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Tue Oct 21 16:55:59 BST 2008

This actually validates my meager understanding of the status quo -- on
all three points.  Thanks.

I'll look forward to further info.

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert F. Smith
Sent: Tuesday, October 21, 2008 11:52 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Trauma outcomes

Pret,

In a nutshell, the problem with ISS and TRISS type scoring systems for
penetrating trauma is that they do not take into account multiple
injuries
in the same body area. GSW victims often suffer multiple severe
abdominal
organ injuries but only one of these may be coded to contribute to the
overall score.

There isn't supposed to be any "mapping". But since Dr. Ellen Mackenzie
developed the program that maps ECD-9 codes which the financial clerks
generate, into "matching" AIS codes, nearly everyone does that. Which is
another huge problem. AIS coding is supposed to be done independently by
specially trained coders.

Lastly, I uh, don't know how much validation there is before data is
submitted to the NTDB. That alone would be a fascinating project.

Rob

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]
On Behalf Of Bjorn, Pret
Sent: Tuesday, October 21, 2008 11:26 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Trauma outcomes

This is thought-provoking stuff.

Honestly -- and it embarrasses me a little to admit this -- I would have
assumed that blunt vs. penetrating mechanism would at least subtly
affect the inter-rater reliability of AIS, and thus ISS.  

It's as simple as observing that penetrating injury is typically its own
triage criterion.  Sophisticates understand that this relates more
specifically to the operative odds than the objective severity; but is
it unfair to wonder if there's some subsequent, subconscious rounding-up
for penetrating injuries?

Bob, maybe you could dumb down the science enough that I might at least
understand: where AIS/ISS is mapped to diagnosis codes (as opposed to
direct grading by clinicians), what methods are used to reconcile
various blunt injuries to their closest penetrating cohorts?

Pret

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Robert Waddell II
Sent: Tuesday, October 21, 2008 10:38 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Trauma outcomes

Disclosure: I work with Dr. Sacco.

If you look at the ISS and TRISS's research from the analytical  
investigator's view the "two different diseases" are not that  
different relative to the patient's physiological perspective.  What  
Dr. Sacco has shown in various tools and what most Trauma Centers are  
using, at variable importance, is the body's response to injury, not  
necessarily the mechanism of injury.  I do not believe he has ever  
looked at race or insurance, but if you evaluate the medical  
priorities of both groups I believe they can most likely be compared.

Take care,

Bob

Robert K. Waddell II
The Sacco Triage Method (STM)

Wyoming office
1302 East 5th Avenue
Cheyenne, Wyoming 82001

307 920 2020

bwaddell at sharpthinkers.com
www.sharpthinkers.com

On Oct 21, 2008, at 8:03 AM, Robert F. Smith wrote:

> It's hard to comment intelligently on this without reading the  
> methodology
> which I haven't been able to do yet. "Controlling for severity of  
> injury"
> covers a lot of water. You can match ISS score with GSW patients and  
> MVC
> patients but you're really comparing two different diseases.
>
> Rob
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org 
> ]
> On Behalf Of Stephen Richey
> Sent: Tuesday, October 21, 2008 9:56 AM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Trauma outcomes
>
> It's not simply passing the buck if the actual cause of the problem is
> something in the social networks in which these patients operate.   
> If it is
> not an issue of insufficient access to care (read as: lack of  
> insurance) and
> many (most?) trauma centers are located in areas with high minority
> populations so it is not a matter of lack of hospitals capable of  
> handling
> these patients close by, then the options are either something  
> drastically
> different in the way the bodies of a black man or a Latino responds  
> to being
> injured versus someone of Caucasian extraction or there is something  
> social
> going on here that is hindering the patient from receiving the care  
> they
> need.
>
> I was simply putting forth possible issues that need to be  
> addressed, even
> if they are proven to be noncontributory to the problem and then  
> dismissed.
> Nothing more, nothing less than an academic exercise.
>
> On Tue, Oct 21, 2008 at 9:48 AM, Bjorn, Pret <pbjorn at emh.org> wrote:
>
>> I forget: what's Latin for "First, blame the victim?"
>>
>> Pret Bjorn, RN
>> Bangor, ME USA
>>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org
>> [mailto:trauma-list-bounces at trauma.org] On Behalf Of Stephen Richey
>> Sent: Tuesday, October 21, 2008 6:48 AM
>> To: Trauma &amp, Critical Care mailing list
>> Subject: Re: Trauma outcomes
>>
>>
>> I wonder how much of a factor delays in access to care because of
>> cultural
>> attitudes plays in this. While working on ambulances was told  
>> numerous
>> times
>> by African Americans and Hispanics (especially men) things to the  
>> effect
>> of
>> "I ain't going to no ****ing hospital b***h! I's tough". Granted,  
>> I've
>> been
>> told the same thing (although worded differently....you haven't been
>> cussed
>> out until you've been told to go to hell by a Cajun) by every ethnic
>> group
>> I've treated and by women, but I still wonder- given that men  
>> engage as
>> a
>> group in more risky activities than women in general- how many of
>> those additional fatalities were caused as much by their own  
>> machismo or
>> the
>> disregard of their "associates" for the severity of the injuries as  
>> by
>> the
>> injuries themselves.
>>
>> Also, I wonder what role the language barrier between Hispanics and
>> non-Hispanics might take in the much higher rate of mortality.  The  
>> same
>> degree of curiosity exists for things like differences in the use
>> of standard injury prevention measures such as seatbelts, helmets,  
>> etc.
>> I've also wondered how the "ghetto lean" a lot of urban youth set  
>> their
>> driver's seats to have affects the frequency and severity of injury  
>> in
>> the
>> event of a car accident....
>>
>> Just my two cents worth of rambling....I could be completely missing
>> something here as I am about half awake....
>>
>> On Tue, Oct 21, 2008 at 6:31 AM, Robert F. Smith
>> <rfsmithmd at comcast.net>wrote:
>>
>>> Dr. Haider appears to have written several articles using trauma  
>>> data
>> to
>>> look at outcomes in different populations. Several are co-authored
>> with Dr.
>>> Eddie Cornwell. This article does not yet appear on the  Pub Med
>> website.
>>>
>>> Rob Smith
>>>
>>> Patterns: Race and Health Coverage Affect Survival
>>> By NICHOLAS BAKALAR
>>>
>>> Whether you survive after a serious accident may depend on your race
>> and
>>> your health insurance, a new study concludes.
>>>
>>> Researchers examined the records of more than 310,000 trauma  
>>> patients
>> whose
>>> cases were entered in a national databank that includes  
>>> information on
>>> race,
>>> age, severity and type of injury, insurance status, and mortality.
>>>
>>> After controlling for severity of injury and other factors, they  
>>> found
>> that
>>> compared with whites, African-Americans had a 17 percent increased
>> risk of
>>> death and Hispanics a 47 percent increased risk.
>>>
>>> When they looked at patients with health insurance, they found a
>> greater
>>> disparity. Insured African-Americans had a 20 percent increased  
>>> death
>> risk
>>> compared with insured whites, and Hispanics a 51 percent increased
>> risk.
>>> The
>>> study appears in the October issue of The Archives of Surgery.
>>>
>>> "This study refutes the notion that racial disparities in trauma  
>>> care
>> are
>>> merely a reflection of insurance status," said the lead author, Dr.
>> Adil H.
>>> Haider, an assistant professor of surgery at Johns Hopkins. "Both
>> insurance
>>> and race are independent predictors of mortality after trauma. And  
>>> of
>> the
>>> two, insurance is the more important predictor."
>>>
>>> The authors acknowledge that the study was retrospective and based  
>>> on
>>> records that did not give complete medical information on each
>> patient.
>>> Also, people with insurance may be generally healthier and have an
>>> increased
>>> ability to survive traumatic injury.
>>>
>>>
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>>> trauma-list : TRAUMA.ORG <http://trauma.org/> <http://trauma.org/>
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>>
>>
>>
>> --
>> Stephen L. Richey, CRT
>> Aviation Injury Research Project Leader
>> Saginaw Valley State University
>> Work E-mail: slrichey at svsu.edu
>> Home Office Phone: 248-366-4452
>>
>> "It is the characteristic excellence of the strong man that he can  
>> bring
>> momentous issues to the fore and make a decision about them. The weak
>> are
>> always forced to decide between alternatives they have not chosen
>> themselves."- Dietrich Bonhoeffer
>> --
>> trauma-list : TRAUMA.ORG <http://trauma.org/>
>> To change your settings or unsubscribe visit:
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>>
>>
>> --
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>>
>
>
>
> -- 
> Stephen L. Richey, CRT
> Aviation Injury Research Project Leader
> Saginaw Valley State University
> Work E-mail: slrichey at svsu.edu
> Home Office Phone: 248-366-4452
>
> "It is the characteristic excellence of the strong man that he can  
> bring
> momentous issues to the fore and make a decision about them. The  
> weak are
> always forced to decide between alternatives they have not chosen
> themselves."- Dietrich Bonhoeffer
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
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