Randall S Friese

Tucson Medical Center, Tucson, Arizona, United States

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Publications (124)208.4 Total impact

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    ABSTRACT: Trauma centers often receive transfers from lower-level trauma centers or nontrauma hospitals. The aim of this study was to analyze the incidence and pattern of secondary overtriage to our Level I trauma center. We performed a 2-year retrospective analysis of all trauma patients transferred to our Level I trauma center and discharged within 24 hours of admission. Reason for referral, referring specialty, mode of transport, and intervention details were collected. Outcomes measures were incidence of secondary overtriage as well as requirement of major or minor procedure. Major procedure was defined as surgical intervention in the operating room. Minor procedures were defined as procedures performed in the emergency department. A total of 1,846 patients were transferred to our Level I trauma center, of whom 440 (24%) were discharged within 24 hours of admission. The mean (SD) age was 35 (21) years, 72% were male, and mean (SD) Injury Severity Score (ISS) 4 (4). The most common reasons for referral were extremity fractures (31%), followed by head injury (23%) and soft tissue injuries (13%).Of the 440 patients discharged within 24 hours, 380 (86%) required only observation (268 of 380) or minor procedure (112 of 380). Minor procedures were entirely consisted of fracture management (n = 47, 42%) and wound care (n = 65, 58%). The mean (SD) interfacility transfer distance was 45 (46) miles. Mean (SD) hospital charges per transfer were $12,549 ($5,863). A significant number of patients transferred to our trauma center were discharged within 24 hours; most of them required observation and/or minor procedures. Appropriately increasing primary hospital resources, in addition to interhospital outreach in the form of education or telemedicine, should be considered to decrease the number of avoidable transfers. Epidemiologic study, level III.
    The Journal of Trauma and Acute Care Surgery 12/2014; 77(6):969-73. · 2.35 Impact Factor
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    ABSTRACT: To optimize neurosurgical resources, guidelines were developed at our institution, allowing the acute care surgeons to independently manage traumatic intracranial hemorrhage less than or equal to 4 mm. The aim of our study was to evaluate our established Brain Injury Guidelines (BIG 1 category) for managing patients with traumatic brain injury (TBI) without neurosurgical consultation. We formulated the BIG based on a 4-year retrospective chart review of all TBI patients presenting at our Level 1 trauma center. We then prospectively implemented our BIG 1 category to identify TBI patients that were to be managed without neurosurgical consultation (No-NC). Propensity scoring matched patients with No-NC to a similar cohort of patients managed with NC before the implementation of our BIG in a 1:1 ratio for demographics, severity of injury, and type and size of intracranial hemorrhage. Primary outcome measure was need for neurosurgical intervention and 30-day readmission rates. A total of 254 TBI patients (127 of NC and 127 of No-NC patients) were included in the analysis. The mean (SD) age was 40.8 (22.7) years, 63.4% (n = 161) were male, median Glasgow Coma Scale (GCS) score was 15 (range, 13-15), and median head Abbreviated Injury Scale (AIS) score was 2 (range, 2-3). There was no neurosurgical intervention or 30-day readmission in both the groups. In the No-NC group, 3.9% of the patients had postdischarge emergency department visits compared with 4.7% of the NC group (p = 0.5). All patients were discharged home from the emergency department. We validated our BIG and demonstrated that acute care surgeons can effectively care for minimally injured TBI patients with good outcomes. A national multi-institutional prospective evaluation is warranted. Therapeutic/care management, level IV.
    The Journal of Trauma and Acute Care Surgery 12/2014; 77(6):984-8. · 2.35 Impact Factor
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    ABSTRACT: Direct laryngoscopy (DL) has long been the gold standard for tracheal intubation in emergency and trauma patients. Video laryngoscopy (VL) is increasingly used in many settings and the purpose of this study was to compare its effectiveness to direct laryngoscopy in trauma patients. Our hypothesis was that the success rate of VL would be higher than that of DL.
    World journal of surgery. 10/2014;
  • Sean McPhillips, Randall Friese, Gary Vercruysse
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    ABSTRACT: Introduction Splenic abscesses associated with leukemia are rare. Most reported cases of splenic abscesses occur after chemotherapy and are related to the immunosuppressive effects of the chemotherapy. Their etiology is most frequently fungal. Presentation Of Case A 58-year-old male presented with splenomegaly and scrotal swelling secondary to a multibacterial splenic abscess which required a splenectomy. Upon investigation he was found to suffer from chronic myeloid leukemia (CML) and epididymitis. Discussion Splenic abscesses are rarely found in leukemic patients. Reported cases are fungal and commonly occur after chemotherapy due to immunosuppression. Scrotal swelling with concurrent splenomegaly can be found in other pathologies including Brucellosis, Lyme disease and even non-Hodgkin primary testicular lymphoma. Scrotal swelling in our case was likely secondary to epididymitis and exacerbated by the effects of splenomegaly upon the systemic circulation promoting venous congestion. Conclusion This case illustrated an unusual presentation of CML because the patient presented with splenomegaly, a multibacterial splenic abscess, and scrotal swelling.
    International Journal of Surgery Case Reports. 10/2014;
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    European Journal of Trauma and Emergency Surgery 10/2014; · 0.26 Impact Factor
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    ABSTRACT: Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement.
    The Journal of Trauma and Acute Care Surgery 10/2014; 77(4):559-563. · 2.35 Impact Factor
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    ABSTRACT: Background We hypothesized that acute mild gallstone pancreatitis (GSP) patients admitted to surgery (SUR) (vs. medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. Methods We performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP during 10/1/2009-5/31/2013. We excluded patients with moderate-to-severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs and complications between the 2 groups. Results Fifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs. 80 hours, P<0.001), a shorter HLOS (3 vs. 5 days, P<0.001), and lower hospital costs ($11,492 + 6,480 vs. $16,183 + 12,145; P=0.03). In our subgroup analysis on patients with an American Society of Anesthesiologists (ASA) score between1-2, the subgroups were well-matched; all outcomes still favored SUR patients. Conclusions Admitting acute mild GSP patients directly to SUR shortened the time to surgery, shortened HLOS, and lowered hospital costs.
    The American Journal of Surgery. 09/2014;
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    ABSTRACT: Platelet dysfunction has been attributed to progression of initial intracranial hemorrhage (ICH) on repeat head computed tomographic (RHCT) scans in patients on prehospital antiplatelet therapy. However, there is little emphasis on the effect of platelet count and progression of ICH in patients with traumatic brain injury. The aim of this study was to determine the platelet count cutoff for progression on RHCT and neurosurgical intervention in patients on antiplatelet therapy.
    The Journal of Trauma and Acute Care Surgery 09/2014; 77(3):417-421. · 2.35 Impact Factor
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    ABSTRACT: Abstract Introduction: Conventionally, a Glasgow Coma Scale (GCS) score of 13-15 defines mild traumatic brain injury (mTBI). The aim of this study was to identify the factors that predict progression on repeat head computed tomography (RHCT) and neurosurgical intervention (NSI) in patients categorized as mild TBI with intracranial injury (intracranial haemorrhage and/or skull fracture). Methods: This study performed a retrospective chart review of all patients with traumatic brain injury who presented to a level 1 trauma centre. Patients with blunt TBI, an intracranial injury and admission GCS of 13-15 without anti-platelet and anti-coagulation therapy were included. The outcome measures were: progression on RHCT and need for neurosurgical intervention (craniotomy and/or craniectomy). Results: A total of 1800 patients were reviewed, of which 876 patients were included. One hundred and fifteen (13.1%) patients had progression on RHCT scan. Progression on RHCT was 8-times more likely in patients with subdural haemorrhage ≥10 mm, 5-times more likely with epidural haemorrhage ≥10 mm and 3-times more likely with base deficit ≥4. Forty-seven patients underwent a neurosurgical intervention. Patients with displaced skull fracture were 10-times more likely and patients with base deficit >4 were 21-times more likely to have a neurosurgical intervention. Conclusion: In patients with intracranial injury, a mild GCS score (GCS 13-15) in patients with an intracranial injury does not preclude progression on repeat head CT and the need for a neurosurgical intervention. Base deficit greater than four and displaced skull fracture are the greatest predictors for neurosurgical intervention in patients with mild TBI and an intracranial injury.
    Brain Injury 08/2014; · 1.51 Impact Factor
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    ABSTRACT: The significance of posttraumatic stress disorder (PTSD) in trauma patients is well recognized. The impact trauma surgeons endure in managing critical trauma cases is unknown. The aim of our study was to assess the incidence of PTSD among trauma surgeons and identify risk factors associated with the development of PTSD.
    The Journal of Trauma and Acute Care Surgery 07/2014; 77(1):148-154. · 2.35 Impact Factor
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    ABSTRACT: The Frailty Index has been shown to predict discharge disposition in geriatric patients. The aim of this study was to validate the modified 15-variable Trauma-Specific Frailty Index (TSFI) to predict discharge disposition in geriatric trauma patients. We hypothesized that TSFI can predict discharge disposition in geriatric trauma patients.
    Journal of the American College of Surgeons 07/2014; 219(1):10-17.e1. · 4.50 Impact Factor
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    ABSTRACT: IMPORTANCE The Frailty Index (FI) is a known predictor of adverse outcomes in geriatric patients. The usefulness of the FI as an outcome measure in geriatric trauma patients is unknown. OBJECTIVE To assess the usefulness of the FI as an effective assessment tool in predicting adverse outcomes in geriatric trauma patients. DESIGN, SETTING, AND PARTICIPANTS A 2-year (June 2011 to February 2013) prospective cohort study at a level I trauma center at the University of Arizona. We prospectively measured frailty in all geriatric trauma patients. Geriatric patients were defined as those 65 years or older. The FI was calculated using 50 preadmission frailty variables. Frailty in patients was defined by an FI of 0.25 or higher. MAIN OUTCOMES AND MEASURES The primary outcome measure was in-hospital complications. The secondary outcome measure was adverse discharge disposition. In-hospital complications were defined as cardiac, pulmonary, infectious, hematologic, renal, and reoperation. Adverse discharge disposition was defined as discharge to a skilled nursing facility or in-hospital mortality. Multivariate logistic regression was used to assess the relationship between the FI and outcomes. RESULTS In total, 250 patients were enrolled, with a mean (SD) age of 77.9 (8.1) years, median Injury Severity Score of 15 (range, 9-18), median Glasgow Coma Scale score of 15 (range, 12-15), and mean (SD) FI of 0.21 (0.10). Forty-four percent (n = 110) of patients had frailty. Patients with frailty were more likely to have in-hospital complications (odds ratio, 2.5; 95% CI, 1.5-6.0; P = .001) and adverse discharge disposition (odds ratio, 1.6; 95% CI, 1.1-2.4; P = .001). The mortality rate was 2.0% (n = 5), and all patients who died had frailty. CONCLUSIONS AND RELEVANCE The FI is an independent predictor of in-hospital complications and adverse discharge disposition in geriatric trauma patients. This index should be used as a clinical tool for risk stratification in this patient group.
    JAMA surgery. 06/2014;
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    ABSTRACT: Falls from ladders account for a significant number of hospital visits. However, the epidemiology, injury pattern, and how age affects such falls are poorly described in the literature.
    Journal of Surgical Research 06/2014; · 2.02 Impact Factor
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    ABSTRACT: The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone. We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011-2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy. A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16-38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28 %; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone. PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.
    World Journal of Surgery 05/2014; · 2.23 Impact Factor
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    ABSTRACT: Introduction The aim of this study was to compare the safety of early (≤48hrs), intermediate (48-72hrs), and late (≥72hrs) VTE prophylaxis in patients with blunt abdominal solid organ injury managed non-operatively. Methods We performed a 6 year (2006-2011) retrospective review of all trauma patients with blunt abdominal solid organ injuries. Patients were matched using propensity score matching in a 2:1:1 (early: intermediate: late) for age, gender, SBP, GCS, ISS, and type and grade of organs injured. . Our primary outcome measures were: hemorrhage complications and need for intervention (operative intervention and/ angioembolization). Results A total of 116 patients (58 early, 29 intermediate, and 29 late) were included. There were no differences in age (p=0.5) ISS (p=0.6), type (p=0.1) and grade of injury of the organ (p=0.6) between the three groups. There were 67 (43.2%) liver, 63 (40.6%) spleen, 49 (31.6%) kidney, and 24 (15.4%) multiple solid organ injuries. There was no difference in operative intervention (p=0.8) and post prophylaxis blood transfusion (p=0.3) between the three groups. Conclusion Early enoxaparin based anticoagulation may be a safe option in trauma patients with blunt solid organ injury. This study showed no significant correlation between early anticoagulation and development of bleeding complications. Level of Evidence III Therapeutic Study, Retrospective Cohort Analysis
    The American Journal of Surgery 05/2014; · 2.52 Impact Factor
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    ABSTRACT: Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI.
    Journal of Surgical Research 05/2014; · 2.02 Impact Factor
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    ABSTRACT: Protocols call for the start of hormonal therapy with levothyroxine after the declaration of brain death. As the hormonal perturbations occur during the process of brain death, the role of the early initiation of levothyroxine therapy (LT) to salvage organs is not well defined. The aim of this study was to evaluate the impact of early LT (before the declaration of brain death) on the number of solid organs procured per donor. We performed an 8-year retrospective analysis of all trauma patients who progressed to brain death. Patients who consented for organ donation, received LT, and donated solid organs were included. Patients were dichotomized into two groups: early LT group, patients who received LT before the declaration of brain death, and late LT group, those who received LT after brain death. The two groups were compared for differences in demographics, clinical characteristics, need for vasopressor, and number of solid organ donation. A total of 100 solid organ donors were identified of which, 41% (n=77) donors who received LT therapy were included. LT before the declaration of brain death was initiated in 37 patients compared with 40 patients who had it started after the declaration of brain death. There was no difference in demographics between the two groups except that patients in the early LT group were more likely to be hypotensive on presentation (54% vs. 25%, p = 0.001). Early LT therapy was associated with an increase in solid organ procurement rate (odds ratio, 1.9; 95% confidence interval, 1.4-2.7; p = 0.01). Sixty-seven patients donated a total of 291 solid organs. The early use of LT and aggressive blood product resuscitation was associated with a significantly higher number of solid organs donated per donor. Earlier use of LT before the declaration of brain death may be considered in potential organ donors. Therapeutic/care management study, level IV.
    The journal of trauma and acute care surgery. 05/2014; 76(5):1301-5.
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    ABSTRACT: Abstract Rural trauma care has been regarded as being the "challenge for the next decade." Trauma patients in rural areas face more struggles than their urban counterparts because of the absence of specialized trauma care, delay in providing immediate care to trauma victims, and longer transport times to reach a trauma center. Telemedicine is a promising tool for facilitating rural trauma care. This stellar tool creates a real-time link between a remotely located specialist and the local healthcare provider, especially during the initial management of the trauma patient, involving resuscitation and even intubation. However, the high cost of purchasing, setting up, and maintaining all the needed equipment has made telemedicine an expensive proposition for rural hospitals, which frequently have limited budgets. But recently, new improvements in communication technology have made smartphones an indispensable part of daily life, even in rural areas. These devices have great potential to improve patient care and enhance medical education because of their wide adoption and ease of use. In this article, we describe our initial teletrauma experience and the effect of smartphone implementation in patient care and medical education at the University of Arizona Medical Center in Tucson.
    Telemedicine and e-Health 04/2014; · 1.40 Impact Factor
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    ABSTRACT: Heart rate and systolic blood pressure are unreliable in geriatric trauma patients. Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury. The aim of this study was to assess the utility of SI in predicting outcomes. We hypothesized that SI predicts mortality in geriatric trauma patients. We performed a 4-year (2007-2010) retrospective analysis using the National Trauma Data Bank. Patients 65 years or older were included. Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns and traumatic brain injury were excluded. A cutoff value of SI greater than or equal to 1 (sensitivity, 81%; specificity, 79%) was used to define hemodynamic instability. The primary outcome measure was mortality. Secondary outcome measures were need for blood transfusion, need for exploratory laparotomy, and development of in-hospital complications. Multiple logistic regressions were performed. A total of 485,595 geriatric patients were reviewed, of whom 217,190 were included. The mean (SD) age was 77.7 (7.1) years, 60% were males, median Glasgow Coma Scale (GCS) score was 14 (range, 3-15), median Injury Severity Score (ISS) was 9 (range, 4-18), and mean (SD) SI was 0.58 (0.18). Three percent (n = 6,585) had an SI greater than or equal to 1. Patients with SI greater than or equal to 1 were more likely to require blood product requirement (p = 0.001), require an exploratory laparotomy (p = 0.01), and have in-hospital complications (p = 0.02). The overall mortality rate was 4.1% (n = 8,952). SI greater than or equal to 1 was the strongest predictor for mortality (odds ratio, 3.1; 95% confidence interval, 2.6-3.3; p = 0.001) in geriatric trauma patients. Systolic blood pressure (p = 0.09) and heart rate (p = 0.2) were not predictive of mortality. SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. SI is superior to heart rate and systolic blood pressure for predicting mortality in geriatric trauma patients. Geriatric trauma patients with SI greater than or equal to 1 should be transferred to a Level 1 trauma center. Prognostic/epidemiologic study, level III.
    The journal of trauma and acute care surgery. 04/2014; 76(4):1111-5.

Publication Stats

661 Citations
208.40 Total Impact Points

Institutions

  • 2014
    • Tucson Medical Center
      Tucson, Arizona, United States
  • 2008–2014
    • The University of Arizona
      • Department of Surgery
      Tucson, Arizona, United States
  • 2011
    • Wilford Hall Ambulatory Surgery Center
      Lackland Air Force Base, Texas, United States
    • University of California, Los Angeles
      • Department of Surgery
      Los Angeles, CA, United States
  • 2010
    • Louisiana State University Health Sciences Center New Orleans
      New Orleans, Louisiana, United States
  • 2005–2009
    • University of Texas Southwestern Medical Center
      • • Department of Surgery
      • • Division of Burn/Trauma/Critical Care
      Dallas, TX, United States
  • 2007
    • University of South Alabama
      • Department of Surgery
      Mobile, AL, United States