Angiographic Coronary Slow Flow Is Not a Valid Surrogate for Invasively Diagnosed Coronary Microvascular Dysfunction.

BACKGROUND: Ischemia with no obstructive coronary arteries is frequently caused by coronary microvascular dysfunction (CMD). Consensus diagnostic criteria for CMD include baseline angiographic slow flow by corrected TIMI (Thrombolysis In Myocardial Infarction) frame count (cTFC), but correlations between slow flow and CMD measured by invasive coronary function testing (CFT) are uncertain. OBJECTIVES: The aim of this study was to investigate relationships between cTFC and invasive CFT for CMD. METHODS: Adults with ischemia with no obstructive coronary arteries underwent invasive CFT with thermodilution-derived baseline coronary blood flow, coronary flow reserve (CFR), and index of microcirculatory resistance (IMR). CMD was defined as abnormal CFR (<2.5) and/or abnormal IMR (≥25). cTFC was measured from baseline angiography; slow flow was defined as cTFC >25. Correlations between cTFC and baseline coronary flow and between CFR and IMR and associations between slow flow and invasive measures of CMD were evaluated, adjusted for covariates. All patients provided consent. RESULTS: Among 508 adults, 49% had coronary slow flow. Patients with slow flow were more likely to have abnormal IMR (36% vs 26%; P = 0.019) but less likely to have abnormal CFR (28% vs 42%; P = 0.001), with no difference in CMD (46% vs 51%). cTFC was weakly correlated with baseline coronary blood flow (r = -0.35; 95% CI: -0.42 to -0.27), CFR (r = 0.20; 95% CI: 0.12 to 0.28), and IMR (r = 0.16; 95% CI: 0.07-0.24). In multivariable models, slow flow was associated with lower odds of abnormal CFR (adjusted OR: 0.53; 95% CI: 0.35 to 0.80). CONCLUSIONS: Coronary slow flow was weakly associated with results of invasive CFT and should not be used as a surrogate for the invasive diagnosis of CMD.

The relationships between acetylcholine-induced chest pain, objective measures of coronary vascular function and symptom status.

Background: Acetylcholine-induced chest pain is routinely measured during the assessment of microvascular function. Aims: The aim was to determine the relationships between acetylcholine-induced chest pain and both symptom burden and objective measures of vascular function. Methods: In patients with angina but no obstructive coronary artery disease, invasive studies determined the presence or absence of chest pain during both acetylcholine and adenosine infusion. Thermodilution-derived coronary blood flow (CBF) and index of microvascular resistance (IMR) was determined at rest and during both acetylcholine and adenosine infusion. Patients with epicardial spasm (>90%) were excluded; vasoconstriction between 20% and 90% was considered endothelial dysfunction. Results: Eighty-seven patients met the inclusion criteria. Of these 52 patients (60%) experienced chest pain during acetylcholine while 35 (40%) did not. Those with acetylcholine-induced chest pain demonstrated: (1) Increased CBF at rest (1.6 ± 0.7 vs. 1.2 ± 0.4, p = 0.004) (2) Decreased IMR with acetylcholine (acetylcholine-IMR = 29.7 ± 16.3 vs. 40.4 ± 17.1, p = 0.004), (3) Equivalent IMR following adenosine (Adenosine-IMR: 21.1 ± 10.7 vs. 21.8 ± 8.2, p = 0.76), (4) Increased adenosine-induced chest pain (40/52 = 77% vs. 7/35 = 20%, p < 0.0001), (5) Increased chest pain during exercise testing (30/46 = 63% vs. 4/29 = 12%, p < 0.00001) with no differences in exercise duration or electrocardiographic changes, and (6) Increased prevalence of epicardial endothelial dysfunction (33/52 = 63% vs. 14/35 = 40%, p = 0.03). Conclusions: After excluding epicardial spasm, acetylcholine-induced chest pain is associated with increased pain during exercise and adenosine infusion, increased coronary blood flow at rest, decreased microvascular resistance in response to acetylcholine and increased prevalence of epicardial endothelial dysfunction. These findings raise questions about the mechanisms underlying acetylcholine-induced chest pain.

Upper Extremity Deep Venous Thrombosis Risk Factors, Associated Morbidity and Mortality in Trauma Patients.

BACKGROUND: The literature on upper extremity deep venous thrombosis (UEDVT) is not as abundant as that on lower extremities. This study aimed to identify the risk factors for UEDVT, associated mortality and morbidity in trauma patients and the impact of pharmacological prophylaxis therein. METHODS: A 3-year retrospective review of patients admitted to a Level 1 trauma center was conducted. Patients aged 18 years or older who had experienced a traumatic event and had undergone an upper extremity ultrasound (UEUS) were included in the study. Multiple logistic regression was used to identify independent risk factors that contributed to UEDVT. RESULTS: A total of 6,607 patients were admitted due to traumatic injuries during the study period, of whom 5.6% (373) had at least one UEUS during their hospitalization. Fifty-six (15%) were diagnosed with an UEDVT, as well as three non-fatal pulmonary emboli (PE) and four (7.1%) deaths, p = 0.03. Pharmacological prophylaxis with low-molecular-weight heparin (LMWH) or unfractionated heparin showed a protective effect against UEDVT; among the patients positive for UEDVT, 14 of 186 patients (7.5%) received LMWH, while 42 of 195 (21.5%) did not receive LMWH (p < 0.001). Multiple logistic regression revealed that the presence of upper extremity fractures, peripherally inserted central catheter (PICC) lines, and traumatic brain injury (TBI) were independent risk factors for UEDVT. CONCLUSIONS: UEDVT are associated with a higher mortality. The presence of upper extremity fractures, PICC lines, and TBI were independent risk factors for UEDVTs. Further, pharmacological prophylaxis reduces the risk of UEDVT.

Predicting Discharge Disposition in Trauma Patients: Development, Validation, and Generalization of a Model Using the National Trauma Data Bank.

BACKGROUND: Limited work has been done in predicting discharge disposition in trauma patients; most studies use single institutional data and have limited generalizability. This study develops and validates a model to predict, at admission, trauma patients' discharge disposition using NTDB, transforms the model into an easy-to-use score, and subsequently evaluates its generalizability on institutional data. METHODS: NTDB data were used to build and validate a binary logistic regression model using derivation-validation (ie, train-test) approach to predict patient disposition location (home vs non-home) upon admission. The model was then converted into a trauma disposition score (TDS) using an optimization-based approach. The generalizability of TDS was evaluated on institutional data from a single Level I trauma center in the U.S. RESULTS: A total of 614 625 patients in the NTDB were included in the study; 212 684 (34.6%) went to a non-home location. Patients with a non-home disposition compared to home had significantly higher age (69 ± 19.7 vs 48.3 ± 20.3) and ISS (11.2 ± 8.2 vs 8.2 ± 6.3); P < .001. Older age, female sex, higher ISS, comorbidities (cancer, cardiovascular, coagulopathy, diabetes, hepatic, neurological, psychiatric, renal, substance abuse), and Medicare insurance were independent predictors of non-home discharge. The logistic regression model's AUC was 0.8; TDS achieved a correlation of 0.99 and performed similarly well on institutional data (n = 3161); AUC = 0.8. CONCLUSION: We developed a score based on a large national trauma database that has acceptable performance on local institutions to predict patient discharge disposition at the time of admission. TDS can aid in early discharge preparation for likely-to-be non-home patients and may improve hospital efficiency.

Right Heart Function in Critically Ill Patients at Risk for Acute Right Heart Failure: A Description of Right Ventricular-Pulmonary Arterial Coupling, Ejection Fraction and Pulmonary Artery Pulsatility Index.

BACKGROUND: The gold standard for right heart function is the assessment of right ventricular-pulmonary arterial coupling defined as the ratio of arterial to end-systolic elastance (Ea/Emax). This study demonstrates the use of the volumetric pulmonary artery (PA) catheter for estimation of Ea/Emax and describes trends of Ea/Emax, right ventricular ejection fraction (RVEF), and pulmonary artery pulsatility index (PAPi) during initial 48hours of resuscitation in the trauma surgical intensive care unit (ICU). METHODS: Review of prospectively collected data for 32 mechanically ventilated adult trauma and emergency general surgery patients enrolled within 6hours of admission to the ICU. Haemodynamics, recorded every 12hours for 48hours, were compared among survivors and non-survivors to hospital discharge. RESULTS: Mean age was 49±20 years, 69% were male, and 84% were trauma patients. Estimated Ea/Emax was associated with pulmonary vascular resistance and inversely related to pulmonary arterial capacitance and PA catheter derived RVEF. Seven (7) trauma patients did not survive to hospital discharge. Non-survivors had higher estimated Ea/Emax, suggesting right ventricular-pulmonary arterial uncoupling, with a statistically significant difference at 48hours (2.3±1.7 vs 1.0±0.58, p=0.018). RVEF was significantly lower in non-survivors at study initiation and at 48hours. PAPi did not show a consistent trend. CONCLUSIONS: Estimation of Ea/Emax using volumetric PA catheter is feasible. Serial assessment of RVEF and Ea/Emax may help in early identification of right heart dysfunction in critically ill mechanically ventilated patients at risk for acute right heart failure.

Development and implementation of a sustainable research curriculum for general surgery residents: A foundation for developing a research culture.

BACKGROUND: Different methods to incorporate research training during residency are suggested, however, long-term impact is not studied well. This study reports development of a research curriculum with milestones, a long-term outcome and sustainability, and its impact on the overall departmental research culture. METHODS: The research curriculum that included a research seminar for resident preparation, annual milestones, and structured research mentoring was implemented in our hybrid program in 2012. The research output for five-year period before and after the implementation was evaluated as peer-reviewed publications, presentations, and grant submissions. Further, secondary effects on faculty and medical student research was evaluated. RESULTS: Following implementation, we observed a significant increase in the number of resident presentations (p < 0.05) and higher trends for publications and grant submissions. Medical student research increased significantly in terms of both presentations and publications (p < 0.05). Consequently, we observed a significant improvement in the overall department research productivity. CONCLUSIONS: Our resident research curriculum was associated with improved long-term research productivity. It allowed residents to work closely with faculty and medical students leading to more collaboration resulting in an enhanced scholarly environment.

Risk factors for pneumonia following rib fractures.

INTRODUCTION: Pneumonia is a known complication following rib fractures. This study was undertaken to identify clinical and demographic factors associated with the development of pneumonia among trauma patients with rib fractures. METHODS: This retrospective study examined trauma patients with one or more rib fractures, who were admitted for inpatient management during the time period 2012 through 2017. Variables studied included age, gender, injury severity score (ISS), mechanism of injury, smoking status, alcohol use, administration of influenza and pneumococcal vaccine, number and side of rib fracture(s), pulmonary contusion, pneumothorax, flail chest, spirometer use, blood transfusion, and intravenous fluid administration. RESULTS: Among 78 cases and 74 controls (matched for age and ISS), patients who developed pneumonia were more likely to be male, have higher number of rib fractures, alcohol consumption of 1-5 drinks per day, and a higher initial volume of intravenous fluids during first 24 h. Patients with pneumonia were more likely to be treated with incentive spirometry. There were no difference in age, ISS, smoking status, side of rib fractures, pulmonary contusion, pneumothorax, flail chest, influenza vaccination, pneumonia vaccination, or mechanism of injury between the two groups. CONCLUSION: Risk factors for the development of pneumonia following rib fractures include male gender, higher number of rib fractures, alcohol consumption, and higher rates of intravenous fluid administration during the initial 24 h following trauma.

Association of System-Level Factors With Secondary Overtriage in Trauma Patients.

Importance: Studies show that secondary overtriage (SO) contributes significantly to the economic burden of injured patients; thus, the association of SO with use of the trauma system has been examined. However, the association of the underlying trauma system design with such overtriage has yet to be evaluated. Objectives: To evaluate whether the distribution of trauma centers in a statewide trauma system is associated with SO and to identify clinical and demographic factors that may lead to SO. Design, Setting, and Participants: A retrospective cohort study was performed using 2008-2012 data from the Ohio Trauma and Emergency Medical Services registries. All patients taken to level III or nontrauma centers from the scene of the injury with an Injury Severity Score less than 15 and discharged alive were included. Among these patients, those with SO were identified as those who were subsequently transferred to a level I or II trauma center, had no surgical intervention, and were discharged alive within 48 hours of admission. The SO group was analyzed descriptively. Multiple logistic regression was used to identify system-level factors associated with SO. Statistical analysis was performed from August 1, 2017, to January 31, 2018. Main Outcomes and Measures: The primary outcome was the occurrence of SO. Results: Of 34 494 trauma patients able to be matched in the 2 registries, 7881 (22.9%) met the inclusion criteria, of whom 965 (12.2%) had SO. The median age in the SO group was 40 years (interquartile range, 26-55 years), with 299 women and 666 men. After adjusting for age, sex, comorbidities, injury type, and insurance status, the study found that system-level factors (number of level I or II trauma centers in the region [>1]) were significantly associated with SO (adjusted odds ratio, 1.98; 95% CI, 1.64-2.38; P < .001; area under the curve, 0.89). The reasons for choice of destination by emergency medical services (specifically, choosing the closest facility: adjusted odds ratio, 1.65; 95% CI, 1.37-1.98; P < .001) and use of a field trauma triage protocol (adjusted odds ratio, 2.21; 95% CI, 1.70-2.87; P < .001), significantly increased the likelihood of SO. Conclusions and Relevance: This study's findings suggest that the distribution of major trauma centers in the region is significantly associated with SO. Subsequent investigation to identify the optimal number and distribution of trauma centers may therefore be critical. Specific outreach and collaboration of level III trauma centers and nontrauma centers with level I and II trauma centers, along with the use of telemedicine, may provide further guidance to level III trauma centers and nontrauma centers on when to transfer injured patients.

Team-Based Learning in the Surgery Clerkship: Impact on Student Examination Scores, Evaluations, and Perceptions.

OBJECTIVE: There is little evidence for effectiveness of team-based learning (TBL) in specialties such as Surgery. We developed and instituted TBLs in surgery clerkship and compared National Board of Medical Examiners (NBME) Surgery Subject Exam scores before and after implementation. We also analyzed students' feedback for their perception of TBLs. DESIGN, SETTING, AND PARTICIPATNTS: The TBLs were transitioned into the curriculum during the 2013-2014 academic year. The "before" and "after" implementation periods were 2011-2013 and 2014-2016, respectively. NBME Surgery Subject Examination scores at our institution and nationally were compared using the independent samples t test. Satisfaction with the clerkship was assessed with Association of American Medical Colleges Graduate Questionnaire data. Student feedback regarding TBL was gathered at the end of each surgery rotation and were analyzed for themes, both positive and negative. RESULTS: Mean NBME score was higher at our institution than nationally, both before (77.10 ± 8.75 vs. 75.20 ± 8.95, p = 0.032) and after (74.65 ± 8.0 vs. 73.10 ± 8.55, p = 0.071) TBL implementation. The mean score decreased following TBL implementation at our medical school (77.10 ± 8.75 vs. 74.65 ± 8.00, p = 0.039), but it was also lower nationally (75.20 ± 8.95 vs. 73.10 ± 8.55, p < 0.001). Further, students were more likely to rate the surgery clerkship as "good and/or excellent" on the Association of American Medical Colleges Graduate Questionnaire after TBL implementation (84.6% vs. 73.7%). In qualitative assessment, learners stated that TBLs were informative, helpful in studying for the shelf exam, and viewed them as an opportunity for interactive learning, and thus requested more TBLs. Areas for improvement included reading materials, directions, and organization of sessions. CONCLUSIONS: Student perception of TBL into our surgery clerkship has been both positive and provided feedback for improvement. In addition, our medical school graduates have continued to assess their surgery experience as "good" or "excellent" by a large majority. Concurrently, our NBME scores remain above the national mean. We believe our medical students benefit from a well-organized TBL and its active approach to learning during the surgery clerkship with no loss of fundamental surgery knowledge.

Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper.

OBJECTIVE: The leadership of the American Surgical Association (ASA) appointed a Task Force to objectively address issues related to equity, diversity, and inclusion with the discipline of academic surgery. SUMMARY OF BACKGROUND DATA: Surgeons and the discipline of surgery, particularly academic surgery, have a tradition of leadership both in medicine and society. Currently, we are being challenged to harness our innate curiosity, hard work, and perseverance to address the historically significant deficiencies within our field in the areas of diversity, equity, and inclusion. METHODS: The ASA leadership requested members to volunteer to serve on a Task Force to comprehensively address equity, diversity, and inclusion in academic surgery. Nine work groups reviewed the current literature, performed primary qualitative interviews, and distilled available guidelines and published primary source materials. A work product was created and published on the ASA Website and made available to the public. The full work product was summarized into this White Paper. RESULTS: The ASA has produced a handbook entitled: Ensuring Equity, Diversity, and Inclusion in Academic Surgery, which identifies issues and challenges, and develops a set of solutions and benchmarks to aid the academic surgical community in achieving these goals. CONCLUSION: Surgery must identify areas for improvement and work iteratively to address and correct past deficiencies. This requires honest and ongoing identification and correction of implicit and explicit biases. Increasing diversity in our departments, residencies, and universities will improve patient care, enhance productivity, augment community connections, and achieve our most fundamental ambition-doing good for our patients.

Prevalence of preoperative penile abnormalities among voluntary male medical circumcision patients in Swaziland.

BACKGROUND: Circumcision has been found to be an effective strategy for lowering the transmission of HIV in Africa. The Luke Commission, a mobile hospital outreach program, has used this information to decrease the rate of HIV in Swaziland by performing voluntary male medical circumcisions throughout the country. During many of these circumcisions, genital medical conditions and penile abnormalities are simultaneously discovered and corrected. PURPOSE: The goal of our study was to evaluate the prevalence of penile abnormalities discovered and treated during voluntary male medical circumcisions performed by The Luke Commission (TLC) throughout rural Swaziland. BASIC PROCEDURES: We completed a retrospective analysis of all male patients who underwent voluntary male medical circumcision performed by TLC during a period from June-August, 2014. The penile abnormalities included: phimosis, paraphimosis, epispadias, hypospadias, ulcers, balanitis, torsion, and foreskin adherent to the glans. MAIN FINDINGS: Of 929 total circumcisions, 771 (83%) patients had at least one pre-existing penile abnormality identified during their examinations and procedures, totaling 1110 abnormalities. Three specific abnormalities were detected - phimosis, adherent foreskin, and hypospadias. The 6-12 and 13-19 age groups had adequate sample sizes to yield precise estimates of prevalence (age group 6-12: 87% (95% confidence interval [CI]=84-90%; age group 13-19: 79% (95% CI=74-84%). PRINCIPLE CONCLUSIONS: The Luke Commission is improving the lives of children and adults with limited access to healthcare through regular preoperative evaluations during male circumcision, and the organization is setting an example for other international healthcare groups. LEVEL OF EVIDENCE: Type of Study: Prognostic Study, Level II.

Is nasotracheal intubation safe in facial trauma patients?

BACKGROUND: In the prehospital setting, oral intubation is preferred in facial trauma patients due to the potential for further injury during nasotracheal intubation. This study compared the complications of nasal vs. oral vs. nasal + oral intubations performed by first responder crews in facial trauma patients. Our objective was to assess patient outcomes and complications to determine the risk of nasal intubation in facial trauma patients in the prehospital setting. METHODS: Patients with facial trauma between 2008 and 13 were abstracted from the Miami Valley Hospital trauma registry: 50 were nasal only (n), 27 nasal + oral (no), and 135 oral only (o) intubation. Analysis of variance with the post-hoc Least Significance Difference Test and the chi square test were used in the analysis. RESULTS: The oral group was older [41.1 ± 17.6 (o) vs. 36.2 ± 14.1 (n) vs. 33.0 ± 15.7 (no), p = 0.032] and had a higher facial abbreviated injury severity (AIS) mean score (1.8 ± 0.6 vs. 1.3 ± 0.5 vs. 1.5 ± 0.5, p < 0.001). The three groups did not differ in mortality (n = 20% vs. o = 18% vs. no = 30%, p = 0.37). The n + o group was intubated longer (p < 0.001) and had longer ICU and hospital lengths of stay (p = 0.015 and p = 0.023). The three groups did not differ on the composite of any pulmonary complication - i.e., any one of sinusitis, pneumonia, atelectasis, and respiratory failure - 44% (no) vs. 24% (o) vs. 30% (n), p = 0.10). However, nasal + oral patients were more likely to have one or more of the eight complication studied [63% (no) vs. 28% (o) vs. 34% (n), p = 0.002], and have a longer ICU and HLOS. CONCLUSIONS: Prehospital nasal intubation is a viable short-term alternative to oral intubation in patients with facial trauma and warrants further research.

Initial impact of the Affordable Care Act on an Ohio Level I trauma center.

BACKGROUND: Hospital financial pressures and inadequate reimbursement contribute to the closure of trauma centers. Uninsured patients contribute significantly to the burden of trauma center costs. The Affordable Care Act implemented changes in 2014 to provide health care coverage for all Americans. This study analyzes the impact of the recent health care changes on an Ohio Level I trauma center financials. METHODS: We conducted an analysis of trauma charges, reimbursement, and supplemental payments at an Ohio Level I trauma center. A 3-year trauma patient cohort (2012-2014) was selected and grouped by reimbursement source (Medicare, Medicaid, other government, commercial, and self-pay/charity). A total of 9,655 patients were reviewed. Data were collected with the Transition Systems Inc. accounting system and analyzed with IBM SPSS Statistics 22.0. RESULTS: For trauma cases, the percentage of self-pay/charity patients decreased during the 2012 to 2014 period (15.1%, 15%, to 6.4%, respectively), while the percentage of Medicaid decreased from 2012 to 2013 followed by a large increase in 2014 (15.4%, 13.9%, to 24.3%, respectively). The percentage of commercially insured patients decreased slightly from 2012 to 2014 (34.2%, 32.3%, to 30.7%, respectively). Uninsured charges decreased notably (approximately $22.5 million and $21 million for 2012-2013 to approximately $8.6 million in 2014). Medicaid charges decreased from 2012 to 2013, followed by a rebound in 2014 ($50.7 million in 2012 to $37.3 million in 2013 to $54.3 million in 2014). The percentage of total charges for self-pay/charity decreased (9.5%, 10.1%, to 4.1%). The percentage of total charges for Medicaid increased (21.4%, 18.0%, to 25.9%). Mean Medicaid reimbursement per patient decreased ($19,000, $14,000, to $13,000). Mean reimbursement per uninsured patient did not vary significantly among years. Total hospital supplemental payments (trauma and nontrauma combined) decreased ($47.6 million, $49 million, to $39.2 million). CONCLUSION: In the first year following the changes implemented by the Affordable Care Act, our hospital saw self-pay/charity charges decrease, Medicaid charges increase, and total hospital supplemental payments decrease. In addition, there was a small, yet noteworthy, downward trend in the number of commercially insured patients. Although more data collection and analysis are needed, this initial financial evaluation of a Level I trauma center following the Affordable Care Act provides insight into insurance trends.

Meeting Increasing Demands for Rural General Surgeons.

Dynamic assessment of the effective surgical workforce recommends 27,300 general surgeons in 2030; 2,525 more than are presently being trained. Rural shortages are already critical and there has been insufficient preparation for this need. A literature review of the factors influencing the choice of rural practice was performed. A systematic search was conducted of PubMed and the Web of Science to identify applicable studies in rural practice, surgical training, and rural general surgery. These articles were reviewed to identify the pertinent reports. The articles chosen for review are directed to four main objectives: 1) description of the challenges of rural practice, 2) factors associated with the choice of rural practice, 3) interventions to increase interest and preparation for rural practice, and 4) present successful rural surgical practice models. There is limited research on the factors influencing surgeons in the selection of rural surgery. The family practice literature suggests that physicians are primed for rural living through early experience, with reinforcement during medical school and residency, and retained through community involvement, and personal and professional satisfaction. However, more research into the factors drawing surgeons specifically to rural surgery, and keeping them in the community, is needed.

Scheduling of advanced practice providers at Level 1 trauma centers.

BACKGROUND: Advanced practice providers (APPs) are essential to the provision of trauma care services, particularly in the wake of residency hour restrictions. Demand for these APPs fluctuates with cyclic patient arrivals; however, most trauma teams continue to staff APPs in a linear fashion. Failure to plan for variable arrivals may contribute to excessive patient wait times and emergency department overcrowding. This study used both qualitative and quantitative approaches to evaluate the impact of APP scheduling on patient wait time and to find schedules minimizing delays in reaching the needed care at the right time. METHODS: A retrospective observation of the availability of APPs and the flow of 2,249 trauma patients at a Level 1 trauma center, using both visual overlays and computer modeling, allowed us to evaluate the baseline condition, two what-if schedules, and two model-generated schedules minimizing patient time without any additional APP hours. RESULTS: A visual overlay of APP staffing on 2010 patient arrivals indicated substantial times of mismatch. Trauma managers considered adding an APP during weekday evenings that would have resulted in a 14.8% increase in APP hours and yielded a 27% reduction in patient wait times according to our model. An alternate schedule was developed and implemented in 2012 with a 10.5% increase in APP hours and yielding a 73% reduction in wait times. We also delineated two schedule options with 57% and 78% reductions in wait time and no increase in APP work hours. CONCLUSION: Evaluating alternate shift times and assignments using visual overlays and computer modeling can provide APP staffing solutions with up to 78% reduction in trauma patient wait time without additional APP labor. Knowing that care at the right time is crucial to arriving patients, making sure APP staffing is synchronized with arriving patients is something trauma center managers cannot ignore. LEVEL OF EVIDENCE: Care management study, level IV.

Successful placement of intracranial pressure monitors by trauma surgeons.

BACKGROUND: The Brain Trauma Foundation guidelines advocate for the use of intracranial pressure (ICP) monitoring following traumatic brain injury (TBI) in patients with a Glasgow Coma Scale (GCS) score of 8 or less and an abnormal computed tomographic scan finding. The absence of 24-hour in-house neurosurgery coverage can negatively impact timely monitor placement. We reviewed the safety profile of ICP monitor placement by trauma surgeons trained and credentialed in their insertion by neurosurgeons. METHODS: In 2005, the in-house trauma surgeons at a Level I trauma center were trained and credentialed in the placement of ICP parenchymal monitors by the neurosurgeons. We abstracted all TBI patients who had ICP monitors placed during a 6-year period. Demographic information, Injury Severity Score (ISS), outcome, and monitor placement by neurosurgery or trauma surgery were identified. Misplacement, hemorrhage, infections, malfunctions, and dislodgement were considered complications. Comparisons were performed by χ testing and Student's t tests. RESULTS: During the 6-year period, 410 ICP monitors were placed for TBI. The mean (SD) patient age was 40.9 (18.9) years, 73.7% were male, mean (SD) ISS was 28.3 (9.4), mean (SD) length of stay was 19 (16) days, and mortality was 36.1%. Motor vehicle collisions and falls were the most common mechanisms of injury (35.2% and 28.7%, respectively). The trauma surgeons placed 71.7 % of the ICP monitors and neurosurgeons for the remainder. The neurosurgeons placed most of their ICP monitors (71.8%) in the operating room during craniotomy. The overall complication rate was 2.4%. There was no significant difference in complications between the trauma surgeons and neurosurgeons (3% vs. 0.8%, p = 0.2951). CONCLUSION: After appropriate training, ICP monitors can be safely placed by trauma surgeons with minimal adverse effects. With current and expected specialty shortages, acute care surgeons can successfully adopt procedures such as ICP monitor placement with minimal complications. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Palliative and end-of-life care training during the surgical clerkship.

BACKGROUND: In 2000, the Liaison Committee on Medical Education required that all medical schools provide experiential training in end-of-life care. To adhere to this mandate and advance the professional development of medical students, experiential training in communication skills at the end-of-life was introduced into the third-year surgical clerkship curriculum at Wright State University Boonshoft School of Medicine. MATERIALS AND METHODS: In the 2007-08 academic year, 97 third-year medical students completed six standardized end-of-life care patient scenarios commonly encountered during the third-year surgical clerkship. Goals and objectives were outlined for each scenario, and attending surgeons graded student performances and provided formative feedback. RESULTS: All 97 students, 57.7% female and average age 25.6 ± 2.04 y, had passing scores on the scenarios: (1) Adult Hospice, (2) Pediatric Hospice, (3) Do Not Resuscitate, (4) Dyspnea Management/Informed Consent, (5) Treatment Goals and Prognosis, and (6) Family Conference. Scenario scores did not differ by gender or age, but students completing the clerkship in the first half of the year scored higher on total score for the six scenarios (92.8% ± 4.8% versus 90.5% ± 5.0%, P = 0.024). CONCLUSIONS: Early training in end-of-life communication is feasible during the surgical clerkship in the third-year of medical school. Of all the scenarios, "Conducting a Family Conference" proved to be the most challenging.

Pilot evaluation of the short-term effect of driving simulation on novice adolescent drivers.

BACKGROUND: Despite widespread application in aviation and other fields, there has been limited use of computerized simulation in driver education. We prospectively studied a group of novice drivers subjected to comprehensive virtual driving simulation modules to identify the subsequent effects on their driving records. We hypothesized that participation in a simulation program would result in fewer offences and crashes. METHODS: Forty high school students who recently obtained their driver's license were randomized into driving simulator (DS) or control groups. The DS group went through 12 modules of driver education. Upon completion, driving records for all the individuals were collected at 6 months, 12 months, and 18 months, and comparisons were made. Statistical analysis was performed using χ², Fisher's exact tests, t tests, and Mann Whitney U-test where appropriate. RESULTS: Of the 20 subjects, 16 in the DS group completed all modules and were compared with 19 individuals in the control group. Sixty-nine percent in the DS group were male versus 89% in the control group. Mean age was similar in both groups. The average time to the first offense after completion in the DS group was 117 days versus 105 days in control group (p = 0.8). At 18 months, 18.8% in the DS group were involved in a driving incident compared with 47.4% in the control group (p = 0.1516). At 18 months, there were 4 incidents (0.25 incidents per person) in the DS group versus 17 incidents (0.89 incidents per person) in the control group. At 18 months, 6.2% in the DS were involved in accidents compared with 21.1% in the control group (p= 0.35). Speeding infractions occurred at 18 months in 12.5% in the DS group versus 26.3% in the control group (p = 0.4150). CONCLUSION: In this prospective pilot evaluation of computerized driving simulation, adolescents subjected to structured simulator training showed trends toward committing fewer offences and accidents. Larger studies examining the practical potential of driving simulation in novice drivers are needed. LEVEL OF EVIDENCE: Prognostic study, level III.

Complications arising from splenic artery embolization: a review of an 11-year experience.

BACKGROUND: Splenic artery embolization (SAE) is a staple adjunct in the management of blunt splenic trauma. We examined complications of SAE over an 11-year period. METHODS: Patients who underwent SAE were identified. Demographic data and the location of the SAE-proximal, distal, or combined-were noted. Major and minor complications were identified. RESULTS: Of 1,383 patients with blunt splenic trauma, 298 (21.5%) underwent operative management, and 1,085 (78.5%) underwent nonoperative management (NOM). SAE was performed in 8.1% of the NOM group. Major complications which occurred in 14% of patients, included splenic abscesses, infarction, cysts, and contrast-induced renal insufficiency. Three-fourths of patients with major complications underwent distal embolization. There were more complications in patients who underwent distal embolization (24% distal vs 6% proximal alone; P = .02). Minor complications, which occurred in 34% of patients, included left-sided pleural effusions, coil migration, and fever. CONCLUSIONS: SAE is a useful tool for managing splenic injuries. Major and minor complications can occur. Distal embolization is associated with more major complications.