When Equality Is Not Equity: The Ethics of Access to Trauma Care: A Surgical Perspective.

OBJECTIVE: The purpose of this surgical perspective is to describe the trauma care needs of the South Side of Chicago and the creation of an adult trauma center at the University of Chicago Medicine and associated hospital-based violence intervention program. BACKGROUND: Traumatic injury is a leading cause of death and disability in the United States. Disparities across the continuum of trauma care exist, which are often rooted in the social determinants of health. Trauma center distribution is critical to timely treatment and should be based on the trauma needs of the area. The previous trauma ecosystem of Chicago was incongruent with the concentration of violent injuries on the south and west sides of the city, leading to a fallacy of distributive justice. METHODS: A descriptive analysis of community partners, trauma program leadership, trauma surgeons, and the violence intervention program director was performed. RESULTS: The UCM trauma center opened in May 2018 and has since been one of the busiest trauma centers in the country, with a 40% penetrating trauma rate. There have been significant reductions in patient transport time on the South Side up to 8.9 minutes ( P <0.001). The violence intervention program employs credible messengers with lived experience representing the community and has engaged over 8000 patients since 2018, developing both community-based and medical-legal partnerships. CONCLUSIONS: The persistent efforts of the community and key stakeholders led to a system change that improved trauma care for the South Side of Chicago.

Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond.

OBJECTIVE: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Capacity Assessment in Emergency Surgery.

AbstractInformed consent is a necessary component of the ethical practice of surgery. Ideally, consent is performed in a setting conducive to a robust patient-provider conversation, with careful consideration of risks, benefits, and outcomes. For patients with medical or surgical emergencies, navigating the consent process can be complicated and requires both careful and expedited assessment of decision-making capacity. We present a recent case in which a patient in need of emergency care refused intervention, requiring urgent capacity assessment and a modification to usual care.

COVID-19 Among African Americans: An Action Plan for Mitigating Disparities.

As the COVID-19 pandemic has unfolded across the United States, troubling disparities in mortality have emerged between different racial groups, particularly African Americans and Whites. Media reports, a growing body of COVID-19-related literature, and long-standing knowledge of structural racism and its myriad effects on the African American community provide important lenses for understanding and addressing these disparities.However, troubling gaps in knowledge remain, as does a need to act. Using the best available evidence, we present risk- and place-based recommendations for how to effectively address these disparities in the areas of data collection, COVID-19 exposure and testing, health systems collaboration, human capital repurposing, and scarce resource allocation.Our recommendations are supported by an analysis of relevant bioethical principles and public health practices. Additionally, we provide information on the efforts of Chicago, Illinois' mayoral Racial Equity Rapid Response Team to reduce these disparities in a major urban US setting.

Cerebrovascular Complications in Early Survivors of Civilian Penetrating Brain Injury.

BACKGROUND: This study investigates the presence of cerebrovascular injuries in a large sample of civilian penetrating brain injury (PBI) patients, determining the prevalence, radiographic characteristics, and impact on short-term outcome. METHODS: We retrospectively reviewed patients with PBI admitted to our institution over a 2-year period. Computed tomography head scans, computer tomography angiograms and venograms of the intracranial vessels were evaluated to determine the wound trajectory, intracranial injury characteristics, and presence of arterial (AI) and venous sinus (VSI) injuries. Demographics, clinical presentation, and treatment were also reviewed. Discharge disposition was used as surrogate of short-term outcome. RESULTS: Seventy-two patients were included in the study. The mechanism of injury was gunshot wounds in 71 patients and stab wound in one. Forty-one of the 72 patients (60%) had at least one vascular injury. Twenty-six out of 72 patients suffered an AI (36%), mostly pseudoaneurysms and occlusions, involving the anterior and middle cerebral arteries. Of the 72 patients included, 45 had dedicated computed tomography venograms, and of those 22 had VSI (49%), mainly manifesting as superior sagittal sinus occlusion. In a multivariable regression model, intraventricular hemorrhage at presentation was associated with AI (OR 9.9, p = 0.004). The same was not true for VSI. CONCLUSION: Acute traumatic cerebrovascular injury is a prevalent complication in civilian PBI, frequently involving both the arterial and venous sinus systems. Although some radiographic features might be associated with presence of vascular injury, assessment of the intracranial vasculature in the acute phase of all PBI is essential for early diagnosis. Treatment of vascular injury remains variable depending on local practice.

Leg Amputations Among Texans Remote From Experienced Surgical Care.

BACKGROUND: Surgical outcomes may differ between low-volume and experienced hospitals. We sought to identify characteristics of remote patients-those living more than 50 miles from an experienced center-who underwent leg amputations for peripheral artery disease (PAD) and foot complications at low-volume and experienced hospitals and identify regions of Texas where such patients live. MATERIALS AND METHODS: Publicly available Texas hospitalization data from 2004 through 2009 were used to identify patients with PAD who underwent leg amputation for foot complications, including foot ulcers, foot infections, and gangrene. Geocoding was used to further identify a subset of remote patients and to estimate distances from zip code of residence to hospital in which care was received. RESULTS: Among all leg amputations, 850 (18.6%) were performed on patients classified as remote, and 3723 (81.4%) were performed on patients classified as nonremote. Compared with nonremote patients, remote patients were more often categorized as white and more frequently received Medicare and/or Medicaid. Of the subset of remote patients, those at low-volume hospitals were older, were less often categorized as Hispanic, more often had Medicaid coverage, were also more frequently admitted through the emergency department, and often had a foot infection compared with those at experienced centers. Geospatial analysis identified five concentrated geographic areas of remote patients who live more than 50 miles from an experienced center. CONCLUSIONS: These findings suggest travel distance may at least influence, if not constrain, the choice of hospital for patients with PAD and foot complications. Efforts to decrease leg amputations among remote patients should be focused on five specific geographic areas of Texas.

Is Bigger Better?: The Effect of Hospital Consolidation on Index Hospitalization Costs and Outcomes Among Privately Insured Recipients of Immediate Breast Reconstruction.

OBJECTIVES: To examine the relationship between hospital market competition and inpatient costs, procedural markup, inpatient complications, and length of stay among privately insured patients undergoing immediate reconstruction after mastectomy. METHODS: A retrospective cross-sectional analysis of privately insured female patients undergoing immediate breast reconstruction in the 2009 to 2011 Nationwide Inpatient Sample was performed. The Herfindahl-Hirschman index was used to describe hospital market competition; associations with outcomes were explored via hierarchical models adjusting for patient, hospital, and market characteristics. RESULTS: A weighted total of 42,411 patients were identified; 5920 (14.0%) underwent free flap reconstruction. In uncompetitive markets, 6.8% (n=857) underwent free flap reconstruction, compared with 13.6% (n=2773) in highly competitive markets and 24.6% (n=2290) in moderately competitive markets. For every 5 additional hospitals in a market, adjusted costs were 6.6% higher (95% CI: 2.8%-10.5%), for free flap reconstruction, and 5.1% higher (95% CI: 2.0%-8.4%) for nonfree flap reconstruction. Similarly, higher procedural markup was associated with increased hospital market competition both for nonfree flap reconstruction (5.5% increase, 95% CI: 1.1%-10.1%) and for free flap reconstruction (8.2% increase, 95% CI: 1.8%-15.0%). Notably, there was no association between incidence of inpatient complications or extended length of stay and hospital market competition among either free flap or nonfree flap reconstruction patients. CONCLUSIONS: Decreasing market competition was associated with lower inpatient costs and equivocal clinical outcomes. This suggests that some of the economies of scale, access to capital and care delivery efficiencies gained from increased market power following hospital mergers are passed onto payers and consumers as lower costs.

Population-based assessment of racial/ethnic differences in utilization of radical cystectomy for patients diagnosed with bladder cancer.

PURPOSE: Radical cystectomy is a surgical treatment for recurrent non-muscle-invasive and muscle-invasive bladder cancer; however, many patients may not receive this treatment. METHODS: A total of 27,578 patients diagnosed with clinical stage I-IV bladder cancer from 1 January 2007 to 31 December 2013 were identified from the Surveillance, Epidemiology, and End Results (SEER) registry database. We used multivariable regression analyses to identify factors predicting the use of radical cystectomy and pelvic lymph node dissection. Cox proportional hazards models were used to analyze survival outcomes. RESULTS: A total of 1,693 (6.1%) patients with bladder cancer underwent radical cystectomy. Most patients (92.4%) who underwent radical cystectomy also underwent pelvic lymph node dissection. When compared with white patients, non-Hispanic blacks were less likely to undergo a radical cystectomy [odds ratio (OR) 0.79, 95% confidence interval (CI) 0.64-0.96, p = 0.019]. Moreover, recent year of surgery 2013 versus 2007 (OR 2.32, 95% CI 1.90-2.83, p < 0.001), greater percentage of college education ≥36.3 versus <21.3% (OR 1.23, 95% CI 1.04-1.44, p = 0.013), Midwest versus West (OR 1.64, 95% CI 1.39-1.94, p < 0.001), and more advanced clinical stage III versus I (OR 29.1, 95% CI 23.9-35.3, p < 0.001) were associated with increased use of radical cystectomy. Overall survival was improved for patients who underwent radical cystectomy compared with those who did not undergo a radical cystectomy (hazard ratio 0.88, 95% CI 0.80-0.97, p = 0.008). CONCLUSION: There is significant underutilization of radical cystectomy in patients across all age groups diagnosed with bladder cancer, especially among older, non-Hispanic black patients.

Surgical referral coordination from a first-level hospital: a prospective case study from rural Nepal.

BACKGROUND: Patients in isolated rural communities typically lack access to surgical care. It is not feasible for most rural first-level hospitals to provide a full suite of surgical specialty services. Comprehensive surgical care thus depends on referral systems. There is minimal literature, however, on the functioning of such systems. METHODS: We undertook a prospective case study of the referral and care coordination process for cardiac, orthopedic, plastic, gynecologic, and general surgical conditions at a district hospital in rural Nepal from 2012 to 2014. We assessed the referral process using the World Health Organization's Health Systems Framework. RESULTS: We followed the initial 292 patients referred for surgical services in the program. 152 patients (52%) received surgery and four (1%) suffered a complication (three deaths and one patient reported complication). The three most common types of surgery performed were: orthopedics (43%), general (32%), and plastics (10%). The average direct and indirect cost per patient referred, including food, transportation, lodging, medications, diagnostic examinations, treatments, and human resources was US$840, which was over 1.5 times the local district's per capita income. We identified and mapped challenges according to the World Health Organization's Health Systems Framework. Given the requirement of intensive human capital, poor quality control of surgical services, and the overall costs of the program, hospital leadership decided to terminate the referral coordination program and continue to build local surgical capacity. CONCLUSION: The results of our case study provide some context into the challenges of rural surgical referral systems. The high relative costs to the system and challenges in accountability rendered the program untenable for the implementing organization.

Preoperative glucose as a screening tool in patients without diabetes.

BACKGROUND: Although hyperglycemia has been associated with poor postoperative outcomes, preoperative hyperglycemia is not used as a screening tool in patients without diabetes. We evaluated preoperative glucose as a marker for postoperative outcomes in patients without diabetes to assess its usefulness as a potential screening tool. MATERIALS AND METHODS: Clinical characteristics for a sample of 6683 patients without diabetes who underwent nonemergent vascular and general surgery were collected from the American College of Surgeons National Surgical Quality Improvement Program, Brigham and Women's Hospital database. Last glucose measured within 30 d before surgery was the main predictor variable with postoperative infection within 30 d as the primary outcome. RESULTS: For patients without known diabetes with preoperative glucose of 100-139 and 140-179 mg/dL, postoperative infection rates were significantly higher (9.33% and 10.16%, respectively) than that of patients with preoperative glucose of 70-99 mg/dL (5.62%, P < 0.001). The risk-adjusted odds of postoperative infection increased by 40% (95% CI, 13%-72%) for each 40 mg/dL increase in preoperative glucose over the range 70-179 mg/dL. Follow-up data demonstrated that 15% of patients with preoperative glucose ≥100 mg/dL were diagnosed with diabetes within 1 y after surgery. CONCLUSIONS: In patients without known diabetes, preoperative glucose is a significant marker for postoperative complications even at moderate levels of hyperglycemia. Some of these patients likely had prediabetes or unrecognized diabetes at the time of surgery. Further studies are needed to determine whether such screening and follow-up of preoperative hyperglycemia in all patients would be effective in lowering complication rates.

Survivor's remorse.

ABSTRACT: In urban, large metropolitan trauma centers, we are accustomed to seeing the most gruesome morbidity and mortality in medicine. By far, the most devastating morbidity and mortality to observe are those inflicted on one human being to another. Gun violence is pervasive in this industrialized country, and it impacts us all. Staff, residents, and faculty in trauma centers bear the brunt of this trauma, second only to the families and communities that suffer the loss of loved ones. This burden is especially heavy for health care workers who share the same ethnic background of those who are disproportionately affected by interpersonal gun violence. Survivors of gun violence exist on a spectrum of chronic illness that ranges in physical and mental morbidity and social disruption in loss of wages and capabilities. This disease not only infects those wounded or killed but also transmits through communities and generations. Urban violence exists because of historic and systematic racism. It continues to persist because racism creates inequities in the quality of education, housing, and investment in urban environments, exacerbated by residential segregation. For two providers, a trainee and a faculty member of African descent, conscious of the determinants that create gun violence, it is overwhelming. We, as health care providers, must tell our stories and the stories of those whose voices are not empowered. We can hope that, by sharing these experiences, we stimulate action and change by raising the moral consciousness of those unaware of the tragedies we witness every day.

Trauma surgical skill sustainment at the University of Chicago AMEDD Military-Civilian Trauma Team Training Site: an observation report.

Background: The Army Medical Department (AMEDD) Military-Civilian Trauma Team Training (AMCT3) Program was developed to enhance the trauma competency and capability of the medical force by embedding providers at busy civilian trauma centers. Few reports have been published on the outcomes of this program since its implementation. Methods: The medical and billing records for the two AMCT3 embedded trauma surgeons at the single medical center were retrospectively reviewed for care provided during August 2021 through July 2022. Abstracted data included tasks met under the Army's Individual Critical Task List (ICTL) for general surgeons. The Knowledge, Skills, and Abilities (KSA) score was estimated based on previously reported point values for procedures. To assess for successful integration of the embedded surgeons, data were also abstracted for two newly hired civilian trauma surgeons. Results: The annual clinical activity for the first AMCT3 surgeon included 444 trauma evaluations and 185 operative cases. The operative cases included 80 laparotomies, 15 thoracotomies, and 15 vascular exposures. The operative volume resulted in a KSA score of 21 998 points. The annual clinical activity for the second AMCT3 surgeon included 424 trauma evaluations and 194 operative cases. The operative cases included 92 laparotomies, 8 thoracotomies, and 25 vascular exposures. The operative volume resulted in a KSA score of 22 799 points. The first civilian surgeon's annual clinical activity included 453 trauma evaluations and 151 operative cases, resulting in a KSA score of 16 738 points. The second civilian surgeon's annual clinical activity included 206 trauma evaluations and 96 operative cases, resulting in a KSA score of 11 156 points. Conclusion: The AMCT3 partnership at this single center greatly exceeds the minimum deployment readiness metrics established in the ICTLs and KSAs for deploying general surgeons. The AMEDD experience provided a deployment-relevant case mix with an emphasis on complex vascular injury repairs.