Initiating advance care planning at admission: a brief intervention to increase goals of care discussions in geriatric trauma patients in an urban level I trauma center.

Objectives: The burden of geriatric trauma continues to rise. Older trauma patients experience higher morbidity and mortality and thus benefit from early goals of care (GOC) discussions and advance care planning (ACP). The American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) recommends holding a family meeting within 72 hours of admission when treating geriatric trauma patients. At our level I trauma center, we sought to increase early GOC discussions by implementing a new history and physical (H&P) note template for geriatric trauma patients. Methods: Patients (aged >65 years) admitted to the trauma surgery service (≥24 hours) were included in the study. The intervention was a change in the H&P note template to include confirmation of code status or previous ACP and identification of a healthcare proxy. Primary outcomes were the rates of recognizing a pre-existing Do-Not-Resuscitate (DNR) status/advanced directives at admission and of documentation of a GOC discussion within 72 hours. Outcomes from a 3-month period (March-May) during the pre-intervention (2021) and post-intervention (2022) periods were compared. Results: The pre-intervention and post-intervention groups had 107 and 150 patients, respectively. We observed an increase in recognition of pre-existing DNR code status at time of admission from 50% to 95% (p=0.003) and documentation of a GOC discussion within 72 hours from 17% to 83% (p<0.0001). We also observed a trend showing that new DNR orders were placed more frequently in the post-intervention period (9% vs 17%, p=0.098). The in-hospital mortality was not significantly different. Conclusions: The importance of GOC discussions and ACP documentation for geriatric trauma patients is evident, but its completion can be challenging. Our intervention of a new H&P note template increased GOC discussions, and this implementation may be feasible in other trauma centers to comply with the ACS-TQIP Geriatric Trauma Management Guidelines. Level of evidence: Level III.

Vacuum-assisted closure instill as a method of sterilizing massive venous stasis wounds prior to split thickness skin graft placement.

Patients with massive venous stasis ulcers that have very high bacterial burdens represent some of the most difficult wounds to manage. The vacuum-assisted closure (VAC) device is known to optimise wound bed preparation; however, these patients have too high a bacterial burden for simple VAC application to facilitate this function. We present the application of the VAC with instillation of dilute Dakins solution as a way of bacterial eradication in these patients. Five patients with venous stasis ulcers greater than 200 cm(2) that were colonised with greater than 10(5) bacteria were treated with the VAC instill for 10 days with 12.5% Dakins solution, instilled for 10 minutes every hour. Two patients had multi-drug-resistant pseudomonas, three with MRSA. All the five had negative quantitative cultures, prior to split thickness skin graft with 100% take and complete healing at 1 year. Adequate delivery of bactericidal agents to the infected tissue can be very difficult, especially while promoting tissue growth. By providing a single delivery system for a bactericidal agent for a short period of time followed by a growth stimulating therapy, the VAC instill provides a unique combination that appears to maximise wound bed preparation.

Teaching Surgery Residents the Skills to Communicate Difficult News to Patient and Family Members: A Literature Review.

BACKGROUND: Trainees and practicing physicians alike find breaking bad, sad, or difficult news to a patient or family member as one of the most challenging communication tasks they perform. Interpersonal and communication skills are a core competency for resident training. However, in disciplines where technical skills have a major emphasis, such as surgery, the teaching of communication skills may not be a priority. OBJECTIVE: The objective of our study is to review literature in order to identify best practices and learning modalities used to teach surgery trainees the communication skills regarding delivery of difficult news to patients and family members. METHODS: The criteria for inclusion in this literature review were that the study (1) addresses surgeons' training (nontechnical skills) in breaking difficult news to patient and/or families, (2) describes a teaching modality or intervention targeted to teach surgery residents how to deliver difficult news to patient/family, and (3) is published in English. RESULTS: Articles (n = 225) were screened for final eligibility. After discarding duplicates and noneligible studies, and after abstract/full-text review, 18 articles were included in the final analysis. Most studies are single site; address general surgery residents at varying training levels; and include case-specific, outpatient, and intensive care unit (ICU) settings. There is a paucity of studies in the trauma and unexpected death setting. There is a recent trend to use Objective Structured Clinical Examination (OSCE) both to teach and assess communication skills. Variable tools are used to assess this competency as described. CONCLUSION: Simulation and OSCE format have emerged as modalities of choice both to teach surgery residents how to deliver difficult news and to assess achievement of this competency. There is a gap in the literature regarding teaching and assessing surgery resident communication skills in delivering difficult news after unexpected events in the trauma and operating room settings.

Care of the family in the surgical intensive care unit.

In the surgical intensive care unit (SICU), the stress of having a critically ill loved one creates significant bereavement and emotional needs for family members. Surgical palliative care has expanded; clinicians do not just treat the patient, but now include the family within the scope of care. Understanding and treating complicated grief, and the emotional and educational needs of the family improves family outcome, improves the surrogate family's ability to act as decision makers, and ultimately may positively affect patient survivor outcome. Care of families in the SICU requires interdisciplinary teams and palliative care processes to appropriately address their needs.

Screening for thoracolumbar spinal injuries in blunt trauma: an Eastern Association for the Surgery of Trauma practice management guideline.

BACKGROUND: Thoracolumbar spine (TLS) injuries have an incidence rate of 5% in blunt trauma patients. The Eastern Association for the Surgery of Trauma published Practice Management Guidelines for the Screening of Thoracolumbar Spine Fracture in 2007. The Practice Management Guidelines Committee was assembled to reevaluate the literature. METHODS: A search of the United States National Library of Medicine and the National Institutes of Health database was performed using MEDLINE through PubMed (www.pubmed.gov). The search retrieved English-language articles from March 2005 to December 2011 that referenced traumatic TLS injuries and fractures. The questions posed were the following: (1) What is the appropriate imaging modality to screen patients for TLS injuries? (2) Which trauma patients require radiographic screening for TLS injuries? (3)Does a patient who is awake and alert without distracting injuries require radiologic workup to rule out TLS injuries? RESULTS: Thirty-seven articles that referenced traumatic TLS injuries in association with screening published between March 2005 and December 2011 were collected and disseminated to the committee. Twelve were found to be relevant. Nine publications from the previous 2006 guidelines were reviewed and referenced to create and validate the updated guidelines. CONCLUSION: Practice patterns have changed regarding screening blunt trauma patients for TLS injuries. Software reformatted multidetector computed tomographic scans are more sensitive and accurate than plain films. Multidetector computed tomographic scans have become the screening modality of choice and the criterion standard in screening for TLS injuries. The literature supports a Level 1 recommendation to validate this based on a preponderance of Class II data. Patients without altered mentation or significant mechanism may be excluded by clinical examination without imaging. Patients with gross neurologic deficits or concerning clinical examination findings with negative imaging should receive a magnetic resonance imaging expediently, and the spine service should be consulted.

Care of the family in the surgical intensive care unit.

In the surgical intensive care unit (SICU), the stress of having a critically ill loved one creates significant bereavement and emotional needs for family members. Surgical palliative care has expanded; clinicians do not just treat the patient, but now include the family within the scope of care. Understanding and treating complicated grief, and the emotional and educational needs of the family improves family outcome, improves the surrogate family's ability to act as decision makers, and ultimately may positively affect patient survivor outcome. Care of families in the SICU requires interdisciplinary teams and palliative care processes to appropriately address their needs.

Pulse wave imaging of normal and aneurysmal abdominal aortas in vivo.

The abdominal aortic aneurysm (AAA) is a common vascular disease. The current clinical criterion for treating AAAs is an increased diameter above a critical value. However, the maximum diameter does not correlate well with aortic rupture, the main cause of death from AAA disease. AAA disease leads to changes in the aortic wall mechanical properties. The pulse-wave velocity (PWV) may indicate such a change. Because of limitations in temporal and spatial resolution, the widely used foot-to-foot method measures the global, instead of regional, PWV between two points at a certain distance in the circulation. However, mechanical properties are nonuniform along the normal and pathological (e.g., the AAA and atherosclerosis) arteries; thus, such changes are typically regional. Pulse-wave imaging (PWI) has been developed by our group to map the pulse-wave propagation along the abdominal aorta in mice in vivo. By using a retrospective electrocardiogram (ECG) gating technique, the radio-frequency (RF) signals over one cardiac cycle were obtained in murine aortas at the extremely high frame rate of 8 kHz and with a field-of-view (FOV) of 12 x 12 mm(2). The velocities of the aortic wall were estimated using an RF-based speckle tracking method. An Angiotensin II (AngII) infusion-based AAA model was used to simulate the human AAA case. Sequences of wall velocity images can noninvasively and quantitatively map the propagation of the pulse wave along the aortic wall. In the normal and sham aortas, the propagation of the pulse wave was relatively uniform along the wall, while in the AngII-treated aortas, the propagation was shown to be nonuniform. There was no significant difference ( p > 0.05) in the PWV between sham (4.67 +/- 1.15 m/s, n=5) and AngII-treated (4.34 +/- 1.48 m/s, n=17) aortas. The correlation coefficient of the linear regression was significantly higher ( p < 0.005) in the sham aortas (0.89 +/- 0.03, n=5 ) than in the AngII-treated ones (0.61 +/- 0.15, n=17). The wall velocities induced by the pulse wave were lower and the pulse wave moved nonuniformly along the AngII-treated aorta ( p < 0.005), with the lowest velocities at the aneurysmal regions. The discrepancy in the regional wall velocity and the nonuniform pulse-wave propagation along the AngII-treated aorta indicated the inhomogeneities in the aortic wall properties, and the reduced wall velocities indicated stiffening of the aneurysmal wall. This novel technique may thus constitute an early detection tool of vascular degeneration as well as serve as a suitable predictor of AAA rupture, complementary to the current clinical screening practice.

Resection-plication-release for hypertrophic cardiomyopathy: clinical and echocardiographic follow-up.

BACKGROUND: Abnormal positioning and size of the mitral valve contribute to the systolic anterior motion and mitral-septal contact that are important components of obstructive hypertrophic cardiomyopathy (HCM). The RPR repair (resection of the septum, plication of the anterior leaflet, and release of papillary muscle attachments) addresses all aspects of this complex pathology. This study reports outcomes regarding effectiveness of the RPR repair. METHODS: Fifty consecutive unselected patients (average age, 55.8 years) undergoing RPR repair for obstructive HCM from 1997 to 2007 were studied. Each patient underwent preoperative and postoperative transthoracic echocardiograms to document gradient, ejection fraction, degree of mitral regurgitation, and systolic anterior motion. Intraoperative transesophageal echocardiogram was used to guide all surgical repairs. Clinical follow-up included patient interviews to determine New York Heart Association (NYHA) status. RESULTS: Concomitant operations were performed in 25 patients (50%). Postoperative mortality was 0%. Average mean left ventricular outflow tract gradients decreased from 134 +/- 40 to 2.8 +/- 8.0. Mitral regurgitation improved from a mean of 2.5 to 0.1 (p < 0.001). Average length of stay was 6.9 +/- 2.7 days. NYHA class improved from 3.0 +/- 0.6 to 1.2 +/- 0.5. Follow-up was 100%, with a mean of 2.5 +/- 1.8 years. Average mitral regurgitation at follow-up was 0.9, with no residual systolic anterior motion. CONCLUSIONS: The RPR repair is safe and effective for symptomatic obstructive HCM. Our data support repair of the mitral valve that results in good intermediate outcomes with respect to gradient, mitral regurgitation, and clinical status.