Cost-benefit analysis of outcomes from the use of fibrin sealant for fixation of skin grafts in small-size burns compared to staples as historical controls: a retrospective review.

INTRODUCTION: Historically, split-thickness skin grafts have been fixed onto the recipient site by suture and/or staples. Fibrin sealants have become available for the fixation in the past 10 years. Fibrin sealants have been shown to be at least as effective as staples, and recent reports show them to cause less pain. However, the product is much more expensive than traditional suture and/or staple fixation. The cost-benefit ratio of sealant has not yet been proven. METHODS: A review of charts for 202 consecutive patients was undertaken for patients with burns that were less than 10% total body surface area (TBSA) that underwent excision and grafting using fibrin sealant at the regional burn center. A historical control comprising 48 consecutive patients with burns that were less than 10% TBSA that underwent excision and grafting using staples as the only means of fixation was used for comparison. Demographics (such as age, weight, and sex), personal history of tobacco use, previous diagnosis of diabetes, type and depth of burn, TBSA, area of grafting, graft and donor locations, mesh type, rate of hematomas, rate of graft loss, rate of complete closure at 1 month, and time to discharge after surgery were recorded for each patient in both cohorts. The data were compared and statistical analysis performed for graft loss complications and number of days until the patient could be discharged home with outpatient wound care. RESULTS: Use of fibrin sealants has resulted in statistically significant lower rates of loss of graft at our institution. Additionally, a decrease in the number of days until discharge to outpatient wound care of nearly 2 days produced a lower cost of care in patients with less than 10% TBSA undergoing excision and grafting. CONCLUSIONS: The use of fibrin sealants allows for fewer graft loss complications and earlier discharge in patients who have burns that are less than 10% TBSA. This decrease in hospital days results in savings, although this difference is not statistically significant.

Department of Surgery/College of Medicine University of South Alabama: historical and contemporaneous perspectives.

Many members of the medical profession in Mobile, Alabama, have exemplified a strong commitment to the education of their colleagues and successors, a tradition (L., traditio, "to hand over") that dates from the early 18th century. The Mobile General (city/county) Hospital (1830 to 1970) and its successor, the Medical Center, University of South Alabama (1971 to the present), were the institutional foci of those endeavors. Because it is individuals who create, design, and vitalize institutions, this monograph is an acknowledgment of the accomplishments of those who gave that endeavor purpose, direction, and meaning, particularly with reference to the evolution of surgical education. Numerous clinical and societal forces--cultural, economic, political, and social-influenced that evolution. This compilation gives attribution to a legacy of commitment to health and medical/surgical care, education, and research within southern Alabama.

Application of the core competencies after unexpected patient death: consolation of the grieved.

OBJECTIVES: To review and assess educational strategies and formats regarding communication with families/survivors in the aftermath of unexpected and untimely patient death. To propose an integrated curriculum designed and intended to foster proficiency, competence, confidence, and composure in relaying catastrophic information in the context of the professional experience of a cohort of seasoned surgeons. BACKGROUND: Unexpected and untimely patient death is emotionally and psychologically wrenching for families, surgeons, and healthcare providers. We have previously proffered that 2 distinct, but interactive, phases of response are relevant when communicating with a family before and after the event: a proactive phase intended to establish a positive therapeutic relationship with the family; and a reactive phase intended to respond to the family in a compassionate and respectful manner and to ensure self-care for the physicians and health care providers. STUDY DESIGN: Survey of a cohort of senior surgeons (membership of the Southern Surgical Association) and Surgical Residency Program Directors (membership of the Association of Program Directors in Surgery). RESULTS: Sixty percent of the senior surgeons surveyed had experienced unexpected patient death. They advised strategies to cope with that clinical situation commensurate with the core competencies of the Accreditation Council for Graduate Medical Education: Medical Knowledge: maximize objective information/data and minimize subjective opinion; Patient Care: critique the events and conduct postmortem analyses; Interpersonal and Communication Skills: honesty, empathy, and patience; Professionalism: provide emotional and psychological support to family and personnel with privacy and in a nonaccusatory manner; Practice-Based Learning and Improvement: preoperative discussion and documentation in the context of informed consent and advanced directives vis-á-vis risk-benefit, effort-yield, and benefit-burden analyses; and Systems-Based Practice: involve chaplains and hospital personnel. Thirty-six percent of the graduate surgical educational programs surveyed allegedly provided educational venues to enable surgical residents to cope with unexpected patient death, although the formats were not specified. CONCLUSIONS: Graduate, postgraduate, and continuing educational programs aspire to prepare physicians and surgeons for independent professional practice-scientifically, humanistically, and artistically. Incorporating educational strategies to enable graduates to cope with the emotional and psychological turmoil of unexpected patient death is relevant.

Spirituality within the patient-surgeon relationship.

OBJECTIVE: To assess the attitudes of general and orthopaedic surgical outpatients regarding inquiry into their religious beliefs, spiritual practices, and personal faith. DESIGN: Prospective, voluntary, self-administered, and anonymously-completed questionnaire, regarding religious beliefs, spiritual practices, and personal faith, March-August, 2009. SETTING: General and orthopaedic surgical outpatient settings, Health Services Foundation, College of Medicine, University of South Alabama, a tertiary care academic medical center in Mobile, Alabama. PARTICIPANTS: All patients referred for evaluation and management of general and orthopaedic surgical conditions, pre- and postoperatively, were approached. METHODOLOGY: The questionnaire solicited data regarding patient: (1) demographics; (2) religious beliefs, spiritual practices, and personal faith; and (3) opinions regarding inquiry into those subjects by their surgeon. The latter opinions were stratified on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Statistical analysis was conducted using software JMP(®) 8 Statistical Discovery Software (S.A.S. Institute Inc., Cary, North Carolina) and a 5% probability level was used to determine significance of results. RESULTS: Eighty-three percent (83%) of respondents agreed or strongly agreed that surgeons should be aware of their patients' religiosity and spirituality; 63% concurred that surgeons should take a spiritual history; and 64% indicated that their trust in their surgeon would increase if they did so. Nevertheless, 17%, 37%, and 36% disagreed or strongly disagreed with those perspectives, respectively. CONCLUSIONS: By inference to the best explanation of the results, we would argue that religiosity and spirituality are inherent perspectives of patient-surgeon relationships. Consequently, those perspectives are germane to the therapeutic milieu. Therefore, discerning each patient's perspective in those regards is warranted in the context of an integrative and holistic patient-surgeon relationship, the intent of which is to restore a patient to health and well-being.

Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.

Conveying to family members that their loved one has unexpectedly died during an operation is perhaps the most stressful task a surgeon must perform. The loss of a patient's life precipitates enormous personal and professional anxiety and stress on a surgeon: profound grief, damage to self-esteem, loss of self-confidence and reputation, and the specter of litigation. Most surgeons feel unskilled in such a setting, yet how they communicate-what they say and how they say it-is extremely important for everyone involved. Two distinct, but interactive, phases of response are relevant when communicating with a family before and after an unexpected death of their loved one: a proactive phase ("CARE") intended to establish a positive therapeutic relationship, and a reactive phase ("SHARE") intended to respond to the crisis in a compassionate and respectful manner and to ensure self-care for the physician.

Screening for abdominal injury prior to emergent extra-abdominal trauma surgery: a prospective study.

OBJECTIVE: To prospectively evaluate the necessity of abdominal screening with computed tomography (CT) in awake and alert blunt trauma patients that require emergent extra-abdominal trauma surgery. METHODS: All blunt trauma patients admitted to a Level I trauma center that required emergent extra-abdominal trauma surgery were entered in a prospective study during the period from April 2001 to June 2003. Awake and alert blunt trauma patients (Glasgow Coma Scale [GCS] score > or =14) with a normal abdominal physical examination requiring extra-abdominal emergent surgery were entered in the study. All patients entered were greater than 14 years of age, hemodynamically stable, and underwent further abdominal evaluation with CT scan following the decision for extra-abdominal surgical intervention. Emergent extra-abdominal trauma surgery occurred within 8 hours of emergency room admission. The results of all diagnostic studies, hemodynamic values, mechanism of injury indications for extra-abdominal surgical intervention and outcome were analyzed. RESULTS: One hundred sixty-two patients were entered in the study with average age of 32 years (range: 14-81). The most common mechanism of injury was motor vehicle crash (76%). One hundred forty-three (88%) patients presented with GCS scores of 15, and 19 (12%) patients presented with GCS scores of 14. The majority of extra-abdominal emergent surgical procedures were orthopedic (88%). Two (1.2%) intra-peritoneal injuries were diagnosed in the study population. One of the injuries was a stable Grade 1 splenic injury and the other was a small bowel mesenteric hematoma. Neither of the 2 abdominal missed injury required blood transfusion or surgical intervention. CONCLUSIONS: Before emergent extra-abdominal trauma surgery, abdominal evaluation with physical examination is sufficient to identify surgically significant abdominal injury in the awake and alert blunt trauma patient. Abdominal screening with computed tomography does not impact patient outcome.