What Happens When An Axle Snaps

The Ford Windstar minivan is being recalled to deal with a design defect in the rear axle. Here is NHTSA analysis video of what happens when the axle separates. The read of the car begins to steer in random, different directions. This makes the steering wheel nearly useless. Note how the professional driver in this video is saved from a rollover by the attached stabilizer bars.

Observation of Occult Pneumothorax

An occult pneumothorax is one that is seen only on CT scan, but not on conventional chest x-ray. They are noted in somewhere between 2% and 10% of major blunt trauma patients. Although management is usually conservative, this has not been well studied.

A paper was presented at the AAST earlier this year based on a prospective, multicenter trial. The authors attempted to determine what factors were predictive of failure of observation. They were able to quantify the size of the pneumothorax by measuring a line from the largest collection to the chest wall.

Sixteen centers participated and enrolled 569 patients, who had 588 occult pneumothoraces. Of those, 21% had immediate chest tube drainage (no reasons were given). The remaining 448 patients were observed, and 27 of those patients failed. Failure was determined if they had progression of the pneumothorax, developed respiratory distress, or developed a hemothorax. 

Risk factors were found to be: positive pressure ventilation (14% of observed group failed), size > 7mm, respiratory distress. 

The authors recommend that patients with respiratory distress and those placed on positive pressure ventilation have a drainage system inserted. Those with pneumothoraces greater than 7mm bear close watching.

Our practice is to monitor any patient with an occult pneumothorax with a followup chest x-ray (one view only) performed after six hours. If the pneumo is still not visible, no further observation is done. If it becomes visible, serial 6 hour x-rays are obtained until it is stable or requires a chest tube.

Reference: Management of blunt traumatic occult pneumothorax: is observation harmful? Results of a prospective multicenter study. Forrest O Moore, et al. Paper #5 presented at 69th Annual AAST Meeting, September 22, 2010.

A Shortage of On-call Surgical Specialists to EDs?

The results of a survey published this month details problems caused by the lack of surgical specialists on call to emergency departments. It was conducted by the Robert Wood Johnson Clinical Scholars program and Yale University. They sent the survey to ED directors at 715 randomly selected hospitals around the country. The response rate was very good, with 62% returning their surveys.

An overwhelming majority (74%) of EDs indicated that they experience inadequate call coverage by surgical specialists. Notable comparisons included:

  • Teaching hospital (68% had problems) vs non-teaching hospital (78%)
  • Level I trauma center (60% had problems) vs Level II trauma center (59%) vs Level III trauma center (77%)

Almost two thirds of respondents said they had lost 24/7 coverage of at least one surgical specialty within the last 4 years. Hospitals in metropolitan areas were more likely to experience this problem, as were hospitals in the Northeast and South, compared to the West and the Midwest.

As you can imagine, coverage issues can cause larger problems. Nearly a quarter of hospitals either lost or downgraded their trauma center level due to lack of surgical specialist coverage. And 27% reported patients leaving before they could be seen by the specialist.

The percentage of hospitals with no coverage or problem coverage by surgical specialty was as follows:

  • General surgery – 36%
  • Trauma surgery – 64%
  • Neurosurgery – 75%
  • Plastics – 81%
  • Hand – 80%
  • Ortho – 50%

It is becoming apparent that there are limits to the amount of on-call specialty coverage that money can buy. Careful coordination and regionalization may offer aid to some centers, but we need to look critically at strategies in use that work and find ways to disseminate them to maintain the best emergency care possible.

Reference: The Shortage of On-call Surgical Specialist Coverage: A National Survey of Emergency Department Directors. Academic Emerg Med 17(12):1374-82, Dec 2010.