Improving Blunt Chest Wall Injury Outcomes: Introducing the PIC Score.

BACKGROUND: To improve care for nonintubated blunt chest wall injury patients, our Level I trauma center developed a treatment protocol and a pulmonary evaluation tool named "PIC Protocol" and "PIC Score," emphasizing continual assessment of pain, incentive spirometry, and cough ability. OBJECTIVE: The primary objective was to reduce unplanned intensive care unit admissions for blunt chest wall injury patients using the PIC Protocol and the PIC Score. Additional outcomes included intensive care unit length of stay, ventilator days, length of hospital stay, inhospital mortality, and discharge destination. METHODS: This was a retrospective cohort study comparing outcomes of rib fracture patients treated at our facility 2 years prior to (control group) and 2 years following PIC Protocol use (PIC group). The protocol included admission screening, a power plan order set, the PIC Score patient assessment tool, in-room communication board, and patient education brochure. Outcomes were compared using independent-samples t tests for continuous variables and Pearson's χ2 for categorical variables with α set to p < .05. RESULTS: There were 1,036 patients in the study (control = 501; PIC = 535). Demographics and injury severity were similar between groups. Unanticipated escalations of care for acute pulmonary distress were reduced from 3% (15/501) in the control group to 0.37% (2/535) in the PIC group and were predicted by a preceding fall in the PIC Score of 3 points over the previous 8-hr shift, marking pulmonary decline by an acutely falling PIC Score. CONCLUSIONS: The PIC Protocol and the PIC Score are easy-to-use, cost-effective tools for guiding care of blunt chest wall injury patients.

Effects of the COVID-19 Pandemic on Respiratory Care Student Enrollment, Retention, and Success on the National Board for Respiratory Care Credentialing Examinations.

BACKGROUND: The purpose of this study was to ascertain whether the COVID-19 pandemic and the instructional changes implemented in response to it affected student enrollment, retention, or success on the National Board for Respiratory Care credentialing examinations at an associate degree respiratory care program in the state of Texas. METHODS: A retrospective analysis of student enrollment, retention data, and graduate success rates on the National Board for Respiratory Care credentialing examinations were used in this study. The data were collected from an associate degree respiratory care program in Texas and included 69 graduates for the 5-year study period. The 3 academic years that led up to the COVID-19 pandemic served as a "pre-pandemic" baseline for comparison. The cohort of 2019-2020 was labeled "early pandemic," the cohort of 2020-2021 was labeled "mid pandemic," and the cohort of 2021-2022 was labeled "late pandemic" for data comparison purposes. Descriptive statistics, the Kruskal-Wallis test, and the Mann-Whitney U test were used for data analysis (P < .05). RESULTS: The number of program applicants significantly decreased between the pre- and late-pandemic groups (P = .001), but overall student enrollment (P = .42) and retention (P = .95) were not significantly affected by the COVID-19 pandemic. The first-time pass rate on the Therapist Multiple-Choice examination low-cut score (P = .005) and high-cut score (P = .007) were significantly reduced in the mid-pandemic group when compared with the previous cohorts. There were no statistically significant differences in the demographic data or online questionnaire responses from the early- and mid-pandemic groups. CONCLUSIONS: The COVID-19 pandemic and the instructional changes implemented in response to it decreased students' first-time pass rate on the Therapist Multiple-Choice examination in the mid-pandemic group compared with the pre- and early-pandemic groups.

Unusual Presentation of Bouveret Syndrome Resulting in Both Gastric Outlet Obstruction and Small Bowel Obstruction with Perforation.

Our case describes an 83-year-old female who presented with severe abdominal pain, nausea, and bilious emesis of one day's duration. She had an endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and percutaneous transhepatic biliary drainage (PTCD) one year prior for choledocholithiasis with acute cholangitis in her home country, Scotland. Unfortunately, while visiting family in the United States, her PTCD became dislodged, and she developed progressive worsening abdominal pain. Computerized tomography of her abdomen showed pneumobilia, perigastric inflammation, a contracted gallbladder, small bowl inflammation with a likely transition point at the mid-jejunum, and a probable duodenal mass. The patient underwent an exploratory laparotomy with intraoperative findings of choledochoduodenal fistula with coincident gastric and small bowel obstruction (SBO) secondary to three large, mixed gallstones. One 3 cm gallstone was located at the pylorus and two (2.3 and 3 cm) gallstones were isolated in the mid-jejunum, with one of those causing isolated transmural pressure necrosis with subsequent perforation. Bouveret syndrome is a rare cause of gastric outlet obstruction (GOO) that manifests via an acquired cholecystoenteric fistula. Our patient presented with a concomitant GOO and SBO with perforation of the mid-jejunum. Timely diagnosis of Bouveret syndrome is essential, as most causes require emergent surgical intervention.

CT Imaging Findings of Porcelain Gallbladder and Epiploic Appendagitis: Two Rare Abdominal Pathologies in an Asymptomatic Patient.

Porcelain gallbladder (PG) and epiploic appendagitis (EA) are rare imaging findings in an asymptomatic patient. The clinical presentation of PG and EA can vary; however, a common presenting complaint is abdominal discomfort. We describe the case of a 54-year-old male with computerized tomography findings consistent with PG and EA. We also performed a review of the literature to understand the etiology, clinical presentation, and diagnosis and treatment options of both PG and EA.

Splenic trauma from colonoscopy: A case series.

INTRODUCTION: Splenic trauma is quite rare after colonoscopy and can be overlooked as a complication when a patient presents with severe abdominal pain. It can be difficult to diagnose without appropriate imaging, but it should be considered as part of the differential in a patient arriving for evaluation of left upper quadrant abdominal pain. PRESENTATION OF CASE: In this case series, we discuss four patients who presented to our institution with splenic trauma specifically after colonoscopy. These patients were diagnosed with splenic trauma utilizing computed tomography (CT) scans of the abdomen and pelvis. They were all immediately transferred to our surgical intensive care unit (SICU) for close monitoring and serial hemoglobin checks. Two of the four patients had decreasing hemoglobin levels and were monitored until they underwent interventional radiology (IR) angiography and angioembolization. The other two patients had significant transfusion requirements and ultimately went to the operating room for an open splenectomy. All four of these patients did well after their interventions, although one of them required longer hospitalization while on the ventilator secondary to Haemophilus infection. DISCUSSION: This case series recognizes that there is potential for quite severe splenic trauma after colonoscopy. While one of the four patients did have a history of prior splenic trauma, the other three had no history of trauma. CONCLUSION: These cases demonstrate that this complication should be managed similarly to traumatic splenic injury unrelated to colonoscopy, and that non-operative treatment remain a possibility. Certainly, non-operative management requires a SICU and IR capabilities to be successful. If the patient becomes unstable, they should undergo the appropriate operative intervention.

Head and neck surgical oncology in the time of a pandemic: Subsite-specific triage guidelines during the COVID-19 pandemic.

BACKGROUND: COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of health care personnel. METHODS: The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging head and neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular. RECOMMENDATIONS: Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred. CONCLUSION: These guidelines are intended to help clinicians caring for patients with HNC appropriately allocate resources during a health care crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.

Trauma 2007: a finger on the pulse.

Truma surgery today is facing a number of significant challenges that offer a stimulus for growth and evolution of tl practice. To successfully face these challenges, reexamination of the discipline, the current practice models for its providers, and the definition/scope of the specialty will be necessary. Further development and application of the cute care surgery model may represent the future direction for trauma care practitioners.

Ethical imperatives in staffing and managing a trauma intensive care unit.

As U.S. trauma surgery evolves to embrace the concept and practice of acute care surgery, the organization and management structure of the intensive care unit must also grow to reflect new challenges and imperatives faced by trauma surgeons. Key issues to be explored in light of acute care surgery include the role of the traumatologist/intensivist in the intensive care unit, as opposed to the traumatologist without specific critical care training, and a potentially expanded role for nonsurgical intensivists as the critical care time available for trauma/intensivists wanes due to increased surgical and non-critical care patient volume. Each of these changes to the practice of trauma/surgical critical care and acute care surgery are evaluated in light of the primacy of appropriately trained intensivists in the critical care unit. The ethics of providing the best care possible is interrogated in light of different service models in both the university and community settings. The roles of residents, fellows, and midlevel practitioners in supporting the goal of the intensivist and the critical care team is similarly explored. A recommendation for an ethical organizational and management structure is presented.