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The Journal of Emergency Medicine 247

mputations attributed solely to tourniquet use. The authorsonclude that prehospital tourniquets and tourniquet use whenhock was absent were strongly associated with saved lives,nd the education and administration of prehospital tourniquetsn the military environment should continue.

[Erica Douglass, MD,

Denver Health Medical Center, Denver, CO]

Comments: This article supports the use of emergency tour-iquets in the unique setting of military prehospital care butacks generalizability beyond this setting. Nonetheless, it raiseshe hypothesis that tourniquets may be useful in certain similarituations of hemorrhage with delay to care.

THE EFFECTS OF TRAUMA CENTER CARE, AD-ISSION VOLUME, AND SURGICAL VOLUME ON

ARALYSIS AFTER TRAUMATIC SPINAL CORD IN-URY. Macias CA, Rosengart MR, Puyana JC, et al. Ann Surg009;249:10–7.

This retrospective review of patients diagnosed with trau-atic spinal cord injury (TSCI) examined the effects of trauma

enter designation, admission volume, and surgical volume onates of paralysis. The authors examined state hospital dis-harge data and the expanded modified Medicare Providernalysis and Review (MEDPAR) across seven states encom-assing 7246 admissions. Hospitals were classified as eitherrauma centers (TC), (if they met criteria for a Level I or II TC),r as non-TC hospitals. It was found that only 57.9% of patientseceived care at a TC, with the probability of admission to a TCecreasing as distance to a TC increased. The average annualSCI admission volume was 16-fold higher at TCs, and TCserformed 30 times the number of TSCI-related surgery thanon-TCs. When using the state hospital discharge data, admis-ion to a TC was strongly related to a decreased rate ofaralysis. The observed paralysis rate at TCs vs. non-TCs was3.1% vs. 20.7%; p � 0.001. Even after adjusting for case mix,he rate remained statistically significant. On the other hand, the

EDPAR data did not show a statistically significant differ-nce in the rate of paralysis at TCs (odds ratio of 0.81). Theuthors also analyzed mortality data and, despite a differenceetween TCs and non-TCs, the association also did not attainlinical significance. The authors conclude that although it ishe recommendation of the American College of Surgeonsommittee on Trauma that all TSCI patients be treated at aC, � 60% of eligible patients are receiving such treatment,nd this leads to a higher likelihood of developing paralysis.urthermore, the decreased rates of paralysis were found to beore likely in those patients with more severe TSCI.

[Maggie DiGeronimo, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study implies that further efforts to ensureransport of patients with TSCI to TCs despite distance mayave a positive effect on rates of paralysis. This may require arastic change in practice as, even after controlling for charac-eristics for triage, increased distance remained associated with

ecreased probability of TC care. Further studies examining the m

xact geographical limitations of transport, timing of paralysiss it relates to TSCI and the estimated time of transport to TC,nd better characterization of the severity of paralysis may helphed light on additional efforts to ensure TSCI patients receiveppropriate care.

WHO SHOULD RECEIVE LIFE SUPPORT DURINGPUBLIC HEALTH EMERGENCY? USING ETHICAL

RINCIPLES TO IMPROVE ALLOCATION DECI-IONS. White DB, Katz MH, Luce JM, et al. Ann Intern Med009;150:132–8.

This article discussed the principles of decision-makinghen allocating scarce resources in the event of a public health

pidemic. The allocation of both vaccines and ventilators dur-ng an influenza pandemic was used as an example to compareeveral standards that might provide guidance when facinghese difficult decisions. Scoring measures for short- and long-erm survival were reviewed in parallel with the ethical prin-iples of modern medical practice to determine basic guidelinesor prioritizing care. The authors suggested that it is importanto consider not only the total number of lives saved, but also theumber of total life-years saved, and the individuals’ chances toass through specific life stages when deciding who shouldeceive care. It is also important to consider the principle ofnstrumental value, which suggests that certain individuals withpecific roles, such as health care providers, may improveverall outcomes if they receive vaccines first. Ultimately, theuthors suggest that early and open discussion on a public levelith consideration of several factors regarding both the quan-

ity and quality of life-years should be considered when deter-ining how scarce resources will be allocated.

[Michael Prendergast, MD,

Denver Health Medical Center, Denver, CO]

Comment: While not providing firm guidelines on resourcellocation, this article covers a number of ethical and philosophicalilemmas that must be overcome when prioritizing care. It ismportant to discuss these dilemmas early and to have the generalublic involved to ensure that these principles are compatible withedical ethics and acceptable to the general community.

ORAL VITAMIN K VERSUS PLACEBO TO COR-ECT EXCESSIVE ANTICOAGULATION IN PA-IENTS RECEIVING WARFARIN. Crowther MA, Ageno, Garcia D, et al. Ann Intern Med 2009;150:293–300.This multi-center, randomized, double-blinded placebo-

ontrolled trial out of Canada examined whether low-dose oralitamin K reduced bleeding events over a 90-day period inatients with warfarin-associated coagulopathy. The authorsnrolled 724 non-bleeding patients with an international nor-alized ratio (INR) value of 4.5–10.0 and randomized them to

eceive either 1.25 mg of oral vitamin K or placebo. Bleedingvents were the primary outcome measurement, with thrombo-mbolism and death being secondary outcome measurements.lthough administration of vitamin K decreased the INR by a

ean of 2.8 1 day after treatment (compared to 1.4 in the