance (28% vs 14%)., Conclusion: Since the legalization of cannabis, THC positivity among MVC fatalities has tripled statewide, and THC positivity among patients presenting to the highest level trauma center has doubled. THC-positive patients are less likely to use protective devices and more likely to rely on publically funded medical insurance. These findings have implications nationally and underscore the need for further research and policy development to address the public health effects and the costs of cannabis-related trauma., Level of Evidence: Prognostic, level III.

Background: Training in ultrasound is variable among residents and practicing traumatologists. Focused Assessment with Sonography in Trauma (FAST) may be underused in non-urbanized areas, possibly due to lack of training., Methods: State trauma registry data from January 2014-June 2016 were reviewed for FAST results. Trauma practitioners were surveyed querying training, confidence, and obstacles to performing FAST., Results: 12,855 records revealed highest FAST use at the urban Level II center (39%, p < 0.0001). Despite similar injury patterns, non-urban/Level III centers' frequency of FAST was only 1-28%. 39 practitioners were surveyed, those with training (54%) were more likely to use FAST (p < 0.05). 61% of practitioners outside the Level II center cited lack of confidence in their ability to perform FAST as the primary reason for omitting the exam., Conclusions: FAST is relatively underused in non-urbanized areas of the state. Lack of confidence in ability to perform FAST was cited as the primary barrier., (Copyright © 2017 Elsevier Inc. All rights reserved.)