High rates of respiratory illnesses upon arrival: lessons from Team USA at the Santiago 2023 Pan American and Parapan American Games.

OBJECTIVE: To describe the incidence and characteristics of injuries and illnesses among Team USA athletes competing at the Santiago 2023 Pan American Games (PAG) and Parapan American Games (PPAG), with a particular focus on the incidence of respiratory illnesses and on injuries for sports new to the Olympic and Paralympic programmes. METHODS: Illnesses and injuries occurring among the 870 Team USA athletes competing in the Santiago 2023 PAG or PPAG were documented within Team USA's Injury and Illness Surveillance system. Illness and injury incidence per 1000 athlete-days (ADs) and incidence ratios (IR) were calculated, both with 95% CIs. RESULTS: Illness (IR 2.5, 95% CI 1.6, 3.9) and injury (IR 1.8, 95% CI 1.3, 2.5) rates were greater during PPAG compared with PAG. Illness rates were higher in the pre-opening ceremony period compared with the competition period for both PAG (IR 2.7, 95% CI 1.1, 5.9) and PPAG (IR 1.9, 95% CI 0.9, 3.8). Respiratory illness was the most common illness with 3.2% and 8.9% of all Team USA athletes reporting a respiratory illness during the PAG and PPAG, respectively. Sports that are relatively new to the Olympic/Paralympic programmes exhibited the highest injury rates during the Games: breaking (250.0 (91.7, 544.2) per 1000 ADs), Para taekwondo (93.8 (19.3, 274.0) per 1000 ADs) and surfing (88.9 (24.2, 227.6) per 1000 ADs). CONCLUSION: Respiratory illness rates were the most common type of illness during both PAG and PPAG and were more likely to occur prior to competition starting. Our data have identified high injury risk populations (breaking, surfing, Para taekwondo) and timing (pre-opening ceremony period) for further risk factor analysis.

Major Barbara Stimson: A Historical Perspective on the American Board of Surgery Through the Accomplishments of the First Woman to Achieve Board Certification.

: Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898-1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimson's motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.

Respiratory depression in the intoxicated trauma patient: are opioids to blame?

Providing effective pain management to acutely intoxicated trauma patients represents a challenge of balancing appropriate pain management with the risk of potential respiratory depression from opioid administration. The objective of this study was to quantify the incidence of respiratory depression in trauma patients acutely intoxicated with ethanol who received opioids as compared with those who did not and identify potential risk factors for respiratory depression in this population. Retrospective medical record review was conducted for subjects identified via the trauma registry who were admitted as a trauma activation and had a detectable serum ethanol level upon admission. Risk factors and characteristics compared included demographics, Injury Severity Score, Glasgow Coma Score, serum ethanol level upon arrival, urine drug screen results, incidence of respiratory depression, and opioid and other sedative medication use. A total of 233 patients were included (78.5% male). Patients who received opioids were more likely to have a higher Injury Severity Score and initial pain score on admission as compared with those who did not receive opioids. Blood ethanol content was higher in patients who did not receive opioids (0.205 vs 0.237 mg/dL, P = .015). Patients who did not receive opioids were more likely to be intubated within 4 hours of admission (1.7% vs 12.1%, P = .02). Opioid administration was not associated with increased risk of respiratory depression (19.7% vs 22.4%, P = .606). Increased cumulative fentanyl dose was associated with increased risk of respiratory depression. Increased cumulative fentanyl dose, but not opioid administration alone, was found to be a risk factor for respiratory depression.

A multidisciplinary initiative to standardize intensive care to acute care transitions.

QUALITY ISSUE: Transfers from intensive care units to acute care units represent a complex care transition for hospitalized patients. Within our institution, variation in transfer practices resulted in unpredictable processes in which patient safety concerns were raised. INITIAL ASSESSMENT: Key stakeholders were engaged across the institution. Patient safety ('incident') reports and a staff survey identified safety concerns. CHOICE OF A SOLUTION: Using lean methodology, current transfer processes were mapped for the four adult intensive care units and waste was identified. During a summit of key stakeholders an ideal transfer process was conceived and a structured handoff tool (checklist) was developed. A daily management system (DMS) was implemented to monitor adherence. EVALUATION: The primary process outcome was adherence to the standardized workflow. Audits at 4, 8, and 12 months after implementation indicated that the checklist was used for 100% of transfers. Secondary outcomes included the percentage of transfers completed within a pre-specified time window of 120 minutes, provider notification of patient arrival on the acute care unit, and staff survey responses assessing adequacy of transfer communication. LESSONS LEARNED: Prior work has shown that structuring handoffs can improve patient safety, but the novelty of this project was addressing the transfer process in its entirety, across silos of care. Factors leading to the success of this project were the involvement of key stakeholders across the entire institution early in the project development phase, employment of lean methodology, and implementation of tools to guide workflow adherence and track causes of deviation from the workflow.

A systematic approach to basic chest radiograph interpretation: a cardiovascular focus.

In this column, I will provide a general overview to the indications and basic chest radiograph features such as density, views and technical quality. A systematic approach to radiographic interpretation is outlined. This proposed approach follows anatomical structures organized in alphabetical order (airway, bone, cardiac, diaphragm, extras and frame), while considering a range of pathophysiological findings. Common cardiovascular findings reviewed include atelectasis, pneumothorax, pleural effusions, congestive heart failure, pulmonary edema, consolidation and pneumonia. While chest radiography is an important diagnostic tool for monitoring patients, correlation to the patient's clinical assessment is always required.

Advanced hemostatic dressings are not superior to gauze for care under fire scenarios.

BACKGROUND: Advanced hemostatic dressings perform superior to standard gauze (SG) in animal hemorrhage models but require 2 minutes to 5 minutes application time, which is not feasible on the battlefield. METHODS: Twenty-four swine received a femoral artery injury, 30 seconds uncontrolled hemorrhage and randomization to packing with SG, Combat Gauze (CG), or Celox Gauze (XG) without external pressure. Animals were resuscitated to baseline mean arterial pressures with lactated Ringers and monitored for 120 minutes. Physiologic and coagulation parameters were collected throughout. Dressing failure was defined as overt bleeding outside the wound cavity. Tissues were collected for histologic and ultrastructural studies. RESULTS: All animals survived to study end. There were no differences in baseline physiologic or coagulation parameters or in dressing success rate (SG: 8/8, CG: 4/8, XG: 6/8) or blood loss between groups (SG: 260 mL, CG: 374 mL, XG: 204 mL; p > 0.3). SG (40 seconds ± 0.9 seconds) packed significantly faster than either the CG (52 ± 2.0) or XG (59 ± 1.9). At 120 minutes, all groups had a significantly shorter time to clot formation compared with baseline (p < 0.01). At 30 minutes, the XG animals had shorter time to clot compared with SG and CG animals (p < 0.05). All histology sections had mild intimal and medial edema. No inflammation, necrosis, or deposition of dressing particles in vessel walls was observed. No histologic or ultrastructural differences were found between the study dressings. CONCLUSIONS: Advanced hemostatic dressings do not perform better than conventional gauze in an injury and application model similar to a care under fire scenario.

Lyophilized plasma reconstituted with ascorbic acid suppresses inflammation and oxidative DNA damage.

BACKGROUND: Lyophilized plasma (LP) has been shown to be as effective as fresh frozen plasma (FFP) for resuscitation in polytrauma and hemorrhagic shock. LP reconstituted with ascorbic acid is associated with suppression of cytokines when compared with fresh frozen plasma. We aimed to determine the effect of using alternate LP reconstitution acids on physiologic parameters, blood loss, coagulation, oxidative DNA damage, and proinflammatory cytokines in a polytrauma and hemorrhagic shock model. METHODS: Thirty swine were anesthetized, subjected to polytrauma, hemorrhagic shock, and randomized to resuscitation with LP-ascorbic acid (AA), LP-citric acid (CA), or LP-hydrochloric acid (HCL). Physiologic data were continuously monitored, blood loss measured, and serum collected at baseline, 2 hours, and 4 hours for enzyme-linked immunosorbent assays. Measured 8-OH-2'-deoxyguanosine (8-OHdG) was a biomarker of oxidative DNA damage. RESULTS: No differences were observed in physiologic measures, blood loss, or coagulation parameters. Interleukin-6 increased over time for all groups, but at 2 hours, the concentration in AA (median [minimum, maximum]: 113 ng/mL [0, 244]) was lower compared with CA (181 ng/mL [69, 314], p = 0.01) and HCL (192 ng/mL [41, 310], p = 0.03). Comparing 4 hours to baseline, a significant increase in oxidative DNA damage was observed in CA (22.9 ng/mL [16.3, 34.3] vs. 15.6 ng/mL [13.6, 26.7], p = 0.03) and HCL (19.6 ng/mL [15.7, 56.7] vs. 15.8 ng/mL [11.6, 21.4], p = 0.01) but not in AA (17.9 ng/mL [12.6, 26.9] vs. 17.1 ng/mL [11.8, 18.4], p = 0.24). CONCLUSIONS: Resuscitation with AA results in decreased interleukin-6 expression and oxidative DNA damage compared with CA and HCL.

Lyophilized plasma with ascorbic acid decreases inflammation in hemorrhagic shock.

BACKGROUND: Delivery of a high ratio of plasma to packed red blood cells to patients who require massive transfusion is associated with improved survival. Hemorrhagic shock causes increased production of pro-inflammatory cytokines. These are associated with late morbidity and mortality. The use of fresh frozen plasma makes high ratio resuscitation logistically difficult and does not address dysfunctional inflammation. Lyophilized plasma (LP) is a stable powdered form of plasma that is both safe and easily reconstituted. Previous work demonstrated that LP reconstituted with ascorbic acid (AA) decreased inflammation. Whether the reduction of inflammation was associated with LP or the AA is unknown. METHODS: Thirty female swine were anesthetized and subjected to a multisystem combat relevant model consisting of femur fracture, controlled hemorrhage, and hypothermia. A standardized grade V liver injury was made and the animals were randomly assigned to receive LP reconstituted with AA, citric acid (CA), or hydrochloric acid (HCl). Blood was drawn at baseline and at 2 hours and 4 hours for interleukin (IL)-6, IL-8, and tumor necrosis factor-α serum concentrations measured by enzyme-linked immunosorbent assay. Lung tissue was harvested and processed for gene expression before euthanizing the animals. RESULTS: No differences were observed in mortality, baseline cytokine serum concentration, or gene expression. Enzyme-linked immunosorbent assay demonstrated that IL-6 concentration increased over time for all groups (p < 0.05), but less so at 2 hours in the AA group compared with CA and HCl. CONCLUSION: In this animal model of trauma, hemorrhage and resuscitation, AA decreases IL-6 expression relative to CA and HCl. These findings confirm previous work from our laboratory and suggest that AA is responsible for suppression of dysfunctional inflammation in this model.

A Multicenter Evaluation of a Firearm Safety Intervention in the Pediatric Outpatient Setting.

PURPOSE: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting. METHODS: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety. RESULTS: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home. CONCLUSION: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home. LEVEL OF EVIDENCE: Level III.

Resuscitation of haemorrhagic shock with normal saline vs. lactated Ringer's: effects on oxygenation, extravascular lung water and haemodynamics.

INTRODUCTION: Pulmonary oedema and impairment of oxygenation are reported as common consequences of haemorrhagic shock and resuscitation (HSR). Surprisingly, there is little information in the literature examining differences in crystalloid type during the early phase of HSR regarding the development of pulmonary oedema, the impact on oxygenation and the haemodynamic response. These experiments were designed to determine if differences exist because of crystalloid fluid type in the development of oedema, the impact on oxygenation and the haemodynamic response to fluid administration in early HSR. METHODS: Twenty anaesthetised swine underwent a grade V liver injury and bled without resuscitation for 30 minutes. The animals were randomised to receive, in a blinded fashion, either normal saline (NS; n = 10) or lactated Ringer's solution (LR; n = 10). They were then resuscitated with study fluid to, and maintained at, the preinjury mean arterial pressure (MAP) for 90 minutes. RESULTS: Extravascular lung water index (EVLWI) began to increase immediately with resuscitation with both fluid types, increasing earlier and to a greater degree with NS. A 1 ml/kg increase in EVLWI from baseline occurred after administartion of (mean +/- standard error of the mean) 68.6 +/- 5.2 ml/kg of normal saline and 81.3 +/- 8.7 ml/kg of LR (P = 0.027). After 150 ml/kg of fluid, EVLWI increased from 9.5 +/- 0.3 ml/kg to 11.4 +/- 0.3 ml/kg NS and from 9.3 +/- 0.2 ml/kg to 10.8 +/- 0.3 ml/kg LR (P = 0.035). Despite this, oxygenation was not significantly impacted (Delta partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2)

Thrombelastography versus AntiFactor Xa levels in the assessment of prophylactic-dose enoxaparin in critically ill patients.

BACKGROUND: A standard dose of enoxaparin is frequently used for deep venous thrombosis (DVT) prophylaxis. Evidence suggests inconsistent bioavailability in intensive care unit (ICU) patients. Antifactor Xa activity (anti-Xa) has been used to monitor enoxaparin dosing but its accuracy and availability are problematic. Thrombelastography (TEG) is used to evaluate coagulation in diverse settings. The purpose of this study was to analyze whether TEG could be used to predict which enoxaparin-treated patients would develop DVT. METHODS: Two hundred sixty-one simultaneous enoxaparin-active (active) and enoxaparin-neutralized (neutral) TEGs were performed in 61 surgical ICU patients over four consecutive days. Patient characteristics and anti-Xa were collected. DVT screening was per ICU protocol. RESULTS: Mean (+/-SEM) age was 54 (+/-2.3) years and Acute Physiology and Chronic Health Evaluation II score was 17 (+/-0.7). There were 30 trauma and 31 general surgery patients (69% men). The DVT rate was 28%. Time to clot formation (R) and percent lysis at 30 minutes were different between active versus neutralized blood (p < 0.001). R time was 1.5 minutes shorter in patients with DVT versus those without (p < 0.001) indicating hypercoagulability in DVT patients. Anti-Xa levels were similar in patients with (0.135 +/- 0.012) and without (0.135 +/- 0.007) DVT (p = 0.97). There were no differences in age, body mass index, injury severity score, Acute Physiology and Chronic Health Evaluation II score, or trauma status between DVT and non-DVT groups. CONCLUSIONS: TEG demonstrates differences between enoxaparin-neutralized and enoxaparin-active blood in ICU patients that may be used to guide dosing. TEG differentiates enoxaparin-treated patients who subsequently develop DVT while anti-Xa levels do not. TEG demonstrates an enoxaparin-related increase in fibrinolysis.

Splenectomy is associated with higher infection and pneumonia rates among trauma laparotomy patients.

Splenectomy increases lifetime risk of thromboembolism (VTE) and is associated with long-term infectious complications, primarily, overwhelming post-splenectomy infection (OPSI). Our objective was to evaluate risk of VTE and infection at index hospitalization post-splenectomy. Retrospective review of all patients who received a laparotomy in the NTDB. Propensity score matching for splenectomy was performed, based on ISS, abdominal abbreviated injury score >3, GCS, sex and mechanism. Major complications, VTE, and infection rates were compared. Multiple logistic regression models were utilized to evaluate splenectomy-associated complications. 93,221 laparotomies were performed and 17% underwent splenectomy. Multiple logistic regression models did not demonstrate an association between splenectomy and major complications (OR 0.96, 95% CI 0.91-1.03, p = 0.25) or VTE (OR 1.05, 95% CI 0.96-1.14, p = 0.33). Splenectomy was independently associated with infection (OR 1.07, 95% CI 1.00-1.14, p = 0.045). Subgroup analysis of patients with infection demonstrated that splenectomy was most strongly associated with pneumonia (OR 1.41, 95% CI 1.26-1.57, p < 0.001). Splenectomy is not associated with higher overall complication or VTE rates during index hospitalization. However, splenectomy is associated with a higher rate of pneumonia.

Optimizing physician skill development for medical students: The four-part assessment.

BACKGROUND: Medical student performance has been poorly correlated with residency performance and warrants further investigation. We propose a novel surgical assessment tool to determine correlations with clinical aptitude. METHODS: Retrospective review of medical student assessments from 2013 to 2015. Faculty rating of student performance was evaluated by: 1) case presentation, 2) problem definition, 3) question response and 4) use of literature and correlated to final exam assessment. A Likert scale interrater reliability was evaluated. RESULTS: Sixty student presentations were scored (4.8 assessors/presentation). A student's case presentation, problem definition, and question response was correlated with performance (r = 0.49 to 0.61, p ≤ 0.003). Moderate correlations for either question response or use of literature was demonstrated (0.3 and 0.26, p < 0.05). CONCLUSION: Our four-part assessment tool identified correlations with course and examination grades for medical students. As surgical education evolves, validated performance and reliable testing measures are required.

A Clinical Tool for the Prediction of Venous Thromboembolism in Pediatric Trauma Patients.

IMPORTANCE: Although rare, the incidence of venous thromboembolism (VTE) in pediatric trauma patients is increasing, and the consequences of VTE in children are significant. Studies have demonstrated increasing VTE risk in older pediatric trauma patients and improved VTE rates with institutional interventions. While national evidence-based guidelines for VTE screening and prevention are in place for adults, none exist for pediatric patients, to our knowledge. OBJECTIVES: To develop a risk prediction calculator for VTE in children admitted to the hospital after traumatic injury to assist efforts in developing screening and prophylaxis guidelines for this population. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of 536,423 pediatric patients 0 to 17 years old using the National Trauma Data Bank from January 1, 2007, to December 31, 2012. Five mixed-effects logistic regression models of varying complexity were fit on a training data set. Model validity was determined by comparison of the area under the receiver operating characteristic curve (AUROC) for the training and validation data sets from the original model fit. A clinical tool to predict the risk of VTE based on individual patient clinical characteristics was developed from the optimal model. MAIN OUTCOME AND MEASURE: Diagnosis of VTE during hospital admission. RESULTS: Venous thromboembolism was diagnosed in 1141 of 536,423 children (overall rate, 0.2%). The AUROCs in the training data set were high (range, 0.873-0.946) for each model, with minimal AUROC attenuation in the validation data set. A prediction tool was developed from a model that achieved a balance of high performance (AUROCs, 0.945 and 0.932 in the training and validation data sets, respectively; P = .048) and parsimony. Points are assigned to each variable considered (Glasgow Coma Scale score, age, sex, intensive care unit admission, intubation, transfusion of blood products, central venous catheter placement, presence of pelvic or lower extremity fractures, and major surgery), and the points total is converted to a VTE risk score. The predicted risk of VTE ranged from 0.0% to 14.4%. CONCLUSIONS AND RELEVANCE: We developed a simple clinical tool to predict the risk of developing VTE in pediatric trauma patients. It is based on a model created using a large national database and was internally validated. The clinical tool requires external validation but provides an initial step toward the development of the specific VTE protocols for pediatric trauma patients.

The Impact of Pre-Hospital Administration of Lactated Ringer's Solution versus Normal Saline in Patients with Traumatic Brain Injury.

Lactated Ringer's (LR) and normal saline (NS) are both used for resuscitation of injured patients. NS has been associated with increased resuscitation volume, blood loss, acidosis, and coagulopathy compared with LR. We sought to determine if pre-hospital LR is associated with improved outcome compared with NS in patients with and without traumatic brain injury (TBI). We included patients receiving pre-hospital LR or NS from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study. Patients with TBI (Abbreviated Injury Scale [AIS] head ≥3) and without TBI (AIS head ≤2) were compared. Cox proportional hazards models including Injury Severity Score (ISS), AIS head, AIS extremity, age, fluids, intubation status, and hospital site were generated for prediction of mortality. Linear regression models were generated for prediction of red blood cell (RBC) and crystalloid requirement, and admission biochemical/physiological parameters. Seven hundred ninety-one patients received either LR (n = 117) or NS (n = 674). Median ISS, AIS head, AIS extremity, and pre-hospital fluid volume were higher in TBI and non-TBI patients receiving LR compared with NS (p < 0.01). In patients with TBI (n = 308), LR was associated with higher adjusted mortality compared with NS (hazard rate [HR] = 1.78, confidence interval [CI] 1.04-3.04, p = 0.035). In patients without TBI (n = 483), no difference in mortality was demonstrated (HR = 1.49, CI 0.757-2.95, p = 0.247). Fluid type had no effect on admission biochemical or physiological parameters, 6-hour RBC, or crystalloid requirement in either group. LR was associated with increased mortality compared with NS in patients with TBI. These results underscore the need for a prospective randomized trial comparing pre-hospital LR with NS in patients with TBI.

Performance improvement and patient safety program-guided quality improvement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients.

BACKGROUND: Morbidity and mortality of cervical spine (C-spine) injury in pediatric trauma patients are high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination, and alternate imaging techniques. We implemented an institutional performance improvement and patient safety (PIPS) program initiative for C-spine clearance in 2010 because of high rates of CT scans among pediatric trauma patients. METHODS: A retrospective review of pediatric trauma patients, aged 0 years to 14 years, in the pre- and post-PIPS implementation periods was conducted. Rates of C-spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics, and injury severity were compared, and compliance with PIPS protocol was reviewed. RESULTS: Patient characteristics and injury severity were similar before and after PIPS implementation. C-spine CT rates decreased significantly between groups (30% vs. 13%, p < 0.001), whereas C-spine plain x-ray rates increased significantly (7% vs. 25%, p < 0.001). There was no difference in C-spine magnetic resonance imaging between groups (12% vs. 10%, p = 0.11). In 2007, 71% of patients received a CT scan for any reason. However, the overall CT rate decreased significantly between groups (60% vs. 45%, p < 0.001). There was an estimated 22% decrease in lifetime attributable risk (LAR) for any cancer due to ionizing imaging exposure in males and 38% decrease in females between the pre- and post-PIPS groups. There was a 54% decrease in LAR for thyroid cancer in males and females between groups; 2014 compliance with the protocol was excellent (82-90% per quarter). CONCLUSIONS: Performance improvement and patient safety program-generated protocol can significantly decrease ionizing radiation exposure. We demonstrate that a simple protocol focused on C-spine imaging has high compliance, decreased C-spine CT scans, and decreased LAR for thyroid cancer. A secondary benefit is a reduction in total CT imaging, with an associated decrease in LAR for all cancers. LEVEL OF EVIDENCE: Therapeutic study, level IV; diagnostic study, level III.

Traumatic diaphragmatic injury in the American College of Surgeons National Trauma Data Bank: a new examination of a rare diagnosis.

BACKGROUND: Traumatic diaphragmatic injury (TDI) is a rarely diagnosed injury in trauma. Previous studies have been limited in their evaluation of TDI because of small population size and center bias. Although injuries may be suspected based on penetrating mechanism, blunt injuries may be particularly difficult to detect. The American College of Surgeons National Trauma Data Bank is the largest trauma database in the United States. We hypothesized that we could identify specific injury patterns associated with blunt and penetrating TDIs. METHODS: We examined demographics, diagnoses, mechanism of injury, and outcomes for patients with TDI in 2012 as this is the largest and most recent dataset available. Comparisons were made using chi-square or independent samples t test. RESULTS: There were a total of 833,309 encounters in the National Trauma Data Bank in 2012. Three thousand eight hundred seventy-three patients had a TDI (.46%). Of those, 1,240 (33%) patients had a blunt mechanism and 2,543 (67%) had a penetrating mechanism. Patients with blunt TDI were older (44 ± 19 vs 31 ± 13 years, P < .001), had a higher injury severity score (33 ± 14 vs 24 ± 15, P < .001), and a higher mortality rate (19.8% vs 8.8%, P < .001). Compared with patients with penetrating injuries, those with blunt TDI were more likely to have injuries to the thoracic aorta (2.9% vs .5%, P < .001), lung (48.7% vs 28.1, P < .001), bladder (5.9% vs .7%, P < .001), and spleen (44.8% vs 29.1%, P < .001). Penetrating TDI was associated with liver and hollow viscus injuries. CONCLUSIONS: Diaphragmatic injury is an uncommon but significant diagnosis in trauma patients. Blunt injuries may be more likely to be occult; however, a pattern of associated injuries to the aorta, lung, spleen, and bladder should prompt further workup for TDI.

A flexible postoperative debriefing process can effectively provide formative resident feedback.

BACKGROUND: Providing residents with formative operative feedback is one of the ongoing challenges in modern surgical education. This is highlighted by the recent American Board of Surgery requirement for formal operative assessments. A flexible and adaptable procedure feedback process may allow attending surgeons to provide qualitative and quantitative feedback to residents while encouraging surgeons-in-training to critically reflect on their own performance. STUDY DESIGN: We designed and implemented a flexible feedback process in which residents initiated a postoperative feedback discussion and completed a Procedure Feedback Form (PFF) with their supervising attending surgeon. Comparisons were made between the quantitative and qualitative assessments of attending and resident surgeons. Free text statements describing strengths and weaknesses were analyzed using grounded theory with constant comparison. RESULTS: We identified 346 assessments of 48 surgery residents performing 38 different cases. There was good inter-rater reliability between resident and attending surgeons' quantitative assessment, Goodman and Kruskal gamma > 0.65. Key themes identified on qualitative analysis included flow, technique, synthesis/decision, outcomes, knowledge, and communication/attitudes. Subthematic analysis demonstrated that our novel debriefing procedure was easily adaptable to a wide variety of clinical settings and grew more individualized for senior learners. CONCLUSIONS: This procedure feedback process is easily adaptable to a wide variety of cases and supports resident self-reflection. The process grows in nuance and complexity with the learner and may serve as a guide for a flexible and widely applicable postoperative feedback process.