RESUMO
OBJECTIVE: The personal statement (PS) is a rich text in which medical students introduce themselves to the programs to which they are applying. There is no prompt or agreed upon structure for the personal statement. Therefore it represents a window in to medical students' beliefs and perceptions. The goal of this study was to identify what events or experiences motivate medial students to pursue a career in general surgery. Previous work in this area has been largely survey and interview-based. This study is unique in that it looks at what medical students say when not prompted. DESIGN: This is a single-institution, retrospective, qualitative review of applicants' PSs. The PSs were coded based on an a priori coding scheme. The coding scheme was based on published literature of why medical students might apply for a general surgery training position. SETTING: Academic, safety-net hospital. PARTICIPANTS: The study evaluated a subset of the PSs of applications submitted through the Electronic Residency Application Service (ERAS) for a categorical general surgery position in our program during the 2022 match. Specifically, 308 of all received applications were included in this study. This is the subgroup of applications that was pulled out for a close review based on holistic screening of received applications. RESULTS: The single most frequently mentioned motivating factor for applying to general surgery training was the experience a student had on the surgery clerkship. The early years of medical school and sub-internships were less frequently identified as motivating experiences. After the overall clerkship experience, the next most frequent motivating factors were that their personality fit well with the culture of surgery and that they realized the important role surgeons played in patient care. 59 applicants wrote about a pre-existing interest in surgery prior to entering medical school. Most frequently this interest developed after witnessing family or friends or applicant themselves have surgery or shadowing a surgeon. CONCLUSIONS: In this study, students most frequently noted the clerkship experience as having sparked their interest in a career in surgery. Having had exposure to surgeons, through personal experience or shadowing, often led to students to develop an interest in pursuing a career in surgery prior to entering medical school. The findings suggest that to increase the attractiveness of surgery to potential applicants, positive exposure to surgeons and surgery as a field of practice are critical.
Assuntos
Escolha da Profissão , Cirurgia Geral , Motivação , Pesquisa Qualitativa , Estudantes de Medicina , Cirurgia Geral/educação , Estudantes de Medicina/psicologia , Estudantes de Medicina/estatística & dados numéricos , Humanos , Estudos Retrospectivos , Masculino , Feminino , AdultoRESUMO
INTRODUCTION: There are no clear recommendations for the perioperative timing and initiation of venous thromboembolism pharmacologic prophylaxis (VTEp) among polytrauma patients undergoing high-risk bleeding orthopedic operative intervention, leading to variations in VTEp administration. Our study examined the association between the timing of VTEp and VTE complications in polytrauma patients undergoing high-risk operative orthopedic interventions nationwide. METHODS: We performed a retrospective cohort study of trauma patients 18 years or older who underwent high-risk bleeding operative orthopedic interventions for pelvic, hip, and femur fractures within 24 hours of admission at American College of Surgeons-verified trauma centers using the 2019-2020 American College of Surgeons Trauma Quality Improvement Program databank. We excluded patients with a competing risk of nonorthopedic surgical bleeding. We assessed operative orthopedic polytrauma patients who received VTEp within 12 hours of orthopedic surgical intervention compared with VTEp received beyond 12 hours of intervention. The primary outcome assessed was overall VTE events. Secondary outcomes were orthopedic reinterventions within 72 hours after primary orthopedic surgery, deep venous thromboembolism, and pulmonary embolism rates. RESULTS: The study included 2,229 patients who underwent high-risk orthopedic operative intervention. The median time to VTEp initiation was 30 hours (interquartile range, 18-44 hours). After adjustment for baseline patient, injury, and hospital characteristics, VTEp initiated more than 12 hours from primary orthopedic surgery was associated with increased odds of VTE (adjusted odds ratio, 2.02; 95% confidence interval, 1.08-3.77). Earlier initiation of prophylaxis was not associated with an increased risk for surgical reintervention (hazard ratio, 0.90; 95% confidence interval, 0.62-1.34). CONCLUSION: Administering VTEp within 24 hours of admission and within 12 hours of major orthopedic surgery involving the femur, pelvis, or hip demonstrated an associated decreased risk of in-hospital VTE without an accompanying elevated risk of bleeding-related orthopedic reintervention. Clinicians should reconsider delays in initiating or withholding perioperative VTEp for stable polytrauma patients needing major orthopedic intervention. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
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Anticoagulantes , Traumatismo Múltiplo , Procedimentos Ortopédicos , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/prevenção & controle , Tromboembolia Venosa/etiologia , Tromboembolia Venosa/epidemiologia , Feminino , Masculino , Traumatismo Múltiplo/complicações , Traumatismo Múltiplo/cirurgia , Estudos Retrospectivos , Pessoa de Meia-Idade , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/métodos , Anticoagulantes/administração & dosagem , Adulto , Idoso , Estados Unidos/epidemiologia , Fatores de Tempo , Centros de Traumatologia , Fraturas do Fêmur/cirurgia , Fraturas do Fêmur/complicações , Tempo para o Tratamento/estatística & dados numéricos , Ossos Pélvicos/lesões , Fatores de Risco , Fraturas do Quadril/cirurgia , Fraturas do Quadril/complicações , Embolia Pulmonar/prevenção & controle , Embolia Pulmonar/etiologiaRESUMO
PURPOSE: Literature on outcomes after SSRF, stratified for rib fracture pattern is scarce in patients with moderate to severe traumatic brain injury (TBI; Glasgow Coma Scale ≤ 12). We hypothesized that SSRF is associated with improved outcomes as compared to nonoperative management without hampering neurological recovery in these patients. METHODS: A post hoc subgroup analysis of the multicenter, retrospective CWIS-TBI study was performed in patients with TBI and stratified by having sustained a non-flail fracture pattern or flail chest between January 1, 2012 and July 31, 2019. The primary outcome was mechanical ventilation-free days and secondary outcomes were in-hospital outcomes. In multivariable analysis, outcomes were assessed, stratified for rib fracture pattern. RESULTS: In total, 449 patients were analyzed. In patients with a non-flail fracture pattern, 25 of 228 (11.0%) underwent SSRF and in patients with a flail chest, 86 of 221 (38.9%). In multivariable analysis, ventilator-free days were similar in both treatment groups. For patients with a non-flail fracture pattern, the odds of pneumonia were significantly lower after SSRF (odds ratio 0.29; 95% CI 0.11-0.77; p = 0.013). In patients with a flail chest, the ICU LOS was significantly shorter in the SSRF group (beta, - 2.96 days; 95% CI - 5.70 to - 0.23; p = 0.034). CONCLUSION: In patients with TBI and a non-flail fracture pattern, SSRF was associated with a reduced pneumonia risk. In patients with TBI and a flail chest, a shorter ICU LOS was observed in the SSRF group. In both groups, SSRF was safe and did not hamper neurological recovery.
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Lesões Encefálicas Traumáticas , Tórax Fundido , Pneumonia , Fraturas das Costelas , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/terapia , Tórax Fundido/cirurgia , Fixação Interna de Fraturas , Humanos , Tempo de Internação , Estudos Retrospectivos , Fraturas das Costelas/complicaçõesAssuntos
Tórax Fundido , Fraturas das Costelas , Tórax Fundido/etiologia , Tórax Fundido/cirurgia , Humanos , PaisRESUMO
BACKGROUND: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality. METHODS: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality. RESULTS: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001). CONCLUSION: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE.
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Traumatismos Abdominais/epidemiologia , Veia Ilíaca/lesões , Lesões do Sistema Vascular/epidemiologia , Veia Cava Inferior/lesões , Tromboembolia Venosa/epidemiologia , Ferimentos Penetrantes/epidemiologia , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Traumatismos Abdominais/cirurgia , Adulto , Bases de Dados Factuais , Feminino , Humanos , Veia Ilíaca/cirurgia , Ligadura , Masculino , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/mortalidade , Lesões do Sistema Vascular/cirurgia , Veia Cava Inferior/cirurgia , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/mortalidade , Ferimentos Penetrantes/diagnóstico , Ferimentos Penetrantes/mortalidade , Ferimentos Penetrantes/cirurgia , Adulto JovemRESUMO
OBJECTIVE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and in-hospital mortality among patients undergoing REBOA for trauma. METHODS: The National Trauma Data Bank (2015-2017) was queried for patients presenting to trauma centers and treated with REBOA. We included REBOA performed on hospital day 1 in patients who survived 6 or more hours from presentation. Univariable and multivariable analyses evaluated associations with major amputation and in-hospital mortality. RESULTS: A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years and the majority were male (73%) and White (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score (ISS) of 31 ± 15, indicating major trauma. In 15 patients (5%), there were 18 major amputations-7 above knee and 11 below knee. A subgroup of 11 amputations were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity injuries of serious to severe Abbreviated Injury Scale severity. Comparing patients with amputations with those without amputations, there were no significant differences in patient demographics, comorbidities, or hospital characteristics. During hospitalization, patients requiring amputation more frequently received open peripheral vascular interventions (40% vs 10%; P = .002), underwent similar numbers of endovascular interventions (6.7% vs 4.7%; P = .5), and more often developed compartment syndrome (13% vs 2%; P = .04). Overall, there were 110 deaths (35%). The major amputation prevalence was similar between patients who died vs those who survived (3.6% vs 5.3%; P = .5). In multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), decreased Glasgow Coma Scale score (OR, 1.18; 95% CI, 1.05-1.32; P = .01), older age (OR, 1.06; 95% CI, 1.03-1.10; P < .001), and increased Injury Severity Score (OR, 1.05; 95% CI, 1.0-1.1; P = .03) were associated with higher mortality. CONCLUSIONS: The majority of major amputations in patients undergoing REBOA were secondary to the initial traumatic mechanism. Injury type and severity, as well as initial hemodynamic derangements, are associated with mortality after REBOA. Despite concerns about prohibitive limb complications of REBOA, baseline injuries seem to be the primary cause of limb loss, but further prospective analysis is needed.
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Amputação Cirúrgica , Aorta/lesões , Oclusão com Balão/efeitos adversos , Ressuscitação/efeitos adversos , Ferimentos e Lesões/terapia , Adulto , Idoso , Amputação Cirúrgica/efeitos adversos , Amputação Cirúrgica/mortalidade , Aorta/diagnóstico por imagem , Aorta/fisiopatologia , Oclusão com Balão/mortalidade , Bases de Dados Factuais , Feminino , Hemodinâmica , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Masculino , Pessoa de Meia-Idade , Ressuscitação/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/fisiopatologiaRESUMO
BACKGROUND: Outcomes after surgical stabilization of rib fractures (SSRF) have not been studied in patients with multiple rib fractures and traumatic brain injury (TBI). We hypothesized that SSRF, as compared with nonoperative management, is associated with favorable outcomes in patients with TBI. METHODS: A multicenter, retrospective cohort study was performed in patients with rib fractures and TBI between January 2012 and July 2019. Patients who underwent SSRF were compared to those managed nonoperatively. The primary outcome was mechanical ventilation-free days. Secondary outcomes were intensive care unit length of stay and hospital length of stay, tracheostomy, occurrence of complications, neurologic outcome, and mortality. Patients were further stratified into moderate (GCS score, 9-12) and severe (GCS score, ≤8) TBI. RESULTS: The study cohort consisted of 456 patients of which 111 (24.3%) underwent SSRF. The SSRF was performed at a median of 3 days, and SSRF-related complication rate was 3.6%. In multivariable analyses, there was no difference in mechanical ventilation-free days between the SSRF and nonoperative groups. The odds of developing pneumonia (odds ratio [OR], 0.59; 95% confidence interval [95% CI], 0.38-0.98; p = 0.043) and 30-day mortality (OR, 0.32; 95% CI, 0.11-0.91; p = 0.032) were significantly lower in the SSRF group. Patients with moderate TBI had similar outcome in both groups. In patients with severe TBI, the odds of 30-day mortality was significantly lower after SSRF (OR, 0.19; 95% CI, 0.04-0.88; p = 0.034). CONCLUSION: In patients with multiple rib fractures and TBI, the mechanical ventilation-free days did not differ between the two treatment groups. In addition, SSRF was associated with a significantly lower risk of pneumonia and 30-day mortality. In patients with moderate TBI, outcome was similar. In patients with severe TBI a lower 30-day mortality was observed. There was a low SSRF-related complication risk. These data suggest a potential role for SSRF in select patients with TBI. LEVEL OF EVIDENCE: Therapeutic, level IV.
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Lesões Encefálicas Traumáticas/complicações , Fixação de Fratura , Fraturas Múltiplas/complicações , Fraturas Múltiplas/cirurgia , Fraturas das Costelas/complicações , Fraturas das Costelas/cirurgia , Adulto , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/terapia , Cuidados Críticos , Feminino , Fraturas Múltiplas/diagnóstico , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Respiração Artificial , Estudos Retrospectivos , Fraturas das Costelas/diagnóstico , Resultado do TratamentoRESUMO
BACKGROUND: The coronavirus disease 2019 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center, a regional safety-net hospital, the Department of Surgery created a dedicated coronavirus disease 2019 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in coronavirus disease 2019 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams. METHODS: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment. Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated surgeon-led team would perform invasive bedside procedures expeditiously and with few complications. RESULTS: From March 30, 2020 to April 30, 2020, there were 1,196 coronavirus disease 2019 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax. CONCLUSION: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be redirected to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources.
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Betacoronavirus , Infecções por Coronavirus/epidemiologia , Transmissão de Doença Infecciosa/prevenção & controle , Pandemias , Equipamento de Proteção Individual/provisão & distribuição , Pneumonia Viral/epidemiologia , Provedores de Redes de Segurança/organização & administração , Cirurgiões/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19 , Infecções por Coronavirus/transmissão , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Pneumonia Viral/transmissão , Estudos Retrospectivos , SARS-CoV-2 , Estados Unidos/epidemiologia , Adulto JovemRESUMO
This article provides a theoretical and practical rational for the implementation of an innovative and comprehensive social wellness program in a surgical residency program at a large safety net hospital on the East Coast of the United States. Using basic needs theory, we describe why it is particularly important for surgical residency programs to consider the residents sense of competence, autonomy, and belonging during residence. We describe how we have developed a comprehensive program to address our residents' (and residents' families) psychological needs for competence, autonomy, and belongingness.