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Trauma and Injury Prevention Section Newsletter - March 2010, Vol 14, #1

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circle_arrow Greetings from the Chair
circle_arrow PanCTosis: Stop the Madness
circle_arrow National Network of Hospital-based Violence Intervention Programs
circle_arrow The Relation between Alcohol Intoxication and Firearm Injury
circle_arrow New Section Members
circle_arrow Members in the News
circle_arrow The Value of an Injury Prevention Research Fellowship


Newsletter Index


Trauma and Injury Prevention Section

 

 

Greetings from the Chair

Rebecca Cunningham, MD, FACEP

CunninghamAs the 21st century unfolds, injury, including unintentional injury and violence, is the fourth leading cause of death in the United States.1  Lifetime costs for U.S. injuries occurring in one year alone (2000) totaled $406 billion, 2  with medical expenditures in just one year (2006) of $68.1 billion, exceeded only by heart disease expenditures at $78 billion. 3 Globally, injury is responsible for 9.8% of the world’s recorded mortality annually, killing an estimated 5 million people, as many deaths as malaria, TB, and HIV combined. 4,5  Despite this current burden, history has demonstrated that support for injury research and its translation into effective policies and programs can result in injury reduction and improved health outcomes.  The enormous clinical burden of caring for injuries has led to increased recognition of the importance of injury research among emergency care providers, and this represents an important opportunity for injury researchers and emergency medicine to develop partnerships that will advance the field.  

I look forward to continuing the growth of the TIPS section over the next 2 years while reaching out to many of our EM colleagues who are advancing injury prevention, research and advocacy. As highlighted by EM physicians Dr. Brendan Carr and Michael J. Mello in an upcoming edition of "Injury Prevention" Inj Prev 2010 16: 70) Investigators exploring the role of alcohol misuse, workplace violence, intimate partner violence, neurological injury, transportation science as well as advocates of Screening, Brief Intervention and Referral to Treatment (SBIRT) have common ground with other EM injury researchers. Others exploring the role of protocols in evaluating and treating injured patients, the physiological response to an acute injury, or the basic science work exploring the effect of acute injury at the cellular level may all primarily identify themselves by their narrow area of research, but many fall under the umbrella of injury researchers.  Looking ahead to the next 2 years I hope to increase communication within the EM injury research, control and prevention community while providing increased resources and didactic learning opportunities for practicing EM physicians looking to include the latest science of injury research into their daily practice and community. 

References

  1. WISQARS Unintentional Injury   WISQARS.  (Last accessed 9/19/09), WISQARS.   
  2. Finkelstein EA, Corso PS, Miller TR. The incidence and economic burden of injuries in the United States.  Oxford University Press. New York, 2006.
  3. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st248/stat248.pdf#xml=http://meps.ahrq.gov/cgi-bin/texis/webinator/search/pdfhi.txt?query=expenditures+by+diagnosis&pr=MEPSPUBS&prox=page&rorder=500&rprox=500&rdfreq=500&rwfreq=500&rlead=500&sufs=0&order=r&cq=&id=4ac0bcc18   (last accessed 9/28/ 2009)
  4. Gosselin, RA, Spiegel DA, Coughlin R, Zirkle LW, Injuries: the neglected burden in developing countries, Bull World Health Organization, 2009 April: 87(4):246; avail at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2672580).
  5. http://www.who.int/healthinfo/global_burden_disease/DTH6%202004.xls  (Last accessed 9/28/09) 

 

  

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PanCTosis: Stop the Madness

Mark Sochor, MD, FACEP 

Mark R. Sochor, MD, FACEPTrauma is a team sport and every part of a team needs to work in concert with one another to have the best possible outcome for the patient.  Trauma codes or alerts are a great example of how emergency medicine, surgery and anesthesia work together to quickly render care to the seriously injured.   My EM universe was very well balanced:  I take care of those who do not need an operation and my surgical colleagues take care of those who do.  As most of us take care of many patients who have experienced a traumatic event we are quite experienced at clearing patients from a backboard and c-collar using the Canadian c-spine rules or NEXUS criteria.  If our patient fails one of the two c-spine rules and are between 16 and 60 years old usually a c-spine film would be ordered to allow us to "clear the c-spine".  I take care of my EM turf and the surgeons do surgery and all is right with my world.  I was recently at a "Hot Topics" CME event when a board certified EM and Traumatic Critical Care physician relayed the following information:  the Eastern Association for the Surgery of Trauma (EAST) practice guidelines for 2009 recommended that ANY PATIENT with blunt cervical spine injury (minor or major) with c-spine tenderness should receive a CT of the c-spine.  What?  Are you kidding? What about c-spine x-rays, the staple in my arsenal against time consuming, expensive unnecessary tests!?  The Hot Topics speaker said upon hearing this that she stood up and asked "you can’t CT every c-spine tenderness case?!"  she went on to explain that the EAST surgeons reasoning was that the studies have shown that c-spine x-rays have such a low sensitivity that they are of no utility and CT should be the only radiologic study ordered if there is suspicion of c-spine injury.  

The literature on which they are depending is a review of the literature in which a total of 3,034 c-spine x-rays detected injury only 53% of the time.  I would never imagine recommending how surgeons manage TPN on the inpatient wards.  Why would a national surgical society make such a recommendation that affects EM?  It’s bad enough that I am being cornered by these traumatologists to repeat panscans on trauma patients just because they were sent from an outside facility and the radiologists cannot reformat the spine portion of the outside CTs.  Now they are recommending that we perform CTs on everyone with c-spine tenderness? Studies  (March JA, Ausband SC, Brown LH. Changes in physical examination caused by use of spinal immobilization. Prehosp Emerg Care. 2002;6:421-424.) have shown that patients strapped to a back board develop c-spine tenderness from the very tool (backboard) that is being utilized to protect their spine.  Can you imagine if every c-spine x-ray turned into a c-spine CT?  The amount of time and expense to emergency medicine would be enormous.  My point to all of this?  We in emergency medicine, who arguably take care of more trauma than any other specialty, need to step up and become the champions of reasonable trauma care.  As a specialty, we seem to have become the whipping boy of our consult services.  Many of us (yours truly included) are still being forced to perform abd/pelvis CT scans with oral contrast to visualize an appendix.  Why do we allow other specialties to dictate how we workup and diagnose a patient?  I find myself ordering CT studies without contrast and I have to state that I am always looking for a kidney stone with RLQ tenderness.  My radiology department must think I never consider appendicitis in my differential and I believe that any belly pain I see is renal colic.   

PanCTosis0310

Emergency medicine needs to stand up for the patient and what is financially and appropriate workups.  The government and many within the health care arena state that emergency medicine care costs too much.  How much of that cost is to satisfy another specialty so we can get the appropriate care for our patients?  How many tests are performed in the emergency department for the consulting service or primary practitioner so they will be satisfied it is not another diagnosis and thus turfed to another specialty or admitted to another service?  Recently there has been great debate about how health care dollars are to be spent and this has led to many demanding evaluation research in health care.  Evaluation research as it relates to health care studies medical therapies and which therapy is actually the most economic while still providing the patient appropriate care.  I think it time for emergency medicine to start performing more of this type of research.  

The Pediatric Emergency Care and Research Network is an example of a multi-center research group which is starting to answer some of the tough questions in pediatric care.  I propose that we in emergency medicine start to form more research networks to evaluate patient workup.  Why is this difficult?  We in emergency are too busy performing our safety net for the nation routine to have any kind of time to eat much less conduct research.  Contributions to any of the emergency medicine research foundations and establishing an NIH emergency medicine institute would be of great value to our specialty.  While the former is already established I am afraid that governmental money to study trauma (non-military) is a long way off.  Stand up for what is right and try not to irradiate your patients! 


 

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National Network of Hospital-based Violence Intervention Programs

Melissa Martin-Mollard, MD   

Background

The National Network of Hospital-based Violence Intervention Programs was established in March 2009 following the convening by Youth ALIVE!, the first ever National Symposium of Hospital-based Violence Intervention Programs.  The philosophy of these programs is that violence is preventable and that trauma centers and emergency rooms have a golden moment of opportunity at the hospital bedside to engage with a victim of violence and to stop the cycle of violence.  Individual programs vary slightly in terms of service provision but the core components are an initial visit at the hospital bedside and follow-up throughout the hospital stay, followed by case management services by trained interventionist staff. 

The Network includes core members from the following 8 programs (including Medical Directors, Clinical Directors, Executive Directors, Program Directors, line staff, and members of Boards of Directors), as well as affiliate members of new and emerging programs:

  • Caught in the Crossfire, Oakland/Los Angeles, CA 
  • Ceasefire, Chicago, IL
  • Healing Hurt People, Philadelphia, PA 
  • Sacramento Violence Intervention Program, Sacramento, CA
  • Project Ujima, Milwaukee, WI
  • Violence Intervention Advocacy Program, Boston, MA
  • Violence Intervention Project, Baltimore, MD
  • Wraparound Project, San Francisco, CA

Mission and Goals

Last summer, the Network was awarded two years of stimulus funding from the U.S. Office of Justice Programs under the 2009 Recovery Act., in addition to continued funding from Kaiser Permanente’s Community Benefit Program.  The overall mission of the National Network is to strengthen existing hospital-based violence intervention programs and help develop similar programs in communities across the country.  The Network’s focus this year is on program sustainability and next year members will focus on best practices. 

Currently, the Network generates a monthly e-bulletin about national, state, and local sustainability resources.  Members are engaged in monthly working group meetings around research and evaluation, workforce development, and policy.  In April 2010, they will be convening a symposium for core Network members to discuss sustainability and in Spring 2011, there will be another symposium which will be open to individuals and programs interested in started similar programs or in learning more about hospital-based approaches to violence prevention and intervention.  Finally, a peer-reviewed best practices training curriculum for programs interested in replicating this hospital-based model is under development.  Eventually, they plan to conduct a multi-site evaluation to show the impact of hospital-based intervention, in order to increase the visibility of these programs at the national level.   

"Hospital-based intervention is a way we can stop the cycle of violence, the revolving door in emergency rooms where a doctor will treat a gunshot wound only to see the patient return again with another.  It’s a golden opportunity to reach youth.  The dream," says Marla Becker, Director of Research & Technical Assistance at Youth ALIVE! "is to have programs like this in every trauma center across the nation." 

For more information about the National Network of Hospital-based Violence Intervention Programs, including a Directory of Programs and the Key Components of Hospital-based Violence Intervention Programs, please visit our website at www.youthalive.org/network   

If you would like to be added to our monthly e-bulletin distribution list, please email Melissa Martin-Mollard


 

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The Relation between Alcohol Intoxication and Firearm Injury 

Brendan Carr, MD 

Researchers from the University of Pennsylvania have been investigating the association between alcohol use and firearm injury.  Results were presented at the American Public Health Association’s Annual Meeting and the Annual Meeting of the Society for the Advancement of Violence and Injury Research. 

Injury is the leading cause of alcohol-related death in the United States, and alcohol is the leading risk factor for injury.  Roughly one-quarter of the annual alcohol-related injury deaths in the US are due to motor vehicle crashes, and much of the research examining the relationship between alcohol use and injury has focused on drunk driving.  Early investigators used driving simulators to demonstrate the effect that alcohol use had on the ability to safely operate a motor vehicle, and the findings have been used to establish minimum blood alcohol concentration levels for drivers in all 50 states.  The associated decrease in alcohol related driving injuries has been celebrated by the Center for Disease Control & Prevention as a public health success story.  Nearly equal one-fifth of alcohol-related injury deaths are the result of firearm injuries.  While drunk driving restrictions have reduced the magnitude of alcohol-related motor vehicle crash deaths considerably, parallel legal effort has been made to reduce the problem of alcohol related firearm death. 

Given the success of regulating the use of motor vehicles while intoxicated, researchers at PENN sought to determine the prevalence and distribution of state and federal legislation regulating the intersection of alcohol and firearms.  To do this, they examined the current criminal codes of all 50 states using the databases Westlaw and LexisNexis to examine restrictions on firearm use while intoxicated.  They found that 26 states restrict firearm use by intoxicated persons: 6 states restrict sale or transfer, 4 states restrict carrying concealed weapons, and 20 states restrict possession or discharge of a firearm while intoxicated.  The researchers concluded that regulating of carrying and use of firearms by intoxicated individuals may represent a public health opportunity to reduce firearm-related injury. 

In the second paper the research team described the feasibility of using a randomized controlled trial as a means to investigate the effect of intoxication on firearm use.  After randomization into the alcohol group or the placebo control group, subjects were tested using the AIS PRISim Firearm Simulator.  This firearm simulator uses real pistols retrofitted to discharge compressed air cartridges that simulate firearm recoil and sound.  Firearm performance was tested in the domains of accuracy, speed, reaction time, and judgment.  Twelve subjects were enrolled in the trial and completed 160 training scenarios.  All subjects in the alcohol arm reached target alcohol level, and a third of placebo subjects reported alcohol consumption.  Intoxicated subjects were less accurate, slower to fire in reaction time scenarios, and quicker to fire in scenarios requiring judgment relative to controls. The authors concluded that it would be feasible to perform a large scale randomized, controlled trial exploring the relationship between alcohol consumption and firearm use.  An improved understanding of this relationship might broaden the universe of policy interventions used to decrease firearm-related injury and death.  Examples might include new regulations or stiffer sentences for gun carrying while intoxicated, restriction of firearm carrying in liquor-serving establishments, or broader education campaigns to prevent use of a firearm while intoxicated.   

References

  1. Carr BG, Porat G, Wiebe DJ, Branas CC.  "A review of legislation in the United States restricting the intersection of firearms and alcohol".  2010. Public Health Reports. In Press.
  2. Carr BG, Wiebe DJ, Richmond TS, Cheney R, Branas CC.  "A randomized controlled feasibility trial of alcohol consumption and the ability to appropriately use a firearm" Inj. Prev. 2009; 15(6): 409-412.

 

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New Section Members 
(Since September 2009)

 

Name

Location/City

Abdullah Al Hadhira, MD

Dhahran, Saudi Arabia

Abraham L Warshaw, MD, FACEP

New York, NY 

Alejandro Villatoro, MD

Cuajimalpa, Mexico

Alun D. Ackery, MD 

Toronto, Canada

Amit Rahman, MD

Syracuse, NY 

Andrew C Allison, DO, FACEP

Weirton, WV 

Andrew R Zinkel, MD

St Paul, Bloomington, MN

Anne M DeLonais-Turner, MD, FACEP

Hannibal, MO 

Arlo F Weltge, MD MPH FACEP

Houston, TX 

Avraham J Schreiber, MD

Cortlandt Manor, NY

Azzah Al-jabarti, MD

Winnipeg, MB Canada

Badrinath Kulkarni, MD

Madera, CA

Beau A. Briese, MD.

Long Beach, CA

Beth Ellen Lapka, MD, FACEP

Sioux Falls, SD

Bo E Madsen, MD

Boston, MA 

Bonnie Simmons, DO, FACEP

Brooklyn, NY 

Carolyn Kay Synovitz, MD MPH FACEP

Altus, OK

Chad Darling, MD, FACEP

Worcester, MA 

Chin Chung Tang, MD

New York, NY

Christo C Courban, MD

Conway, SC 

Christopher Baugh, MD

Boston, MA 

Christopher Fee, MD, FACEP

San Francisco, CA 

Colman O'Leary, MD

Limerick, Ireland

David M Somand, MD

Ann Arbor, MI

Dean E Johnson, MD, FACEP

York, PA 

Debra M. Feldman, MD FACEP                     

Cincinnati, OH

Dickson S Cheung, MD, FACEP

Lone Tree, CO 

Drew C Fuller, MD

Baltimore, MD

Elizabeth S Plemmons, MD, FACEP

Wyandotte, MI 

Eric R. Hawkins, MD                                        

Charlotte, NC

Eric S Kenley, MD

Chicago, IL

Geoffrey Bauer, MD

Gary, IN 

Glenn W Mitchell, MD MPH FACEP

Chesterfield, MO

Gregory T Guldner, MD, FACEP

Loma Linda, CA

Griffin L Davis, MD, FACEP

Washington, DC 

Hyun Soo Chung, MD

Seoul, South Korea

J Thomas Ward, Jr., MD, FACEP

Plano, TX

James A Espinosa, MD, FACEP

Stratford, NJ 

Jamira Jones, MD

Dallas, TX

Jason K Fleming, MD, FACEP

Honolulu, HI 

Jean C Ling, MD

Leesburg, VA

Jesse Pines, MD, MBA

Philadelphia, PA

Kaushal Shah, MD, FACEP

New York, NY

 


 

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Members in the News

 

Don’t miss "Emergency Medicine and Injury Research: Challenges and Opportunities Injury Prevention 2010" by Drs. Brendan Carr and Michael J. Mello in Injury Prevention

  

 


 

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The Value of an Injury Prevention Research Fellowship

Megan Ranney, MD

Injury prevention is a perfect niche for a public health-minded emergency physician.  Injuries account for 25% of the visits to American EDs each year;1 the costs associated with the care and rehabilitation of these injuries surpass $80 billion per year;2 and, most importantly, the majority of these injuries are eminently preventable.  Indeed, injury prevention may be among the most effective and cost-efficient means of decreasing health-care costs and ED volume.   

Despite these impressive statistics, it is often difficult to create momentum behind our trauma & injury prevention projects.  Bureaucracy, legislative inertia, and local culture sometimes limit our efforts.  More often, our biggest hurdles are our own colleagues, administrators, residents, and legislators, who don’t understand the importance of our field or the evidence behind our efforts.  We may be convinced that injury prevention is a worthwhile use of limited time and money.  But without good-quality research and strong advocacy skills, we cannot expect to be able to convince others!  Accumulating the evidence and the skills can be difficult when combined with the demands of a full-time clinical position. 

This is why an injury prevention fellowship is so invaluable.  In brief, a fellowship provides protected time in which to develop expertise in local, national, and international applications of injury prevention.  A more extensive (but by no means complete) catalog of the skills one can gain by completing an injury prevention fellowship includes: 

  • Intensive, one-on-one mentoring in research methodology.
  • Access to the resources associated with your mentor (whether it be a CDC-affiliated or hospital-funded center, your fellowship is bound to have resources to support your pilot projects).
  • A master’s in public health or other advanced degree – to  strengthen research skills and give a broad theoretical context for your work
  • Exposure to experts in injury prevention outside of our specialty (although the field of injury prevention has many emergency physician leaders, it is important to acknowledge the role that pediatricians, psychologists, economists, and epidemiologists [to name a few] have played in the development of the field)
  • Experience (and tutoring) in advocacy skills – a crucial part of any injury prevention effort
  • Connections with community groups that are interested in the same issues you are, and the time to work with them to develop mutually beneficial projects
  • Increased stature in the eyes of your chair, your medical school, and your hospital the opportunity to develop national and international partnerships with other injury prevention experts
  • A salary that is not limited by the ACGME
  • A mere two years out of a (presumably long) career as a practicing emergency physician.
  • The opportunity to develop credentials and connections for a non-clinical career, if that choice ever becomes necessary.
  • Most of all, a fellowship provides protected time with which to develop one’s research "niche". 

I would be happy to share my own injury prevention research fellowship experiences (2008-2010) with anyone intrigued by this list.  And to you TIPS members who feel that you are long past the fellowship stage, consider encouraging a junior faculty member to explore this possibility!   

For more information about injury prevention fellowships visit www.emorycenterforinjurycontrol.org or contact:   

E-mail Dr. Michael J. Mello , Dr. Rebecca Cunningham , or Dr. Debra Houry .

References

  1. CDC Web-based Injury Statistics Query and Reporting System (WISQARS™). US Department of Health and Human Services, Centers for Disease Control and Prevention.
  2. Finkelstein EA, Corso PS, Miller TR., "Incidence and Economic Burden of Injuries in the United States" New York, NY: Oxford University Press; 2006. 

 

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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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