Diurnal salivary cortisol measurement in the neurosurgical-surgical intensive care unit in critically ill acute trauma patients.

Acute trauma patients represent a specific subgroup of the critically ill population due to sudden and dramatic changes in homeostasis and consequently extreme demands on the activity of the hypothalamic-pituitary-adrenocortical (HPA) axis. Salivary cortisol is an accepted surrogate for serum free cortisol in the assessment of HPA axis function. The purpose of this study was (1) to establish the feasibility of salivary cortisol measurement in acute trauma patients in the neurosurgical-surgical intensive care unit (NSICU), and (2) to determine the diurnal pattern of salivary cortisol in the acute phase after injury. Saliva from 50 acute trauma patients was prospectively collected twice a day at 6AM and 4PM during the first week after injury in the NSICU. Mean PM cortisol concentrations were significantly higher in subjects versus controls (p<0.001). Subjects failed to develop the expected PM versus AM decrease in cortisol concentration seen in controls (p=0.005). Salivary cortisol did not vary significantly with baseline Glasgow Coma Scale (GCS), Injury Severity Score, sex, injury type, ethnicity, or age. When comparing mean AM and PM salivary cortisol by GCS severity category (GCS ⩽8 and GCS >8) the AM salivary cortisol was significantly higher in patients with GCS ⩽8 (p=0.002). The results show a loss of diurnal cortisol variation in acute trauma patient in the NSICU during the first week of hospitalization. Patients with severe brain injury had higher morning cortisol levels than those with mild/moderate brain injury.

Geriatric trauma hip fractures: is there a difference in outcomes based on fracture patterns?

BACKGROUND: Annually in the US, there are over 300,000 hospital admissions due to hip fractures in geriatric patients. Consequently, there have been several large observational studies, which continue to provide new insights into differences in outcomes among hip fracture patients. However, few hip fracture studies have specifically examined the relationship between hip fracture patterns, sex, and short-term outcomes including hospital length of stay and discharge disposition in geriatric trauma patients. METHODS: We performed a retrospective study of hip fractures in geriatric trauma patients. Hip fracture patterns were based on ICD -9 CM diagnostic codes for hip fractures (820.00-820.9). Patient variables were patient demographics, mechanism of injury, injury severity score, hospital and ICU length of stay, co-morbidities, injury location, discharge disposition, and in-patient mortality. RESULTS: A total of 325 patient records met the inclusion criteria. The mean age of the patients was 82.2 years, and the majority of the patients were white (94%) and female (70%). Hip fractures patterns were categorized as two fracture classes and three fracture types. We observed a difference in the proportion of males to females within each fracture class (Femoral neck fractures Z-score = -8.86, p < 0.001, trochanteric fractures Z-score = -5.63, p < 0.001). Hip fractures were fixed based on fracture pattern and patient characteristics. Hip fracture class or fracture type did not predict short-term outcomes such as in-hospital or ICU length of stay, death, or patient discharge disposition. The majority of patients (73%) were injured at home. However, 84% of the patients were discharged to skilled nursing facility, rehabilitation, or long-term care while only 16% were discharged home. There was no evidence of significant association between fracture pattern, injury severity score, diabetes mellitus, hypertension or dementia. CONCLUSIONS: Hip fracture patterns differ between geriatric male and female trauma patients. However, there was no significant association between fracture patterns and short-term patient outcomes. Further studies are planned to investigate the effect of fracture pattern and long-term outcomes including 90-day mortality, return to previous levels of activity, and other quality of life measures.

Liver dysfunction by model for end-stage liver disease score improves mortality prediction in injured patients with cirrhosis.

BACKGROUND: Cirrhosis is associated with poor outcomes in the trauma setting. We aimed to evaluate the utility of Model for End-Stage Liver Disease (MELD) in assessing additional mortality risk in trauma patients with cirrhosis. METHODS: Injured patients with liver dysfunction were identified by hospital and trauma registry query. Presence of cirrhosis was confirmed by laparotomy, biopsy, or imaging. MELD classification, Child-Turcotte-Pugh (CTP) classification, Injury Severity Score (ISS), and Trauma ISS (TRISS) were recorded, and the primary outcome variable was hospital mortality. We assessed the validity of the four scoring systems in prediction of mortality, individually and in combinations, by comparing the areas under receiver operating characteristic curves (AUC), which is the probability, for scores that increase with the risk of death that a randomly chosen deceased subject will score higher than a randomly chosen living subject. RESULTS: A total of 163 patients with confirmed cirrhosis were included. ISS (AUC = 0.849, p < 0.001) and TRISS (AUC = 0.826, p < 0.001) were the strongest predictors of mortality. MELD (AUC = 0.725) was not a significantly stronger predictor of mortality than CTP (AUC = 0.639; p = 0.38). ISS + MELD (AUC = 0.891) and ISS + CTP (AUC = 0.897) were stronger predictors than ISS alone (AUC = 0.849; p < 0.001) for both. The MELD score was more available from the records than the CTP score (91.4% vs. 75.5%). CONCLUSION: In trauma patients with cirrhosis, a score that evaluates the degree of liver dysfunction enhances the ability of ISS alone to predict mortality. The MELD score is more readily available than the CTP score for the prediction of mortality in trauma patients.

Pediatric radiation exposure during the initial evaluation for blunt trauma.

BACKGROUND: Increased utilization of computed tomography (CT) scans for evaluation of blunt trauma patients has resulted in increased doses of radiation to patients. Radiation dose is relatively amplified in children secondary to body size, and children are more susceptible to long-term carcinogenic effects of radiation. Our aim was to measure radiation dose received in pediatric blunt trauma patients during initial CT evaluation and to determine whether doses exceed doses historically correlated with an increased risk of thyroid cancer. METHODS: A prospective cohort study of patients aged 0 years to 17 years was conducted over 6 months. Dosimeters were placed on the neck, chest, and groin before CT scanning to measure surface radiation. Patient measurements and scanning parameters were collected prospectively along with diagnostic findings on CT imaging. Cumulative effective whole body dose and organ doses were calculated. RESULTS: The mean number of scans per patient was 3.1 ± 1.3. Mean whole body effective dose was 17.43 mSv. Mean organ doses were thyroid 32.18 mGy, breast 10.89 mGy, and gonads 13.15 mGy. Patients with selective CT scanning defined as ≤2 scans had a statistically significant decrease in radiation dose compared with patients with >2 scans. CONCLUSIONS: Thyroid doses in 71% of study patients fell within the dose range historically correlated with an increased risk of thyroid cancer and whole body effective doses fell within the range of historical doses correlated with an increased risk of all solid cancers and leukemia. Selective scanning of body areas as compared with whole body scanning results in a statistically significant decrease in all doses.

Pediatric vascular injuries: acute management and early outcomes.

BACKGROUND: Although uncommon in children, traumatic vascular injuries have the potential for lifelong disability. We reviewed these injuries, their acute management, and early outcomes at a Level I trauma center. METHODS: Retrospective review of patients identified through trauma registry was query of all noniatrogenic vascular injuries in a pediatric population during a 13-year period. Demographics, injury type and management, concomitant injuries, and inpatient outcomes were analyzed. RESULTS: From 1995 to 2008, 8,247 children with traumatic injuries were admitted. Of which 116 (1.4%) sustained 138 significant vascular injuries; 111 arterial and 27 venous. Mean age was 12.7 years ± 4.1 years. Penetrating mechanism was more frequent (57.8%; 67 of 116) than blunt (42.2%; 49 of 116). The overall mean injury severity score was 17.3, of which 12.3 ± 11.7 was for penetrating trauma and 24.1 ± 19.3 for blunt trauma. Thirteen of the 36 patients with torso injuries and one with carotid/jugular injury died. The surviving 102 patients sustained 118 vascular injuries (102 arterial and 16 venous). Of this group, 15 (14.6%) had multiple vascular injuries. There were 23 (22.5%) with torso injuries, 72 (70.6%) with extremity injuries, and 7 (6.9%) with cerebrovascular injuries. Primary repair was the most common arterial repair technique for survivors (25.5%, 26 of 102) and was used more frequently in penetrating trauma (35.0%, 21 of 60) than blunt trauma (12.0%, 5 of 42). Limb salvage was 97.4% (113 of 116). CONCLUSIONS: Pediatric vascular trauma is uncommon. Penetrating mechanism is more common than blunt. Injuries to the torso carry a high mortality. Limb salvage is almost universal.

Local variations in the epidemiology, microbiology, and outcome of necrotizing soft-tissue infections: a multicenter study.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) are rare and highly lethal. METHODS: A retrospective chart review of patients with NSTIs treated at 6 academic hospitals in Texas between January 1, 2004 and December 31, 2007. Patient demographics, presentation, microbiology, treatment, and outcome were recorded. Analysis of variance, chi-square test, and logistic regression analysis were performed. RESULTS: Mortality rates varied between hospitals from 9% to 25% (n = 296). There was significant interhospital variation in patient characteristics, microbiology, and etiology of NSTIs. Despite hospital differences in treatment, primarily in critical care interventions, patient age and severity of disease (reflected by shock requiring vasopressors and renal failure postoperatively) were the main predictors of mortality. CONCLUSIONS: Significant center differences occur in patient populations, etiology, and microbiology of NSTIs, even within a concentrated region. Management should be based on these characteristics given that adjunctive treatments are unproven and variations in outcome are likely because of patient disease at presentation.

Performance on brief practice examination identifies residents at risk for poor ABSITE and ABS qualifying examination performance.

OBJECTIVE: Performance on the American Board of Surgery (ABS) Qualifying Exam (QE) correlates well with chief resident American Board of Surgery In-Training Exam (ABSITE) scores. Yearly ABSITE performance is a useful gauge of resident fund of knowledge and can identify residents at risk of QE failure. We hypothesize that a brief practice exam administered 1-3 times each academic year can identify residents at risk of poor ABSITE performance and also identify early in the chief resident year those at risk for poor QE performance. METHODS: In 2005 we began administering 2-3 times/year an approximately 50 question exam consisting of questions authored by residents and edited by faculty based on the ABSITE exam keywords. The exam was considered mandatory and educational time was allotted. Data were analyzed by determining an individual's score deviation from the mean within PGY class. The standard deviation was then compared to the corresponding years ABSITE percentile and in the final year, QE performance using the Spearman rank correlation test. RESULTS: A total of 710 individual practice exams were offered and 462 (65.1%) were completed in 9 sessions. Two hundred sixty-three residents completed both a practice examination and ABSITE in the year preceding the administration of the ABSITE. Twenty-six chief residents completed a practice examination in the year immediately preceding the ABS QE. Correlations between practice exam scores and ABSITE score percentile were statistically significant (p= 0.01-0.05) for each year the test was administered. The correlation between the practice exam score for chief residents preceding the QE and first attempt QE score was also significant (r =0.416, p<0.05). CONCLUSIONS: A resident's performance on a brief practice exam administered throughout the year is significantly correlated with both ABSITE performance and ABS QE performance. Such a test can be a useful adjunct for identifying residents at risk for poor ABSITE performance as well as identify prior to return of ABSITE scores those residents at risk for poor ABS QE performance.

Malpractice risk and cost are significantly reduced after tort reform.

BACKGROUND: Rising medical malpractice premiums have reached a crisis point in many areas of the United States. In 2003 the Texas legislature passed a comprehensive package of tort reform laws that included a cap at $250,000 on noneconomic damages in most medical malpractice cases. We hypothesized that tort reform laws significantly reduce the risk of malpractice lawsuit in an academic medical center. We compared malpractice prevalence, incidence, and liability costs before and after comprehensive state tort reform measures were implemented. STUDY DESIGN: Two prospectively maintained institutional databases were used to calculate and characterize malpractice risk: a surgical operation database and a risk management and malpractice database. Risk groups were divided into pretort reform (1992 to 2004) and post-tort reform groups (2004 to the present). Operative procedures were included for elective, urgent, and emergency general surgery procedures. RESULTS: During the study period, 98,513 general surgical procedures were performed. A total of 28 lawsuits (25 pre-reform, 3 postreform) were filed, naming general surgery faculty or residents. The prevalence of lawsuits filed/100,000 procedures performed is as follows: before reform, 40 lawsuits/100,000 procedures, and after reform, 8 lawsuits/100,000 procedures (p < 0.01, relative risk 0.21 [95% CI 0.063 to 0.62]). Virtually all of the liability and defense cost was in the pretort reform period: $595,000/year versus $515/year in the postreform group (p < 0.01). CONCLUSIONS: Implementation of comprehensive tort reform in Texas was associated with a significant decrease in the prevalence and cost of surgical malpractice lawsuits at one academic medical center.

Time and degree of glycemic derangement are associated with increased mortality in trauma patients in the setting of tight glycemic control.

BACKGROUND: Tight glucose control (TGC) may reduce mortality in critically ill trauma patients. We hypothesize that euglycemia is beneficial, and a measure considering time and degree of hyperglycemia is most associated with mortality. METHODS: We performed a review of intensive care unit trauma patients admitted for more than 3 days between January 2005 and December 2007 on a TGC protocol with a goal of 80 to 110 mg/dL. Hyperglycemic, hypoglycemic, and euglycemic time ranges, and area of interpolated curves above and below 80 to 110 mg/dL were assessed. Associations with mortality were based on logistic regression models adjusted for age, injury severity score, and admission Glasgow Coma Scale score. RESULTS: A total of 546 patients were identified, and 68 (13%) died. Time spent as hyperglycemic (P = .29) and hyperglycemic area under the curve (P = .58) were not associated with mortality; hyperglycemic area/time (P = .01) was associated with mortality. Regarding hypoglycemia, area over the curve (P = .009) and time spent as hypoglycemic (P = .002) were associated with mortality. CONCLUSIONS: TGC prevents prolonged, high degrees of hyperglycemia; avoiding hypoglycemia likely provides mortality benefit for trauma patients.

The use of laparoscopic surgery in pregnancy: evaluation of safety and efficacy.

BACKGROUND: Laparoscopic surgery in pregnant women has become increasingly more common since the 1990s; however, the safety of laparoscopy in this population has been widely debated, particularly in emergent and urgent situations. METHODS: A retrospective chart review of all pregnant women following a nonobstetric abdominal operation at a University hospital between 1993 and 2007. Perioperative morbidity and mortality for the mother and fetus were evaluated. RESULTS: Ninety-four subjects were identified; 53 underwent laparoscopic procedures and 41 underwent open procedures. Cholecystectomy and appendectomy were performed in both groups with salpingectomy/ovarian cystectomy only in the laparoscopic group. No maternal deaths occurred, while fetal loss occurred in 3 cases within 7 days of the operation and in 1 case 7 weeks postoperatively. This and other perinatal complications occurred in 36.7% of the laparoscopic group and 41.7% of the open group. CONCLUSION: Laparoscopic appendectomy and cholecystectomy appear to be as safe as the respective open procedures in pregnant patients; however, this population in particular remains at risk for perinatal complications regardless of the method of abdominal access.

Computed tomography grading systems poorly predict the need for intervention after spleen and liver injuries.

Computed tomography (CT) grading systems are often used clinically to forecast the need for interventions after abdominal trauma with solid organ injuries. We compared spleen and liver CT grading methods to determine their utility in predicting the need for operative intervention or angiographic embolization. Abdominal CT scans of 300 patients with spleen injuries, liver injuries, or both were evaluated by five trauma faculty members blinded to clinical outcomes. Studies were graded by American Association for the Surgery of Trauma criteria, a novel splenic injury CT grading system, and a novel liver injury grading system. The sensitivity and specificity of each methodology in predicting the need for intervention were calculated. The kappa statistic was used to determine interrater variability. Twenty-one per cent (39/189) of patients with splenic injuries visible on CT scans required interventions, whereas 14 per cent (21/154) of patients with liver injuries visible on CT required interventions. The overall sensitivity of all grading systems in predicting the need for surgery or angioembolization of the spleen or liver was poor; the specificity seemed to be fairly good. When evaluators were compared, the strength of agreement for the various scoring systems was only moderate. Anatomic CT grading systems are ineffective screening tools for excluding the need for operation or embolization after splenic or hepatic trauma. Although insensitive, CT is a good predictor (highly specific) of the need for intervention if certain definitive abnormalities are identified. Considerable inconsistency exists in interpretation of abdominal CT scans after trauma, even among experienced clinicians.

Upper airway injury and its management.

Injuries to the upper airways are rare, but carry a significant morbidity and mortality. The degree of injury and presentation varies; thus recognition often requires a high index of suspicion based on mechanism. Effective management of laryngotracheal injuries begins with immediate control of the airway whether by orotracheal and surgical route. Definitive management of upper airway injuries relies on an understanding of the anatomy of the larynx, trachea and surrounding structures. Associated injuries are common and must be addressed concomitantly. Postoperative complications are frequent, requiring perioperative vigilance and long-term follow-up to ensure best outcome.

Common complications following thoracic trauma: their prevention and treatment.

Although there are a wide range of complications following thoracic trauma, respiratory failure, pneumonia, and pleural sepsis are the most common potentially preventable problems. Respiratory failure and pneumonia are directly related to the severity of the injury and the age and condition of the patient. A program aimed at aggressive pain control, mobilization, and pulmonary care can reduce the risk of respiratory failure, pneumonia, and death in these patients. Pleural sepsis develops in the face of a retained hemothorax, which becomes contaminated with bacteria. The most common source for this contamination is not pneumonia, but external contamination from the wound itself or at the time of placement of the tube thoracostomy. Measures that reduce the volume of retained pleural blood and reduce or eliminate any bacterial contamination are likely to reduce the incidence of pleural sepsis. The authors review these complications and describe a plan to reduce these complications.

Surgical critical care and private practice surgeons: a different world out there!

BACKGROUND: Few graduating residents seek surgical critical care (SCC) fellowships; fewer than half of positions fill. We hypothesized substantial differences exist in practice patterns and attitudes between SCC surgeons in academic practice (ACs) and in private practice (PVTs). STUDY DESIGN: A survey instrument was sent to 1,544 board-certified SCC intensivists in North America. RESULTS: Of those invited, 489 responded (32% response rate). Respondents were mostly men (88%) and Caucasian (86%), with a mean age of 48 years; 60% were ACs, 28% were PVTs, and 12% reported "other;" 94% currently practiced SCC. PVTs (50%) were more likely than ACs (18%) to provide SCC for only their own patients, less likely (24% versus 74%) to function as an "ICU attending," and less likely to work with residents (36% versus 91%) and fellows (4% versus 60%; all p < 0.001). PVTs (48%) spent more time performing elective operations than ACs (27%; p < 0.001). They were more likely than ACs to relinquish management of SCC patients to medical consultants: infectious disease (34% versus 12%), cardiology (31% versus 12%), and pulmonary (23% versus 3%; all p < 0.001). Conflicts with medical specialists were a bigger problem for PVTs (43%) than for ACs (17%; p < 0.001). CONCLUSIONS: Private practice surgical intensivists are more likely than academic intensivists to provide critical care for only their own patients and to use consultants to avoid conflicts.

Laparoscopic appendectomy is superior to open appendectomy in obese patients.

BACKGROUND: There are minimal data comparing laparoscopic appendectomy (LA) with open appendectomy (OA) in obese patients. METHODS: We reviewed consecutive adult patients from 2003 to 2005 who underwent an appendectomy at a University-affiliated teaching hospital. Obesity was defined as a body mass index of 30 or greater. Outcome measures included length of stay, surgical times, intra-abdominal abscesses, wound infections, and hospital charges. RESULTS: There were 116 patients with a mean body mass index of 35. Eighty-five patients underwent LA, 12 were converted to open, 4 of 12 (31%) were perforated. Thirty-one patients underwent OA. Overall, 21 (18%) were perforated. Length of stay for LA was better, 3.4 days versus 5.5 days for OA (P = .02), and wound closure rate was better, 90% for LA versus 68% for OA (P < .01). Other outcome measures were equivalent. CONCLUSIONS: LA is associated with shorter lengths of stay, fewer open wounds, and equivalent hospital charges and intra-abdominal abscess rates; and should be considered the procedure of choice for obese patients with appendicitis.

Pneumoperitoneum after percutaneous endoscopic gastrostomy in patients in the intensive care unit.

Percutaneous endoscopic gastrostomy (PEG) has been associated with up to a 55 per cent incidence of pneumoperitoneum in the literature. A review was conducted of 120 consecutive PEG tube insertions in patients in the intensive care unit (ICU) to determine the incidence and significance of postprocedural pneumoperitoneum in this population. One hundred twenty consecutive PEG insertions in patients in the ICU were retrospectively reviewed. Chest radiographs were reviewed for 48 hours postprocedure, noting if any pneumoperitoneum was apparent on radiologic examination. If present, the time to resolution was noted. Documented PEG complications were also examined. Post-PEG pneumoperitoneum was detected in 6.7 per cent of patients in the ICU. Mean time to resolution was 2.7 days. The complication rate was 10.8 per cent, including dislodgement requiring laparotomy, transcolonic placement, and upper gastrointestinal bleeding. There were no complications resulting from PEG placement in patients with postprocedural pneumoperitoneum. Two transcolonic PEGs were undetected by postprocedure chest radiographs. The incidence of post-PEG pneumoperitoneum in our ICU population was 6.7 per cent. We believe that this incidence, although lower than historical rates, accurately reflects the current rate of detectable pneumoperitoneum in patients in the ICU. PEG-related complications were not associated with postprocedure pneumoperitoneum.

Intensive insulin protocol improves glucose control and is associated with a reduction in intensive care unit mortality.

BACKGROUND: Intensive insulin therapy to maintain serum glucose levels between 80 and 110 mg/dL has previously been shown to reduce mortality in the critically ill; recent data, however, have called this benefit into question. In addition, maintaining uniform, tight glucose control is challenging and resource demanding. We hypothesized that, by use of a protocol, tight glucose control could be achieved in the surgical trauma intensive care unit (STICU), and that improved glucose control would be beneficial. STUDY DESIGN: During the study period, a progressively more rigorous approach to glucose control was used, culminating in an implemented protocol in 2005. We reviewed STICU patients' blood glucose levels, measured by point-of-care testing, from 2003 to 2006. Mortality was tracked over the course of the study, and patient charts were retrospectively reviewed to measure illness and injury severity. RESULTS: Mean blood glucose levels steadily improved (p < 0.01). In addition to absolute improvements in glucose control, total variability of glucose ranges in the STICU steadily diminished. A reduction in STICU mortality was temporally associated with implementation of the protocol (p < 0.01). There were fewer intraabdominal abscesses and fewer postinjury ventilator days after implementation of the protocol. There was a small increase in the incidence of clinically relevant hypoglycemia. CONCLUSIONS: Improvements in glucose control in the ICU can be achieved by using a protocol for intensive insulin therapy. In our ICU, this was temporally associated with a significant reduction in mortality.

A large single-center experience with treatment of patients with crotalid envenomations: outcomes with and evolution of antivenin therapy.

BACKGROUND: Antivenin (crotalid) polyvalent (ACP; Antivenin Crotalidae Polyvalent; Wyeth, Melville, NY) is associated with frequent allergic reactions. Allergic reactions are fewer with ovine Fab antivenin (FabAV). This study describes the management of crotalid envenomations in patients treated with FabAV or ACP, and without antivenin. METHODS: We performed a retrospective chart review of crotalid envenomations over 10 years. Demographic data, hematologic profiles, details of antivenin administration, and in-hospital morbidity and mortality were collected. RESULTS: There were no mortalities and a single amputation. Fewer fasciotomies were performed in the FabAV (9%) group versus the ACP group (24%). Mean hospital stay was 3.4 days. No allergic reactions were associated with FabAV. Fourteen of 211 reactions were associated with ACP (P < .001). Coagulopathy was frequent. CONCLUSIONS: FabAV represents an improvement in management of crotalid envenomations because of reduced allergic reactions. Serious morbidity and mortality is rare. Coagulopathy is frequent but bleeding is not. Limb salvage is high. Surgical debridement and ACP are contraindicated when FabAV is available.

Transparent and open discussion of errors does not increase malpractice risk in trauma patients.

OBJECTIVE: We set out to determine if there is an increased medical malpractice lawsuit rate when trauma patient cases are presented at an open, multidisciplinary morbidity and mortality conference (M&M). INTRODUCTION: Patient safety proponents emphasize the importance of transparency with respect to medical errors. In contrast, the tort system focuses on blame and punishment, which encourages secrecy. Our question: Can the goals of the patient safety movement be met without placing care providers and healthcare institutions at unacceptably high malpractice risk? METHODS: The trauma registry, a risk management database, along with the written minutes of the trauma morbidity and mortality conference (M&M) were used to determine the number and incidence of malpractice suits filed following full discussion at an open M&M conference at an academic level I trauma center. RESULTS: A total of 20,749 trauma patients were admitted. A total of 412 patients were discussed at M&M conference and a total of seven lawsuits were filed. Six of the patients were not discussed at M&M prior to the lawsuit being filed. One patient was discussed at M&M prior to the lawsuit being filed. The incidence of lawsuit was calculated in three groups: all trauma patients, all trauma patients with complications, and all patients presented at trauma M&M conference. The ratio of lawsuits filed to patients admitted and incidence in the three groups is as follows: All Patients, 7 lawsuits/20,479 patients (4.25 lawsuits/100,000 patients/year); M&M Presentation, 1 lawsuit/421 patients (29.6 lawsuits/100,000 patients/year); All Trauma Complications, 7 lawsuits/6,225 patients (14 lawsuits/100,000 patients/year). Patients with a complication were more likely to sue (P < 0.01); otherwise, there were no statistical differences between groups. CONCLUSIONS: A transparent discussion of errors, complications, and deaths does not appear to lead to an increased risk of lawsuit.

Trauma surgery malpractice risk: perception versus reality.

OBJECTIVE: We set out to compare the malpractice lawsuit risk and incidence in trauma surgery, emergency surgery, and elective surgery at a single academic medical center. SUMMARY AND BACKGROUND DATA: The perceived increased malpractice risk attributed to trauma patients discourages participation in trauma call panels and may influence career choice of surgeons. When questioned, surgeons cite malpractice risk as a rationale for not providing trauma care. Little data substantiate or refute the perceived high trauma malpractice risk. We hypothesized that the malpractice risk was equivalent between an elective surgical practice and a trauma/emergency practice. METHODS: Three prospectively maintained institutional databases were used to calculate and characterize malpractice incidence and risk: a surgical operation database, a trauma registry, and a risk management/malpractice database. Risk groups were divided into elective general surgery (ELECTIVE), urgent/emergent, nontrauma general surgery (URGENT), and trauma surgery (TRAUMA). Malpractice claims incidence was calculated by dividing the total number of filed lawsuits by the total number of operative procedures over a 12-year period. RESULTS: Over the study period, 62,350 operations were performed. A total of 21 lawsuits were served. Seven were dismissed. Three were granted summary judgments to the defendants. Ten were settled with payments to the plaintiffs. One went to trial and resulted in a jury verdict in favor of the defendants. Total paid liability was 4.7 million dollars(391,667 dollars/year). Total legal defense costs were 1.3 million dollars(108,333 dollars/year). The ratio of lawsuits filed/operations performed and incidence in the 3 groups is as follows: ELECTIVE 14/39,080 (3.0 lawsuits/100,000 procedures/year), URGENT 5/17,958, (2.3 lawsuits/100,000 procedures/year), and TRAUMA 2/5312 (3.1/100,000 procedures/year). During the study period, there were an estimated 49,435 trauma patients evaluated. The incidence of malpractice lawsuits using this denominator is 0.34 lawsuits/100,000 patients/year. CONCLUSIONS: These data demonstrate no increased risk of lawsuit when caring for trauma patients, and the actual risk of a malpractice lawsuit was low.