Michael H Thomason

Carolinas Medical Center University, Charlotte, North Carolina, United States

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Publications (28)49.09 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: In the era of resident work hour restrictions, many trauma centers across the country have incorporated advanced clinical providers (ACPs) as integral partners in the care of critically ill patients. In addition to providing daily care, ACPs have also begun performing invasive procedures. Few studies have addressed ACPs procedural complications. The purpose of this study was to compare the complication rates from surgical procedures performed by resident physicians (RPs) and ACPs in the critical care setting.
    The Journal of Trauma and Acute Care Surgery 07/2014; 77(1):143-147. · 2.35 Impact Factor
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    ABSTRACT: Aeromedical transport (AMT) is an effective but costly means of rescuing critically injured patients. Although studies have shown that it improves survival to hospital discharge compared with ground transportation, an efficient threshold or universal criteria for this mode of transport remains to be established. Herein, we examined the effect of implementing a Trauma Advisory Committee (TAC) initiative focused on reducing AMT overtriage (OT) rates. TAC outreach coordinators implemented a process improvement (PI) initiative and collected data prospectively from January 2007 to December 2011. OT was defined as patients who were airlifted from scene and later discharged from the emergency department. Serving as liaisons to surrounding counties, TAC outreach coordinators conducted quarterly PI meetings with local emergency medical service agencies. Patients were grouped into those who were airlifted from TAC counties versus counties outside TAC's jurisdiction (non-TAC). Standard statistical methods were used. From 2007 to 2011, 3,349 patients were airlifted from 30 counties, 1,427 (43%) from TAC counties and 1,922 (57%) from non-TAC counties. The OT rates from TAC counties declined compared with non-TAC counties each year and reached statistical significance in 2008 (17% vs. 23%, p < 0.05), 2009 (11% vs. 17%m p < 0.05), and 2011 (6% vs. 12%, p < 0.05). The reduction in OT continued over the study duration, with improvement in TAC counties compared with previous years. Implementation of a regional TAC PI initiative focused on OT issues led to a more efficient use of AMT. Prognostic study, level III; therapeutic study, level IV.
    The journal of trauma and acute care surgery. 07/2013; 75(1):92-6.
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    ABSTRACT: Man-made (9/11) and natural (Hurricane Katrina) disasters have enlightened the medical community regarding the importance of disaster preparedness. In response to Joint Commission requirements, medical centers should have established protocols in place to respond to such events. We examined a full-scale regional exercise (FSRE) to identify gaps in logistics and operations during a simulated mass casualty incident. A multiagency, multijurisdictional, multidisciplinary exercise (FSRE) included 16 area hospitals and one American College of Surgeons-verified Level I trauma center (TC). The scenario simulated a train derailment and chemical spill 20 miles from the TC using 281 moulaged volunteers. Third-party contracted evaluators assessed each hospital in five areas: communications, command structure, decontamination, staffing, and patient tracking. Further analysis examined logistic and operational deficiencies. None of the 16 hospitals were compliant in all five areas. Mean hospital compliance was 1.9 (± 0.9 SD) areas. One hospital, unable to participate because of an air conditioner outage, was deemed 0% compliant. The most common deficiency was communications (15 of 16 hospitals [94%]; State Medical Asset Resource Tracking Tool system deficiencies, lack of working knowledge of Voice Interoperability Plan for Emergency Responders radio system) followed by deficient decontamination in 12 (75%). Other deficiencies included inadequate staffing based on predetermined protocols in 10 hospitals (63%), suboptimal command structure in 9 (56%), and patient tracking deficiencies in 5 (31%). An additional 11 operational and 5 logistic failures were identified. The TC showed an appropriate command structure but was deficient in four of five categories, with understaffing and a decontamination leak into the emergency department, which required diversion of 70 patients. Communication remains a significant gap in the mass casualty scenario 10 years after 9/11. Our findings demonstrate that tabletop exercises are inadequate to expose operational and logistic gaps in disaster response. FSREs should be routinely performed to adequately prepare for catastrophic events.
    The journal of trauma and acute care surgery. 09/2012; 73(3):592-7; discussion 597-8.
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    ABSTRACT: Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours. From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error. During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours. Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.
    The Journal of trauma 05/2010; 68(5):1052-8. · 2.35 Impact Factor
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    ABSTRACT: Since the institution of the Accreditation Council for Graduate Medical Education resident work restrictions, much discussion has arisen regarding the potential effect on surgical resident training. We undertook this study to examine the effects on resident operative experience. We retrospectively analyzed chief residents' Accreditation Council for Graduate Medical Education case logs before (PRE) and after (POST) the 80-hour work restriction. Overall, 22 resident logs were evaluated, six PRE and 16 POST. Four case categories were examined: total major cases, total trauma operative cases, total chief cases, and total teaching assistant cases. Significance was defined as P < 0.05. Comparing the PRE and POST groups demonstrated a trend toward fewer total major cases (1061 vs 964, P = 0.38) and fewer total trauma operative cases (55 vs 47, P = 0.37). Teaching assistant cases increased from 67 to 91 but also failed to reach significance (P = 0.37). However, further comparison between the PRE and POST groups yielded a statistically significant decrease in the number of total chief cases (494 vs 333, P = 0.0092). The significant decrease in the number of total chief cases demonstrates that the work hour restriction most affected the chief year operative experience. Further evaluation of resident participation in nonoperative facets may reveal additional deficiencies of surgical training under work hour restrictions.
    The American surgeon 11/2009; 75(11):1065-8. · 0.92 Impact Factor
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    ABSTRACT: We previously demonstrated that utilization of erythropoietin (r-EPO) did not significantly reduce blood utilization in trauma patients. We undertook this study to analyze blood utilization 1 year after r-EPO removal from our trauma service anaemia practice management guideline. Electronic records of patients admitted to the trauma service were retrospectively reviewed for units of packed red blood cells (pRBCs) transfused and for units of r-EPO administered 12 months before the initiation of an anaemia practice guideline (PRE), 12 months during the use of an anaemia guideline (GUIDE), and 12 months following removal of r-EPO from the guideline (POST). Hospital acquisition cost was also reviewed for the respective time periods. Nominal data were analyzed using chi-squared or Fisher's exact tests, and interval data were compared using ANOVA followed by Tukey's test where appropriate. Results were considered significant for P<0.05. Over the 3-year study period, 4881 patients were admitted to the trauma service and included in this study. The hospital length of stay, intensive care unit length of stay, and units of pRBC transfused were similar among all three groups. Group I (PRE) received a total of 228 doses of r-EPO at a cost of $102,600. Group II (GUIDE) received a total of 410 doses at a cost of $184,500. Group III (POST) received 28 doses of r-EPO at a cost of $12,600. Removal of erythropoietin from our trauma service anaemia practice management guideline did not result in increased blood utilization. However, it yielded a hospital acquisition cost savings of $171,900.
    Injury 07/2009; 40(12):1330-5. · 2.46 Impact Factor
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    ABSTRACT: Increasing patient volume and residents' work hour restrictions have increased the workload at trauma centers. Further, comprehensive tertiary surveys after initial stabilization and appropriate follow-up plans for incidental findings are time consuming. Midlevel providers (MLP) can help streamline this process. We initiated a care plan in which MLPs conducted all tertiary surveys and coordinated follow-ups for incidental findings. From November 2005 through May 2006, we implemented a MLP-driven initiative aimed at performing tertiary surveys within 48 hours of admission on all trauma patients admitted to our Level-1 trauma center. Tertiary surveys consisted of a complete history and physical, radiographic evaluations and appropriate consultations. Incidental findings were recorded and communicated to the trauma attending. A follow-up plan was devised, and the course of action was documented. Patients or family members were informed, and their acknowledgments were filed. Data are presented as mean +/- SE. There were 1,027 patients admitted during the study period. Blunt mechanisms accounted for 81% of the injuries (primarily motor vehicle crashes and falls). Seventy-six patients had 87 incidental findings (7.4%); 53 were men. The mean age was 51.8 years +/- 2.1 years and mean injury severity score was 18.5 +/- 1.4. Incidental findings of clinical significance included 18 pulmonary nodules or neoplasms, 9 adrenal masses (>4 mm), 7 patients with lymphadenopathy, 5 benign cystic lesions, and 3 renal masses. Other neoplastic lesions included bladder (2), thyroid (2), ovary (1), breast (1), and rectum (1). With prevalent medicolegal pressure and restricted residents' work hours, a MLP-initiative to streamline the tertiary survey effectively addresses incidental findings. This MLP-driven care plan can help reduce residents' workload, provides appropriate follow-up, and minimizes legal risks inherent to incidental findings on the trauma service.
    The Journal of trauma 08/2008; 65(2):331-4; discussion 335-6. · 2.35 Impact Factor
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    ABSTRACT: The arterial base deficit has been demonstrated to be a marker of shock and predictive of survival in injured patients. The venous blood, however, may better reflect tissue perfusion. Its usefulness in trauma is unknown. We compared central venous with arterial blood gas analysis to determine which was a better predictor of survival in injured patients. A prospective, nonrandomized series of acutely injured patients was investigated. Patients who had an arterial blood gas analysis for acid-base determination had a simultaneous central venous blood gas analysis and routine blood tests. Patient demographics, Injury Severity Score, and survival past 24 hours were recorded. Arterial and venous blood samples were analyzed for pH, PCO2, PO2, HCO3, hemoglobin-oxygen saturation, base deficit, and lactate. One hundred patients were enrolled. There were 76 survivors and 24 nonsurvivors. Wilcoxon rank sum test and multivariate logistic regression were used for each recorded variable; only central venous base deficit was predictive of survival past 24 hours (P = .0081). Specifically, arterial base deficit was not predictive of survival past 24 hours. In a prospective series of acutely injured patients, central venous base deficit, not arterial base deficit, was predictive of survival past 24 hours.
    The American journal of emergency medicine 03/2008; 26(2):119-23. · 1.54 Impact Factor
  • Journal of Surgical Research - J SURG RES. 01/2008; 144(2):338-338.
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    ABSTRACT: Trauma ultrasound (US) utilizing the focused assessment with sonography in trauma (FAST) is often performed to detect traumatic free peritoneal fluid (FPF). Yet its accuracy is unclear in certain trauma subgroups such as those with major pelvic fractures whose emergent diagnostic and therapeutic needs are unique. We hypothesized that in patients with major pelvic injury (MPI) trauma ultrasound would perform with lower accuracy than has previously been reported. Retrospective analysis of adult trauma patients with pelvic fractures seen at an urban Level I emergency department and trauma center. Patients were identified from the institutional trauma registry and ultrasound database from 1999 to 2003. All patients aged >16 years with MPI (Tile classification A2, all type B and C pelvic fractures, and type C acetabular fractures determined by a blinded orthopedic traumatologist) and who had a trauma US performed during the initial emergency department evaluation were included. All ultrasounds were performed by emergency physicians or surgeons using the four-quadrant FAST evaluation. Results of US were compared with one of three reference standards: abdominal/pelvic computed tomography, diagnostic peritoneal tap, or exploratory laparotomy. Two-by-two tables were constructed for diagnostic indices. In all, 96 patients were eligible; 9 were excluded for indeterminate ultrasound results. Of the remaining 87 patients, the pelvic fracture types were distributed as follows: 9% type A2, 72% type B, 16% type C, and 3% type C acetabular fractures. Overall US sensitivity for detection of FPF was 80.8%, specificity was 86.9%, positive predictive value was 72.4%, and negative predictive value was 91.4%. Categorization of sensitivity according to pelvic ring fracture type is as follows: type A2 fractures: sensitivity and specificity, 75.0%; type B fractures: sensitivity, 73.3%, specificity, 85.1%; and type C fractures (pelvis and acetabulum): sensitivity and specificity, 100%. Of the true-positive US results, blood was the FPF in 16 of 21 (76%) and urine from intraperitoneal bladder rupture in 4 in 21 (19%) patients. US in the initial evaluation of traumatic peritoneal fluid in major pelvic injury patients has lower sensitivity and specificity than previously reported for blunt trauma patients. Additionally, uroperitoneum comprises a substantial proportion of traumatic free peritoneal fluid in patients with MPI.
    The Journal of trauma 01/2007; 61(6):1453-7. · 2.35 Impact Factor
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    ABSTRACT: Trauma patients presenting with a Glasgow Coma Scale (GCS) score of 14-15 are considered to have mild traumatic brain injury (TBI) with overall good neurologic outcomes. Current practice consists of initial stabilization, followed by a head CT, and neurosurgical consultation. Aside from serial neurologic examinations, patients with a GCS of 15 rarely require neurosurgical intervention. In this study, we examined the added value of neurosurgical consultation in the care of patients after TBI with a GCS of 15. We retrospectively reviewed the medical records of patients presenting after blunt trauma with an abnormal head CT and GCS of 15 between January 2004 and January 2005. Patients with a normal head CT and <48 hours hospital stay were excluded. Data included demographics, mechanisms of injury, Injury Severity Score, the radiologists' dictated interpretations of the head CT, and neurosurgical interventions. Fifty-six patients met the inclusion criteria. The mean age was 41+/-2.3 years, and the mean Injury Severity Scores was 10.2 +/-0.6. Mechanisms of injury included 64 per cent motor vehicle crash, 16 per cent motorcycle crash, 13 per cent fall, and 7 per cent all-terrain vehicle crash. The initial CT scans showed 43 per cent parenchymal contusions, 38 per cent subarachnoid hemorrhage, 14 per cent subdural hematomas, and 5 per cent epidural hematomas. All patients received a routine follow-up head CT, and 16 per cent showed changes (five improved and four were worse compared with initial CT scans). None of these patients received a neurosurgical intervention, and two were transferred to a rehabilitation service. In this era of limited resources, trauma patients who present with a GCS score of 15 after mild TBI can be safely managed without neurosurgical consultation, even in the presence of an abnormal head CT scan.
    The American surgeon 12/2006; 72(12):1162-5; discussion1166-7. · 0.92 Impact Factor
  • Critical Care Medicine 11/2006; 34(12):A50. · 6.12 Impact Factor
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    ABSTRACT: Peer-review judgments are necessary for effective trauma performance improvement (PI), but may be influenced by peer pressure and the tendency to vote with the majority. Incorporation of Audience Response System (ARS) technology into trauma PI should result in improved outcome assessments. We compared 30 months of nonanonymous trauma care judgments with 30 months of anonymous judgments obtained with the use of a keypad-based ARS. Statistical methods included the chi2 test and the Wilcoxon rank sum test. Use of the ARS resulted in a 28% reduction in deaths judged nonpreventable and a 24% reduction in trauma care judged to be appropriate (p < 0.0001). Unanimous outcome judgments were also significantly reduced (p < 0.0001). Outcome judgments obtained anonymously were significantly more divergent and less positive than those obtained nonanonymously. Anonymously derived outcome judgments may provide a better opportunity to identify adverse outcomes and thereby potentially improve trauma PI and trauma care.
    The Journal of trauma 07/2006; 61(1):135-41; discussion 141-3. · 2.35 Impact Factor
  • Critical Care Medicine - CRIT CARE MED. 01/2006; 34.
  • Critical Care Medicine - CRIT CARE MED. 01/2006; 34.
  • Critical Care Medicine - CRIT CARE MED. 01/2006; 34.
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    ABSTRACT: The goal of resuscitation is to correct the mismatch between oxygen delivery and that of cellular demands. The pulmonary artery catheter (PAC) is frequently used to gauge the adequacy of resuscitation and guide therapy based on ventricular filling pressures. Transesophageal echocardiography (TEE) has emerged as a potential tool in assessing adequacy of acute hemodynamic resuscitation. The purpose of this study was to evaluate the role of TEE in assessing preload during ongoing volume resuscitation in trauma patients. A retrospective review was conducted of acutely injured patients undergoing TEE during resuscitation from hemorrhagic shock from January 2002 to 2004 at a Level I trauma center. The indication for TEE was persistent hemodynamic instability in the absence of ongoing surgical hemorrhage. Variables included hemodynamic and PAC parameters, pre-TEE resuscitation volume, and vasopressor requirements. The impact of TEE findings on therapeutic decisions was evaluated. Twenty-five patients underwent TEE, 18 (72%) had an indwelling PAC with a mean pulmonary artery occlusion pressure of 19.3 mm Hg (range, 12-29 mm Hg) and mean cardiac index of 2.9 L/min/m2 (range, 1.6-4.6 L/min/m2). Twelve patients (48%) were receiving inotropes and/or vasopressors for hypotension at the time of TEE. Resuscitation volume within 6 hours before TEE included a mean of 6.5 L of crystalloid and 12.2 units of blood products (packed red blood cells, fresh frozen plasma, and platelets). TEE revealed left ventricular hypovolemia in 13 patients (52%) and altered therapy in 16 patients (64%), including additional volume (n = 13), addition of an inotrope (n = 4), and addition of a vasodilator (n = 1) in one patient with ventricular overdistention. Comparison of the abnormal and normal TEE groups revealed that only cardiac index was significantly different (2.6 L/min/m2 in the abnormal group vs. 3.9 L/min/m2 in the normal group; p = 0.005). Significant mitral valve regurgitation leading to valve replacement was identified in one patient. No clinically relevant pericardial effusion was identified. TEE altered resuscitation management in almost two thirds of patients. Many patients with "acceptable" pulmonary artery occlusion pressure parameters may in fact have inadequate left ventricular filling. In addition, TEE offers the advantage of direct assessment of cardiac valve competency, myocardial wall contractility, and pericardial fluid.
    The Journal of trauma 08/2005; 59(1):36-40; discussion 40-2. · 2.35 Impact Factor
  • The Journal of trauma 06/2005; 58(5):1091. · 2.35 Impact Factor
  • Critical Care Medicine - CRIT CARE MED. 01/2005; 33.
  • Critical Care Medicine - CRIT CARE MED. 01/2005; 33.