Does Practice Match Training? Consultation Practices in Surgical Critical Care.

INTRODUCTION: Intensive care unit (ICU) patient and provider attributes may prompt specialty consultation. We sought to determine practice patterns of surgical critical care (SCC) physicians for ICU consultation. METHODS: We surveyed American Association for the Surgery of Trauma members. Various diagnoses were listed under each of nine related specialties. Respondents were asked for which conditions they would consult a specialist. Conditions were cross-referenced with the SCC fellowship curriculum. Other perspectives on practice and consultation were queried. RESULTS: 314 physicians (18.6%) responded (68% male; 79% White; 96.2% surgical intensivist); 284 (16.8%) completed all questions. Percentage of clinical time practicing SCC was 26-50% in 57% and >50% in 14.5%. ICUs were closed (39%), open (25%), or hybrid (36%). Highest average confidence ratings (1 = least, 5 = most) for managing select conditions were ventilator, 4.64; palliative care, 4.51; infections, 4.44; organ donation, hemodynamics (tie), 4.31; lowest rating was myocardial ischemia, 3.85. Consults were more frequent for Cardiology, Hematology, and Neurology; less frequent for nephrology, palliative care, gastroenterology, infectious disease, and pulmonary; and low for curriculum topics (<25%) except for infectious diseases and palliative care. Attending staffing 24 h/day was associated with a lower mean number of topics for consultation (mean 24.03 versus 26.31, P = 0.015). CONCLUSIONS: ICU consultation practices vary based on consultant specialty and patient diagnosis. Consultation is most common for specialty-specific diseases and specialist interventions, but uncommon for topics found in the SCC curriculum, suggesting that respondents' scope of practice closely matched their training.

Joint Society of Critical Care Medicine-Extracorporeal Life Support Organization Task Force Position Paper on the Role of the Intensivist in the Initiation and Management of Extracorporeal Membrane Oxygenation.

OBJECTIVES: To define the role of the intensivist in the initiation and management of patients on extracorporeal membrane oxygenation. DESIGN: Retrospective review of the literature and expert consensus. SETTING: Series of in-person meetings, conference calls, and emails from January 2018 to March 2019. SUBJECTS: A multidisciplinary, expert Task Force was appointed and assembled by the Society of Critical Care Medicine and the Extracorporeal Life Support Organization. Experts were identified by their respective societies based on reputation, experience, and contribution to the field. INTERVENTIONS: A MEDLINE search was performed and all members of the Task Force reviewed relevant references, summarizing high-quality evidence when available. Consensus was obtained using a modified Delphi process, with agreement determined by voting using the RAND/UCLA scale, with score ranging from 1 to 9. MEASUREMENTS AND MAIN RESULTS: The Task Force developed 18 strong and five weak recommendations in five topic areas of extracorporeal membrane oxygenation initiation and management. These recommendations were organized into five areas related to the care of patients on extracorporeal membrane oxygenation: patient selection, management, mitigation of complications, coordination of multidisciplinary care, and communication with surrogate decision-makers. A common theme of the recommendations is extracorporeal membrane oxygenation is best performed by a multidisciplinary team, which intensivists are positioned to engage and lead. CONCLUSIONS: The role of the intensivist in the care of patients on extracorporeal membrane oxygenation continues to evolve and grow, especially when knowledge and familiarity of the issues surrounding extracorporeal membrane oxygenation selection, cannulation, and management are applied.

Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers.

BACKGROUND: There are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study. MATERIALS AND METHODS: The Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16-44 y), middle age (45-64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group. RESULTS: A total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16-24 (13.0%), 25-34 (11.9%), 35-44 (11.9%), 45-54 (15.6%), 55-64 (15.7%), 65-74 (20.3%), 75-84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62-2.30), emergency room lactate (OR: 1.14, CI: 1.02-1.27), injury severity score (OR: 1.06, CI: 1.03-1.09), and cardiac arrest (OR: 10.60, CI: 3.05-36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24-1.53), cardiac arrest (OR: 12.24, CI: 5.38-27.81), craniotomy (OR: 5.62, CI: 1.93-16.37), and thoracotomy (OR: 2.76, CI: 1.28-5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02-1.13), MODS (OR: 1.47, CI: 1.26-1.72), laparotomy (OR: 2.04, CI: 1.02-4.08), and cardiac arrest (OR: 11.61, CI: 4.35-30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups. CONCLUSIONS: In blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Diabetes mellitus is not associated with major morbidity following open abdominal aortic aneurysm repair.

BACKGROUND: It has been suggested that there is an increased morbidity and mortality risk for diabetics undergoing elective aortic surgery. This, however, is not universally accepted. In this study, we utilize a national database to determine if diabetes is associated with adverse outcomes following open, elective, infrarenal abdominal aortic aneurysm (AAA) repair. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent an open, elective, nonruptured AAA repair from January 1, 2005 to December 31, 2007. Patient demographics, comorbidities, and outcomes were compared by diabetes status. Multivariate analysis was performed adjusting for demographics and comorbidities. RESULTS: There were 2110 American College of Surgeons' National Surgical Quality Improvement Program patients who underwent an open, elective, nonruptured AAA repair during this time period. Of these patients, 245 (11.6%) had diabetes mellitus. The overall mortality rate was 3.7% (5.3% for diabetics and 3.5% for nondiabetics, P = 0.171). On bivariate analysis, diabetics were more likely to present preoperatively with cardiovascular and renal comorbidities. Postoperatively, there was no significant difference in mortality or in cardiac, pulmonary, or renal complications. Diabetics were more likely to develop superficial surgical site infections (SSIs) (4.5% versus 1.6%, P = 0.002). On multivariate regression, there was no difference in mortality or major complications between diabetics and nondiabetics (OR 1.4, 95% CI 0.68-2.71). Diabetics, however, were almost three times more likely to develop superficial SSIs (OR 2.8, 95% CI 1.29-6.00). CONCLUSIONS: Diabetes mellitus is not associated with significantly worse major outcomes following open, elective, infrarenal AAA repair. Diabetics, however, are more likely to develop superficial SSIs.

Successful treatment of distal intestinal obstruction syndrome with N-acetylcysteine and polyethylene glycol via colonoscopy.

We describe a case of a 46-year-old woman with cystic fibrosis who presented with several days of abdominal pain and distension. She was found to have a small bowel obstruction with inspissated stool in the distal ileum on CT imaging. Despite initial management with conservative measures, her symptoms worsened. She was taken for urgent colonoscopy with administration of 4% N-acetylcysteine (NAC) and polyethylene glycol (PEG) at the distal ileum with resultant dissolution of the fecalith. Over the following days, her symptoms improved, and she was discharged with outpatient follow-up.

The General Surgery Residency Experience: A Multicenter Study of Differences in Wellbeing by Race/Ethnicity.

Objectives: We explored differences by race/ethnicity in regard to several factors that reflect or impact wellbeing. Background: Physician wellbeing has critical ramifications for the US healthcare system, affecting clinical outcomes, patient experience, and healthcare economics. Within surgery, literature examining the association between race/ethnicity and wellbeing has been limited and inconclusive. Methods: Residents at 16 academic General Surgery training programs completed an online questionnaire. Racial/ethnic identity, gender identity, post-graduate year (PGY) level, and gap years were self-reported. Differences by race/ethnicity in flourishing (global wellbeing) as well as factors reflecting resilience (mindfulness, personal accomplishment, workplace support, workplace control) and risk (depression, emotional exhaustion, depersonalization, stress, anxiety, workplace demand) were assessed. Results: Of 300 respondents (response rate 34%), 179 (60%) were non-male, 123 (41%) were residents of color (ROC), and 53 (18%) were from racial/ethnic groups that are underrepresented in medicine (UIM). Relative to White residents, ROC have significantly lower flourishing and higher anxiety, and these remain significant when adjusting for gender, PGY level, and gap years. Relative to residents overrepresented in medicine (OIM), UIM residents have significantly lower emotional exhaustion and depersonalization after adjusting for gender, PGY level and gap years. Conclusions: Disparities in resident wellbeing based on race/ethnicity and UIM/OIM status exist. However, the experience of ROC is not homogeneous. As part of the transformative process to address systemic racism, eliminate disparities in surgical training, and reconceptualize wellbeing as a fundamental asset for optimal surgeon performance, further understanding the specific contributors and detractors of wellbeing among different individuals and groups is critical.

Screening, Brief Intervention, and Referral to Treatment to Prevent Post-Traumatic Stress Disorder After Gunshot Wounds.

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)-a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

Does the pattern of injury in elderly pedestrian trauma mirror that of the younger pedestrian?

BACKGROUND: Walking is the primary mode of transportation for people aged 65 y and over; hence pedestrian injuries are a substantial source of morbidity and mortality among elderly patients in the United States. This study is aimed at evaluating the pattern of injury in the elderly pedestrians and how it differs from younger patients. METHODS: Retrospective analysis of the National Trauma Data Bank (2002-2006) was performed, with inclusion criteria defined as pedestrian injuries based on ICD-9 codes, excluding age < 15 y. The following age categories in years were created: 15-24 (reference group), 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85-89. The injury prevalence was compared, and multivariate regression for mortality was conducted adjusting for demographic and injury characteristics. RESULTS: A total of 79,307 patients were analyzed. Superficial injuries were the most common at 29.1%, with lower extremity fractures and intracranial injuries following at 25.1% and 21.4% respectively. The very elderly (75-84 and 85-89) had significantly higher rates of fractures of the pelvis(16.2% and 16.8% versus 8.1% in the youngest group), upper (19.3% and 18.4% versus 9.8%), lower extremities (31.1% and 31.9% versus 22.5%) and intracranial injuries (25.5% and 28.7% versus 22.4%), but sustained lower rates of hepatic (2.3% and 1.7% versus 3.0%) injuries, with no difference seen in pancreatic, splenic, and genitourinary injuries. On multivariate analysis, very elderly patients were six to eight times more likely to die (OR 6.24 and 8.27, P < 0.001). CONCLUSION: Elderly patients have higher rates of fractures and intracranial injuries with an extremely worse mortality after pedestrian trauma.

The impact of insurance status on actuarial survival in hospitalized trauma patients: when do they die?

BACKGROUND: Previous work has suggested that insurance status, gender, and ethnicity all have an independent association with mortality after trauma. The purpose of this study is to investigate whether these factors exerted survival impact that could be observed throughout the hospital stay. METHODS: Using the National Trauma Data Bank (version 7.0), a Cox proportional hazards survival analysis was performed on young (19-30 years old) trauma patients to mitigate the impact of comorbid confounders. Variables included in the model were age, gender, ethnicity, Injury Severity Score, presence of shock at presentation, mechanism of injury, insurance status, year of admission, teaching status of the hospital, diagnosis of substance abuse or psychotic disorders, and complications after admission. Rate ratios (RRs) comparing the slopes of the adjusted survival curves were calculated using the Mantel-Cox method. RESULTS: A total of 192,488 young trauma patients were identified with complete data. Increased hazard of death was seen in patients who were uninsured (hazard ratio [HR]=1.69, 95% confidence interval [CI]=1.59-1.80, p<0.001), of a minority ethnicity (HR=1.08, 95% CI=1.01-1.15, p=0.025) or men (HR=1.14, 95% CI=1.04-1.23, p=0.004). RRs were significantly larger between insurance status (RR=1.75, 95% CI=1.58-1.94, p<0.001) than between race (RR=1.23, 95% CI=1.10-1.37, p<0.001) or between gender (RR=1.16, 95% CI=1.01-1.32, p=0.030). CONCLUSION: Risk of death on the first hospital day after injury differs by insurance status, and this disparity becomes more pronounced throughout the hospital stay. Further study is necessary to determine whether this is a result of additional unmeasured patient covariates with insurance status or a difference in provider behavior in response to patient insurance status.

"Diversity in Surgery-How Do We Change the Narrative: Pipeline to Professor?"

The goal of our paper is to provide our perspectives on why there is a need to change the narrative in academic surgery to improve health equity by increasing the pipeline of pre-med students to professors. It is well documented that Health disparities hurt many different people, but they especially hurt Black, Indigenous, and People of color. Black men and women have a decreased life expectancy. Differences in care are associated with greater mortality among minority patients and that care provided to black patients by black physicians can lead to improved compliance with medications and care plans. The lack of black diversity in the medical profession proportional to the societal ethnic distribution is alarming. We have opportunities for improvement for recruitment, retention and promotion within the field of surgery.

Pediatric trauma at an adult trauma center.

BACKGROUND: Accidental traumatic injury is the number 1 cause of morbidity and mortality in the pediatric population. In this study, we aim to prove that certain pediatric patients can be treated with good outcomes at an adult level 1 trauma center. METHODS: Retrospective analysis using the Howard University Hospital trauma registry identified 71 patients treated at Howard University Hospital between the ages of 1 and 17 years old. Specific variables were identified and collected for each patient. RESULTS: The majority of pediatric traumas treated at Howard University Hospital between June 2004 and May 2005 had high survival rates (93%). The patients who did not survive (7%) included 3 patients who were dead on arrival and 2 who died shortly after arrival to the hospital. CONCLUSIONS: Certain pediatric populations who present with minor and/or isolated injuries can be treated in an adult level 1 trauma center with similar outcomes to treatment in a pediatric level 1 trauma center.

Predictors for survival of penetrating trauma using emergency department thoracotomy in an urban trauma center: the Cardiac Instability Score.

BACKGROUND: Emergency department thoracotomy (EDT) is a procedure used in an attempt to save lives of patients in extremis. This study aims to determine predictors of survival and futility by proposing a scoring scale that measures cardiac instability and its use in predicting survival of victims of penetrating trauma undergoing EDT. METHODS: This retrospective study analyzes patients who underwent EDT during a 45-month period at Howard University Hospital, Washington, DC. Vital signs and Glasgow Coma scale (GCS) scores were analyzed at the scene and in the emergency department. A cardiac instability score (CIS) was devised to assign values to vital signs, and the GCS was based on scores from the emergency department. RESULTS: Emergency department vital signs, female gender, absence of cardiopulmonary resuscitation (CPR), and high CIS were found to be statistically significant predictors of survival. CONCLUSIONS: The CIS correlated with survival of patients who underwent EDT and was found to be statistically significant in determining the outcome of an EDT.

Driving in the Geriatric Population.

Driving helps older adults stay mobile and independent. The risk of being injured or killed in a motor vehicle crash increases with age. This trend has been attributed more to an increased susceptibility to injury and medical complications among older drivers rather than an increased risk of crash involvement. Older adults tend to take steps to stay safe on the road. They tend to have a high incidence of seat belt use and a lower incidence of impaired driving. Furthermore, older drivers self-select safer driving conditions by avoiding night, bad weather, and high-speed roads compared with younger drivers.

Abdominal compartment syndrome in traumatic hemorrhagic shock: is there a fluid resuscitation inflection point associated with increased risk?

BACKGROUND: The volume of fluid administered during trauma resuscitation correlates with the risk of abdominal compartment syndrome (ACS). The exact volume at which this risk rises is uncertain. We established the inflection point for ACS risk during shock resuscitation. METHODS: Using the Glue Grant database, patients aged ≥16 years with ACS were compared with those without ACS (no-ACS). Stepwise analysis of the sum or difference of the mean total fluid volume (TV)/kg, TV and/or body weight, (µ) and standard deviations (σ) vs % ACS at each point was used to determine the fluid inflection point. RESULTS: A total of 1,976 patients were included, of which 122 (6.2%) had ACS. Compared with no-ACS, ACS patients had a higher emergency room lactate (5.8 ± 3.0 vs 4.5 ± 2.8, P < .001), international normalized ratio (1.8 ± 1.5 vs 1.4 ± .8, P < .001), and mortality (37.7% vs 14.6%, P < .001). ACS group received a higher TV/kg (498 ± 268 mL/kg vs 293 ± 171 mL/kg, P < .001) than no-ACS. The % ACS increased exponentially with the sum of µ and incremental σ, with the sharpest increase occurring at TV and/or body weight = µ + 3σ or 1,302 mL/kg. CONCLUSIONS: There is a dramatic rise in ACS risk after 1,302 mL/kg of fluid is administered. This plot could serve as a guide in limiting the ACS risk during resuscitation.

Morbidity or mortality? Variations in trauma centres in the rescue of older injured patients.

INTRODUCTION: Prior analysis demonstrates improved survival for older trauma patients (age>64years) treated at trauma centres that manage a higher proportion of geriatric patients. We hypothesised that 'failure to rescue' (death after a complication during an in-hospital stay) may be responsible for part of this variation. The objective of the study was to determine if trauma centre failure to rescue rates are associated with the proportion of older trauma seen. METHODS: We analysed data from high volume level 1 and 2 trauma centres participating in the National Trauma Data Bank, years 2007-2011. Centres were categorised by the proportion of older trauma patients seen. Logistic regression analyses were used to provide risk-adjusted rates for major complications (MC) and, separately, for mortality following a MC. Models were adjusted for patient demographics, comorbid conditions, mechanism and type of injury, presenting vital signs, injury severity, and multiple facility-level covariates. Risk-adjusted rates were plotted against the proportion of older trauma seen and trends determined. RESULTS: Of the 396,449 older patients at 293 trauma centres that met inclusion criteria, 30,761 (8%) suffered a MC. No difference was found in the risk-adjusted incidence of MC by proportion of older trauma seen. A MC was associated with 34% of all deaths. Of those that suffered a MC, 7413 (24%) died and 76% were successfully rescued. Centres treating higher proportions of older trauma were more successful at rescuing patients after a MC occurred. Patients seen at centres that treat >50% older trauma were 33% (OR=0.67, 95% CI 0.47-0.96) less likely to die following a MC than in centres treating a low proportion (10%) of older trauma. CONCLUSIONS: Centres more experienced at managing geriatric trauma are more successful at rescuing older patients with serious complications. Processes of care at these centres need to be further examined and used to inform appropriate interventions.

Race and socioeconomic disparities in national stoma reversal rates.

BACKGROUND: Many temporary stomas are never reversed leading to significantly worse quality of life. Recent evidence suggests a lower rate of reversal among minority patients. Our study aimed to elucidate disparities in national stoma closure rates by race, medical insurance status, and household income. METHODS: Five years of data from the Nationwide Inpatient Sample (2008 to 2012) was used to identify the annual rates of stoma formation and annual rates of stoma closure. Stomas labeled as "permanent" or those created secondary to colorectal cancers were excluded. Temporary stoma closure rates were calculated, and differences were tested with the chi-square test. Separate analyses were performed by race/ethnicity, insurance status, and household income. Nationally representative estimates were calculated using discharge-level weights. RESULTS: The 5-year average annual rate of temporary stoma creation was 76,551 per year (46% colostomies and 54% ileostomies). The annual rate of stoma reversal was 50,155 per year that equated to an annual reversal rate of 65.5%. Reversal rates were higher among white patients compared with black patients (67% vs 56%, P < .001) and among privately insured patients compared with uninsured patients (88% vs 63%, P < .001). Reversal rates increased as the household income increased from 61% in the lowest income quartile to 72% in the highest quartile (P < .001). CONCLUSIONS: Stark disparities exist in national rates of stoma closure. Stoma closure is associated with race, insurance, and income status. This study highlights the lack of access to surgical health care among patients of minority race and low-income status.

Trauma associated splenic artery aneurysms: an analysis of the National Trauma Data Bank.

BACKGROUND: Trauma associated splenic artery aneurysm (SAA) is potentially life threatening and infrequently studied. We evaluated the subject using a large trauma database. METHODS: The National Trauma Data Bank (2002 to 2006) was queried. All patients aged greater than or equal to 18 years with a primary diagnosis of SAA (International Classification of Diseases: Ninth Revision code 442.83) were identified. Data on demographics, injury severity, pre-existing comorbidities, surgical interventions, complications, and mortality were analyzed. RESULTS: One hundred twenty-four patients were included with a mean age of 40 ± 13 years and 72% were male. Mean Injury Severity Score was 24 ± 12. All patients suffered blunt trauma, and 5% of the patients (n = 6) had systolic blood pressure less than 90 mm Hg on arrival. The most frequent interventions were surgical ligation of aneurysm (45%), bronchoscopy (35%), endovascular procedures (27%), splenectomy (27%), and thoracostomy tube (25%). About 1.7% developed pulmonary collapse. Mean length of stay was 13 days and mortality was 1.6%. CONCLUSIONS: Trauma associated SAA has low mortality and most patients require surgical intervention. Pulmonary dysfunction and invasive pulmonary procedures are frequent despite low rate of chest injuries possibly due to anatomic proximity of lung and spleen.