Trauma and Injury Prevention Section Newsletter - September 2008, Vol. 12, #2
Letter from the Chair
As I step down as Chair I have been reflecting on what a great pleasure and opportunity it was and still is to be involved with the Section of Trauma and Injury Prevention. When I had initially joined the section as a resident we had just lost our council representative because we had less than 100 members of the section. There was great concern that trauma would not have a voice if the section were to dissipate. Great leaders such as Greg Larkin and Mary Pat McKay and others (too numerous to name) working in the background stepped up and we were able to achieve the numbers to regain our representation. We then set the lofty goals of sustaining the membership as well as securing a Section Grant. Both these tasks have been accomplished and the section membership has grown to nearly 180 members and we are currently finishing up our Section Grant. There is still plenty to accomplish in terms of making trauma and injury a priority for both the college and the funding agencies. However, it is a lot easier to concentrate on being an injury prevention champion when you are not worried about treading the water and going down for the last time. If you would have told me that there would be CPT codes for alcohol intervention counseling when I started in this section I would have thought it was a pipe dream. I continue to see bits of progress every year on the injury prevention front. Does it occur as soon as I would like? No, because I am an ED doc first and nothing can happen fast enough. Do I see the benefit of digging in for the long haul? Absolutely!! Without our section, important issues in injury prevention would be buried or put on the back burner. We need to continue to apply the pressure to legislators and the College in order to have this injury epidemic brought under control. The NIH and CDC have started to devote a scant amount of funding but we continue to struggle with having the trauma bill funded. Trauma and its causes has become the 300 pound elephant in the room for ACEP and ACS. We all know it’s there but we don’t know how to recruit others (funding agencies, other specialties, citizen groups) to help us deal with it. A glaring example of why we need to continually apply pressure is the repealing of helmet laws. The evidence is clear that helmet use prevents morbidity and mortality of motorcycle riders. However, states continue to buckle under the pressure from private citizens groups.
Another example of outside influences taking precedence over science is the fact that CDC funded injury centers cannot talk about firearms, as a matter of fact you will not find firearms or guns listed in the index on injury prevention centers. Here is the excerpt from Health and Human Services who fund the CDC centers: "The Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act specifies that: "None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control." This issue was eloquently communicated by Mike Stobb’s associated press article on guns and suicide after the DC hand gun ban was lifted. I remember back in the 1970s when motorist’s seat belt use was less than 35% but now that rate is 85% and many lives are being saved and injuries avoided. We as a group need to continually rethink and repackage our message until the injury epidemic is eliminated or at least brought under control. Your participation in the section helps to continually apply pressure to make the world a safer place for your patients, friends and families.
Keep up the good work and please take time to share articles or thought pieces with your colleagues through this newsletter. I can honestly say it was a pleasure to serve as Chair and I thank the section members for all their hard work and support they have given the College throughout the years.
Mark R. Sochor, MD, FACEP
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ACEP Federal Affairs Director
ACEP, American College of Surgeons, American Association of Orthopedic Surgeons, Advocates for EMS and over 25 other organizations continue to lobby Congress for FY 2009 appropriations for the reauthorized Trauma Care Systems program (P.L. 110-23, May 2007). The legislation authorized $10 million in funding for the Trauma/EMS program for FY 2009, but with Congressional session growing short, we are concerned that Congress will approve a continuing resolution which will fund programs at FY 2008 levels, leaving Trauma care out for now.
Passage of MIPPA 2008 increases Medicare Physician Payments by 1.1% in 2009.
Another year, another band aid "fix" to physician payment. The small increase, coupled with the change in application of the budget neutrality adjustment should give an average of 2% or more to emergency physician E/M codes. The.05% update will continue for the remained of 2008.
TIPS Section Grant Update
"Injury Prevention Efforts at U.S. Trauma Centers: Alcohol Screening and Intervention Practices."
The response to the mail/online survey was very respectable 35% as of early June. The Principal Investigator, Dr. Rebecca Cunningham opted for an additional mailing that went out August 1 and was supported by a combination of funding from the Section (a small portion your dues) and the University of Michigan. The response rate as of September 5th now stands at 45%.
Dr. Cunningham will share preliminary findings with you at our annual meeting at SA. Tues, October 28th at 3:30 -5:30 p.m. in Room 265 at McCormick Place.
For those who may have missed the previous description of the grant, the purpose of our study is to assess the types (if any) of alcohol screening and intervention currently in use in Level I and II trauma center EDs. Recent ACS trauma center certification requires Level Is to have a trauma prevention program with a separately identifiable coordinator and demonstrated evidence of prevention activities. While much of the intervention activity takes place with inpatients, ACEP believes opportunities exist in the ED as well. We plan to publish results and use them to tailor educational sessions for emergency physicians as well as to track behavioral changes in target communities and justify payment for alcohol screening and brief intervention services. Approximately 440 surveys were originally mailed on February 28, 2008.
Other SBI Initiatives
ACEP has been following activities of Ensuring Solutions to Alcohol Problems at George Washington University Medical Center in DC. Over the past several years, this organization has worked to overturn state UPPL laws which preclude insurance payment for health care services rendered to individuals with any alcohol or substance impairment. This group has been supported through a series of grants from The Pew Charitable Trust, NHTSA, NIH’s NIAAA, DHHS’ SAMSHA , etc. For more information see: www.ensuringsolutions.org
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Letter from the Chair-elect
See You in Chicago!
Ernest E. Sullivent, III, MD, FACEP
It’s hard to believe, but October is again just around the corner and Scientific Assembly approaches. This year, SA will offer a slate of outstanding lectures and activities, all in one of our nation’s greatest and most dynamic cities. Registration for the meeting is moving at a fast pace and has already exceeded expectations. If you have not registered yet, please consider doing so. To maximize course selection and hotel availability, early registration is strongly encouraged.
We will again be holding our annual TIP Section meeting at Scientific Assembly. The meeting is scheduled for Tuesday, October 28th at 3:30 - 5:30 p.m. in Room 265 at McCormick Place. If you are attending SA, or in the area, please join us for TIPS! The two-hour meeting will consist of a presentation followed by our annual business meeting. We will evaluate the past year’s events, and consider new directions for the coming 12 months - and your input is needed and welcomed.
We are pleased to announce that this year’s speaker will be Italo Subbarao, DO, MBA. Dr. Subbarao is currently Director of Public Health Readiness Office at the AMA’s Center for Public Health Preparedness and Disaster Response, and Deputy Editor of the new Journal of Disaster Medicine and Public Health Preparedness - an official AMA publication. Dr. Subbarao is an expert in health system planning, mitigation, disaster response and recovery and in promoting comprehensive planning through private-public partnerships. He has provided field and technical support to the health systems impacted by a number of well known catastrophic events, including Hurricane Katrina, the Pakistan Earthquake, the Virginia Tech mass casualty incident, the F-5 tornado at Greensburg Kansas, the San Diego Wildfires, Iowa Floods, and Hurricane Dolly. Dr. Subbarao’s office also coordinated the AMA/CDC 2nd Public Health Congress in July 2007 focusing on community planning and response to pandemic influenza. Dr. Subbarao is residency trained in emergency medicine and has completed additional fellowship training in Disaster Medicine at Johns Hopkins University.
On another note, on behalf of the TIP Section, I want to extend a very heartfelt thanks to Mark Sochor, MD, FACEP for his leadership these past three years as Chair, and the two years prior to that as Chair-Elect. We are grateful for his enthusiasm, dedication, and contributions to the Section these past five years.
See you in Chicago!
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Blast Injury Educational Materials Available
Ernest E. Sullivent, MD, FACEP
As noted by the Institute of Medicine last year, "Explosions are by far the most common cause of casualties associated with terrorism." Terrorism continues to spread worldwide, as do incidents of mass casualty bombings. The time for us to prepare for such incidents is now, and a key component of that preparedness is having medical professionals informed about the unique characteristics of blast injury victims and their management. It is our responsibility to not only learn about blast injury for ourselves, but also to help educate the nurses and pre-hospital providers who will also be a critical component of our response. Physicians involved in mass casualty bombings from Madrid and India made this point very clear.
As presented in our newsletter last year, ACEP -in collaboration with CDC- has made available a one-hour course and a three-hour seminar complete with curriculum guides entitled, "Bombings: Injury Patterns and Care." These power point presentations allow anyone who has read the curriculum guide to present their own course locally. The courses can be adapted, adding or deleting slides as the presenter sees fit.
Since that time, an interactive course, a poster, and a pocket guide have also been developed. A CD-ROM of the original courses and of the interactive course continues to be available. To download any of these products, or to place an order for the free CD-ROMs, poster, or pocket card, visit the American College of Emergency Physicians website at www.acep.org/blastinjury.
An updated version of the course, "Bombings: Injury Patterns and Care," will be presented at Scientific Assembly by Scott M. Sasser, MD, FACEP. This updated course will be available for distribution sometime later in the year. In addition, fact sheets on different aspects of blast injury are under development, and many are already posted on the web. These are concise, two-page documents containing only essential facts for various topics in blast injury treatment (e.g., blast lung, ear injuries, pediatrics). Additional fact sheets on other topics should be available shortly. These may be downloaded at: http://www.bt.cdc.gov/masscasualties/blastinjuryfacts.asp.
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Recommendations for Postexposure Prophylaxis following Bombings and other Mass Casualty Events Just Released
Ernest E. Sullivent, MD, FACEP
A number of explosive events in recent years offer evidence that such detonations are a potential source for transmission of infections between those injured in the blast. The Israeli Health Ministry in August 2001 announced that tissue from two suicide bombers had tested positive for evidence of hepatitis B virus (HBV), while a 2002 case report from Israel described evidence of hepatitis B virus in a bone fragment that had traumatically implanted into a bombing survivor. Traumatically implanted bone fragments removed from five survivors of the 2005 London bombings were taken directly to forensic custody without testing for blood borne pathogens. These observations suggest that emergency responders and health-care providers in the United States need uniform guidance on prophylactic interventions appropriate for persons injured by bombings or mass casualty events.
Wounds resulting from mass-casualty events require the same considerations for management as similar injuries resulting from trauma cases not involving mass casualties, including the risk for tetanus. In addition, exposure of wounds, abraded skin, or mucous membranes to blood, body fluids, or tissue from other injured persons (including suicide bombers and bombing casualties) might carry a risk for infection with a blood borne virus. Injured survivors of mass-casualty events are at risk for infection with HBV, hepatitis C virus (HCV), or human immunodeficiency virus (HIV) and for tetanus.
Hours after the London bombings in July, 2005, the UK Health Ministry contacted the CDC for guidance for healthcare providers in regard to postexposure prophylaxis for survivors. CDC did not have any published guidance, and in fact no such guidance was published anywhere in the world. In response to this need for guidance, CDC convened a 14-person workgroup to find consensus on this complex issue. The CDC has just released, "Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus, and Tetanus in Persons Wounded During Bombings and Other Mass-Casualty Events — United States, 2008." The report was simultaneously published August 1st in the MMWR Recommendations and Reports1 and the AMA’s Disaster Medicine and Public Health Preparedness2 journal.
This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, human immunodeficiency virus or tetanus in persons wounded during bombings or other mass casualty events. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to blood, body fluids, or tissue from other injured persons and thus be at risk for blood borne infections. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be effectively implemented, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma and emergency response medical communities participating in CDC’s Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) project. The recommendations contained in this report represent the consensus of U.S. federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.
The report can be accessed (free) on the MMWR website at: http://www.cdc.gov/MMWR/preview/mmwrhtml/rr5706a1.htm
- Chapman LE, Sullivent EE, Grohskopf LA, et al. Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus, or Tetanus in Persons Wounded During Bombings and Similar Mass-Casualty Events — United States, 2008. Recommendations of the Centers for Disease Control and Prevention (CDC). MMWR 2008;57(No. RR-6):1-21.
- Chapman LE, Sullivent EE, Grohskopf LA, et al. Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus, or Tetanus in Persons Wounded During Bombings and Similar Mass-Casualty Events — United States, 2008. Recommendations of the Centers for Disease Control and Prevention (CDC). Disaster Medicine and Public Health Preparedness 2008;2(2). Accessed at: www.dmphp.org.
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CDC’s Annual Survey ED Survey: Emergency Visits Continue to Increase
Monika Brunner, ACEP Public Affairs Assistant
The findings below are based on data from the 2008 National Hospital Ambulatory Medical Care Survey (2006 data).
An August 6, 2008 Center for Disease Control and Prevention (CDC) annual report on hospital emergency department use reported that visits jumped from 115.3 million in 2005 to 119.2 in 2006. According to the National Center for Health Statistics, a division of the CDC, the number of hospital emergency departments dropped from 4,109 to 3,833.
The number of visits described as "emergent" or "urgent" (15.9 million), and the number of patients arriving by ambulance (18.4 million), was unchanged from 2005 to 2006.
This raises the question of resource needs in the ED. Roughly 11 percent of all ambulatory medical care visits in the U.S. occur in the ED, but emergency physicians represent only 3.3 percent of active physicians. Moreover, the wait time for patients before seeing an ER physician has been rising steadily, from 38 minutes in 1997, to 47 minutes in 2004, to 56 minutes in 2006.
The most frequent major disease categories assigned by ED physicians were injuries and poisonings (24.3 percent); symptoms, signs, and ill-defined conditions (20.1 percent); and diseases of the respiratory system (10.0 percent). The most common reasons for children under 15 to visit EDs are fever, cough, vomiting, earache and injuries to the head, neck and face. The most common reasons for such visits by adults include chest pain, abdominal pain, back pain, headache and shortness of breath.
In 2006, visits for injury, poisoning, or adverse effects of medical treatment grew to 42.4 million visits (35.5 percent), up slightly from 41.9 million (36.4 percent) in 2005. The most affected age groups included young adults 15 to 24 years of age (19.2/100 persons), adults 75 years of age and older (18.8/100 persons), and children 1 to 4 years of age (16.1/100 persons).
The most frequent causes of injury were unintentional falls (2005 - 20.8 percent, 2006 - 20.3 percent) and motor vehicle traffic accidents (2005 - 10.1 percent, 2006 - 9.5 percent). Intentional injuries represented 5.9 percent of injury-related ED visits, a modest increase from 5.2 percent in 2005. The most common bodily injuries were to the wrist, hand, and fingers (10.6 percent), followed by lower leg and ankle (4.3 percent). Cervical spine injuries were 2.1 percent of injury-related ED visits.
Nursing home patients have the highest ED use (139/100 residents), followed by Medicaid (82 visits/100 persons with Medicaid) and the over 75 years (60 visits/100 persons).
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Cheerleading-related Injuries Rising Sharply
Monika Brunner, ACEP Public Affairs Assistant
According to a trend estimation by the Consumer Product Safety Commission, and based on emergency room data from 114 hospitals, 208,800 children aged between 5 and 18 were treated in emergency departments for cheerleading related injuries from 1990 to 2002. The number of incidents per year more than doubled during this 13 year period, showing an increase by 110% from 10,900 in 1990 to 22,900 in 2002.
The body parts injured were listed as lower extremity (37.2%), upper extremity (26.4%), head/neck (18.8%), trunk (16.8%), and other (0.8%). Injury diagnoses were listed as strains/sprains (52.4%), soft tissue injuries (18.4%), fractures/dislocations (16.4%), lacerations/avulsions (3.8%), concussions/closed head injuries (3.5%), and other (5.5%).
While 98.7% of patients were treated and released from the ED, patients sustaining fractures or dislocations were more likely to be admitted to the hospital.
Research conducted by the National Center for Catastrophic Sports Injury Research reported that cheerleading accounts for over one half of all catastrophic injuries among female high school and college athletes.
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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.