CJEM Articles: William Pickett

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  • Impact of a prison triage system on injuries seen in emergency departments
    July 2001 3 3
    Ken Reid, Mary Pearson, Michael O'Connor, Nick Kuzak, Terry O'Brien, William Pickett

    Objectives: 1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system.

    Design: A chart review.

    Setting: The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males.

    Observations: Injuries to male prisoners (ages 18-75 years) who were treated in the ED during 1996-98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996-98 were compared with those seen during a similar period prior to the introduction of the triage system (1981-84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay.

    Results: 148 prisoner injuries were identified for 1996-98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p < 0.001), blunt head injuries (10.1% vs. 2.2%, p < 0.001), hospital admissions (42.6% vs. 4.1%, p < 0.001) and deaths (2.7% vs. 0.6%, p < 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after],p < 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p < 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p < 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p < 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99).

    Conclusions: The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.

  • Clinical diagnosis of clavicle fractures: a pilot study
    April 2001 3 2
    Jim Landine, Robert McGraw, William Pickett

    Objective: Clavicle fractures are commonly encountered in the emergency department (ED). Our objective was to determine whether emergency physicians can clinically predict the presence and location of a clavicle fracture prior to obtaining x-rays.
    Methods: Over a 16-month period we prospectively studied ED patients who had injuries compatible with a clavicle fracture. Following clinical examination and prior to obtaining radiographs, ED physicians or senior emergency medicine (EM) residents were asked to predict whether the clavicle was fractured and, if fractured, the location of the fracture. Clinical predictions were later compared to the radiologist's report.
    Results: Between April 1999 and August 2000, 184 patients with possible clavicle fracture were seen and 106 (58%) were enrolled. Of these, 94 had an acute fracture, and all 94 fractures were predicted on clinical grounds prior to x-ray. In 6 cases, physicians predicted a fracture but the radiograph was negative. In 6 additional cases, physicians were clinically unsure and the radiograph was negative. Physicians correctly predicted fracture location in 83 of 94 cases (88%; 95% confidence interval [CI], 82%-95%). In the 64 cases where physicians predicted a middle third fracture, they were 100% accurate (95% CI, 95%-100%). Errors made by physicians were conservative; that is, they occasionally predicted fractures in patients with only soft tissue injury, but they did not "miss" existing fractures.
    Conclusions: The results of this pilot study suggest that ED physicians can clinically predict the presence and location of clavicle fractures with a high degree of accuracy. It may be that x-rays are not always necessary in patients suspected of having a clavicle fracture. Future studies should define the indications for diagnostic radiography in patients with suspected clavicle fractures.