A Sisyphean Task for Residents: Preparing Literature Reviews About Adverse Events Presented at Morbidity and Mortality Conferences.

OBJECTIVE: Surgery Morbidity and Mortality (M&M) presentations include a thorough literature review. This requires a significant amount of time expenditure frequently incompatible with the current surgical resident work hours. Additionally, literature reviews can be redundant for commonly encountered adverse events. The goal of this study was to explore (a) how surgery residents perform literature reviews, and (b) how repetitive presented adverse events are. DESIGN: A survey was sent out during the academic year 2019-2020. The Morbidity and Mortality repository for that academic year was indexed, and the proportion of adverse events having occurred more than once calculated. The amount of time spent on literature reviews, proportion of repetitive adverse events as well as degree of thoroughness of reviews was evaluated on a 1 to 5 Likert scale. SETTING: Tulane University General Surgery program, New Orleans, LA, USA. PARTICIPANTS: All clinically active residents. RESULTS: All residents, filled out the survey. Seventeen out of 29 (58.6%) residents reported dedicating approximately one hour performing literature reviews. Median studying time was 1 hour (interquartile range: 1-1.5 hours). Seventeen out of 29 (58.6%) residents employed 2 resources. The most common combination of resources was PubMed and Google (11/29, 37.9%). Most residents (21/29, 72.4%) believed that their thoroughness was at most average (≤3/5 on a Likert scale) and 27/29 (93.1%) believed that their literature review could have been more thorough. More than half of the adverse events presented were found to be redundant during that academic year. CONCLUSIONS: Time spent reviewing the literature does not allow for a thorough review, and a significant portion of adverse events presented are redundant. A central repository for literature reviews of adverse events would improve the quality of reviews and avoid duplicating efforts.

AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma.

BACKGROUND: Tourniquet use for extremity hemorrhage control has seen a recent increase in civilian usage. Previous retrospective studies demonstrated that tourniquets improve outcomes for major extremity trauma (MET). No prospective study has been conducted to date. The objective of this study was to evaluate outcomes in MET patients with prehospital tourniquet use. We hypothesized that prehospital tourniquet use in MET decreases the incidence of patients arriving to the trauma center in shock. METHODS: Data were collected prospectively for adult patients with MET at 26 Level I and 3 Level II trauma centers from 2015 to 2020. Limbs with tourniquets applied in the prehospital setting were included in the tourniquet group and limbs without prehospital tourniquets were enrolled in the control group. RESULTS: A total of 1,392 injured limbs were enrolled with 1,130 tourniquets, including 962 prehospital tourniquets. The control group consisted of 262 limbs without prehospital tourniquets and 88 with tourniquets placed upon hospital arrival. Prehospital improvised tourniquets were placed in 42 patients. Tourniquets effectively controlled bleeding in 87.7% of limbs. Tourniquet and control groups were similarly matched for demographics, Injury Severity Score, and prehospital vital signs (p > 0.05). Despite higher limb injury severity, patients in the tourniquet group were less likely to arrive in shock compared with the control group (13.0% vs. 17.4%, p = 0.04). The incidence of limb complications was not significantly higher in the tourniquet group (p > 0.05). CONCLUSION: This study is the first prospective analysis of prehospital tourniquet use for civilian extremity trauma. Prehospital tourniquet application was associated with decreased incidence of arrival in shock without increasing limb complications. We found widespread tourniquet use, high effectiveness, and a low number of improvised tourniquets. This study provides further evidence that tourniquets are being widely and safely adopted to improve outcomes in civilians with MET. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Frequency and Characteristics of Social Media Use among General Surgery Trainees.

INTRODUCTION: With increased social isolation due to COVID-19, social media has been increasingly adopted for communication, education, and entertainment. We sought to understand the frequency and characteristics of social media usage among general surgery trainees. MATERIALS AND METHODS: General surgery trainees in 15 American training programs were invited to participate in an anonymous electronic survey. The survey included questions about demographics, frequency of social media usage, and perceptions of risks and benefits of social media. Univariate analysis was performed to identify differences between high users of social media (4-7 h per week on at least one platform) and low users (0-3 h or less on all platforms). RESULTS: One hundred fifty-seven of 591 (26.6%) trainees completed the survey. Most respondents were PGY3 or lower (75%) and high users of social media (74.5%). Among high users, the most popular platforms were Instagram (85.7%), YouTube (85.1%), and Facebook (83.6%). YouTube and Twitter were popular for surgical education (77.3% and 68.2%, respectively). The most reported benefits of social media were improving patient education and professional networking (85.0%), where high users agreed more strongly about these benefits (P = 0.002). The most reported risks were seeing other residents (42%) or attendings (17%) with unprofessional behavior. High users disagreed more strongly about risks, including observing attendings with unprofessional behavior (P = 0.028). CONCLUSIONS: Most respondents were high users of social media, particularly Instagram, YouTube, and Facebook. High users incorporated social media into their surgical education while perceiving more benefits and fewer risks of social media.

Prehospital Tourniquets Placed on Limbs Without Major Vascular Injuries, Has the Pendulum Swung Too Far?

BACKGROUND: Combat applications of tourniquets for extremity trauma have led to increased civilian prehospital tourniquet use. Studies have demonstrated that appropriate prehospital tourniquet application can decrease the incidence of arrival in shock without increasing limb complications. The aim of this study was to examine outcomes of prehospital tourniquet placement without definitive vascular injury. METHODS: Retrospective review was performed of a prospectively maintained database by the American Association for the Surgery of Trauma from 29 trauma centers. Patients in this subset analysis did not have a significant vascular injury as determined by imaging or intra-operatively. Patients who received prehospital tourniquets (PHTQ) were compared to patients without prehospital tourniquets (No-PHTQ). Outcomes were amputation rates, nerve palsy, compartment syndrome, and in-hospital mortality. RESULTS: A total of 622 patients had no major vascular injury. The incidence of patients without major vascular injury was higher in the PHTQ group (n = 585/962, 60.8 vs n = 37/88, 42.0%, P < .001). Cohorts were similar in age, gender, penetrating mechanism, injury severity scores (ISS), abbreviated injury score (AIS), and mortality (P > .05). Amputation rates were 8.3% (n = 49/585) in the PHTQ group compared to 0% (n = 0/37) in the No-PHTQ group. Amputation rates were higher in PHTQ than No-PHTQ with similar ISS and AIS (P = .96, P = .59). The incidence of nerve palsy and compartment syndrome was not different (P > .05). CONCLUSIONS: This study showed a significant amount of prehospital tourniquets are being placed on patients without vascular injuries. Further studies are needed to elucidate the appropriateness of prehospital tourniquets, including targeted education of tourniquet placement.

Empowering the Resident Learner.

Surgical resident autonomy is an essential element of the transition from supervised training to independent practice. However, in an age of duty hour restrictions, legislative constraints, increased litigation, and heightened societal expectations, training an autonomous resident proves increasingly difficult. To tackle these barriers to training successful surgeons, the American College of Surgeons Committee on Resident Education initiated the Resident Mentored Autonomy Project. As a subdivision of this project, the Empowered Learner research team here presents a framework for training the self-directed and empowered surgical resident learner. There are many strategies by which surgical faculty, program directors and chairs, and residents themselves may engage to improve resident operative autonomy.

Elevated K/iCa ratio is an ancillary predictor for mortality in patients with severe hemorrhage: A decision tree analysis.

INTRODUCTION: Trauma patients receiving massive transfusion protocol (MTP) are at risk of citrate-induced hypocalcemia and hyperkalemia. Here we evaluate potassium (K), ionized calcium (iCa), and K/iCa ratio as predictors of mortality. METHODS: This retrospective study includes all adult trauma patients who received MTP within 1 h at our level I trauma center between 2014 and 2019. Receiver operating characteristic curve analysis assessed predictive accuracy of K/iCa ratio at admission on 120-day mortality. RESULTS: Of 614 patients, 146 received MTP within 1 h and 38 expired. Patients who expired had higher K/iCa ratio than survivors (median [IQR] = 5.7 [3.8-7.2] vs 3.7 [3.1-4.9], p < 0.001). Area under the curve of K/iCa was 0.72 (95%CI = 0.62-0.82, p < 0.001) with sensitivity = 63.2% and specificity = 77.6%. At the optimum K/iCa cutoff (5.07), patients with high ratios had 4 times higher mortality risk (HR = 3.97, 95%CI = 1.89-8.32, p < 0.001). CONCLUSION: Elevated K/iCa ratio was an independent predictor of mortality in trauma patients managed with MTP.

New Injury Severity Score and Trauma Injury Severity Score are superior in predicting trauma mortality.

BACKGROUND: Trauma scores are used to give clinicians appropriate quantitative context in making decisions. Studies show that anatomical trauma scores predicted intensive care unit admission better, while physiological trauma scores predicted mortality better. We hypothesize that trauma scores have a hierarchy of efficacies at predicting mortality and operative decision making. METHODS: We performed a retrospective analysis of our trauma patient database at a level 1 trauma center from 2016 to 2020 and calculated the following trauma scores: Glasgow Coma Scale, Revised Trauma Score, Trauma Injury Severity Score, Injury Severity Score, Shock Index, and New Trauma Injury Severity Score (NISS). Receiver operating characteristic curves were used to evaluate the sensitivity and specificity of trauma scores for predicting mortality. RESULTS: A total of 738 patients were included (mean ± SD age, 35.7 ± 15.6 years). Area under the curve (AUC) results from the DeLong test showed that NISS predicted mortality the best compared with other trauma scores. New Trauma Injury Severity Score was superior in predicting mortality for penetrating trauma (AUC, 0.86 ± 0.02; p < 0.001) compared with blunt trauma (AUC, 0.73 ± 0.04; p < 0.001). Trauma Injury Severity Score was the best predictor of mortality for patients with gunshot wounds (AUC, 0.83; 95% confidence interval [CI], 0.73-0.92; p < 0.001), motor vehicle accidents (AUC, 0.80; 95% CI, 0.61-1.00; p = 0.01), and falls (AUC, 0.73; 95% CI, 0.61-0.85; p = 0.007). CONCLUSION: New Trauma Injury Severity Score was the best scoring index for predicting mortality in trauma patients, especially for penetrating trauma. Clinicians should consider incorporating other trauma scores, especially NISS and Trauma Injury Severity Score, in determining injury severity and the likelihood of mortality. These scores can help physicians determine the best course of action in patient management. LEVEL OF EVIDENCE: Prognostic and Epidemiologic; level IV.

Surgical stabilization of traumatic rib fractures is associated with reduced readmissions and increased survival.

BACKGROUND: Surgical stabilization for rib fractures (SSRF) in trauma patients remains controversial, with guidelines currently suggesting the procedure for only select patient groups. How surgical stabilization for rib fractures affect hospital readmission in patients with traumatic rib fractures is unknown. We hypothesized that surgical stabilization for rib fractures would not decrease the risk of readmission. METHODS: The National Readmission Database was examined for adults with any rib fractures from 2010 to 2017. Readmission up to 90 days was examined. Patients receiving surgical stabilization for rib fractures were compared with those receiving nonoperative treatment. RESULTS: In total, 864,485 patients met criteria, with 13,701 (1.6%) receiving SSRF. For patients receiving SSRF, 338 (1.5%) were readmitted. Readmitted patients had higher Charlson Comorbidity Index and were more likely to have flail chest. On multivariate propensity score-matched analysis, SSRF (Hazard Ratio [HR]: 0.55, 95% confidence interval [CI] 0.33-0.92, P = .022) was associated with reduced readmission. Addition of surgical stabilization for rib fractures to video-assisted thoracoscopic surgery (VATS) (Odds Ratio [OR]: 0.95, 95% CI 0.52-1.73, P = .86) or thoracotomy (OR: 1.97, 95% CI 0.83-4.70, P = .13) was not associated with increased readmission. On further propensity matched analysis, VATS + SSRF when compared with SSRF alone (HR: 0.75, 95% CI 0.18-3.20, P = .696), and VATS + SSRF when compared with VATS alone (HR: 0.49, 95% CI 0.11-2.22, P = .355) was also not associated with increased readmission. SSRF on primary admission was associated with increased in-hospital survival (HR: 0.27, 95% CI 0.22-0.32, P < .001). For patients with retained hemothorax who underwent VATS, addition of SSRF did not improve survival (HR = 0.92, 95% CI 0.58-1.46, P = .72). However, for patients requiring thoracotomy for retained hemothorax, concomitant SSRF was associated with improved survival (HR = 0.14, 95% CI 0.06-0.32, P < .001). CONCLUSION: Surgical stabilization for rib fractures is associated with reduced readmission risk while also being associated with improved survival. Patients who had a thoracotomy for retained hemothorax appear to especially benefit from concomitant surgical stabilization for rib fractures.

Surgical stabilization of rib fractures is associated with improved survival but increased acute respiratory distress syndrome.

BACKGROUND: How the surgical stabilization of rib fractures after trauma affects the development of acute respiratory distress syndrome and impacts survival has yet to be determined in a large database. We hypothesized that surgical stabilization of rib fractures would not decrease the incidence of acute respiratory distress syndrome. METHODS: The National Trauma Data Bank was queried for all traumatic rib fractures in 2016. Patients were divided into groups with single rib fractures, multiple rib fractures, and flail chest. Nonoperative therapy was compared with stabilization of rib fractures of 1 to 2 ribs or 3+ ribs. RESULTS: There were 114,972 total patients with rib fractures meeting inclusion criteria, with 5,106 (4.4%) having flail chest, 24,726 (21.5%) having single rib fractures, and 85,140 (74.1%) having multiple rib fractures. Those with flail chest (15.9%) were most likely to get rib plating in comparison to multiple rib fractures (0.9%) and single rib fractures (0.2%); P < .001. On logistic regression, surgical stabilization of rib fractures 1 to 2 ribs (odds ratio: 0.17, 95% confidence interval: 0.10-0.28) or 3+ ribs (odds ratio: 0.17, 95% confidence interval: 0.11-0.28), with nonoperative therapy as the reference was associated with survival. Variables associated with mortality included increasing age, male sex, increasing injury severity score, decreased Glasgow coma scale, requirement of transfusions, and hypotension on admission. Surgical stabilization of rib fractures 3+ ribs (odds ratio: 2.30, 95% confidence interval: 1.58-3.37) was associated with acute respiratory distress syndrome but not 1 to 2 ribs (odd ratio: 1.55, 95% confidence interval: 0.97-2.48). On logistic regression of only patients with flail chest, stabilization of rib fractures was associated with decreased mortality but not increased risk of acute respiratory distress syndrome. CONCLUSION: The increased risk of acute respiratory distress syndrome should be considered in the preoperative assessment for stabilization of rib fractures.

Should Surgery Residents Receive Pre-operative Skin Preparation Training: An Association of Program Directors in Surgery Survey.

PURPOSE: Surgical site infections (SSI) are a significant source of peri-operative morbidity and a financial burden on the healthcare system. Effective pre-operative skin preparation has been shown to reduce SSI incidence, however studies demonstrated that most healthcare providers do not adhere to proper techniques. Skin prep technique is not taught to U.S. surgical residents in a standardized format. The objective of this study was to perform a survey of U.S. surgical training programs to determine the practice patterns of surgical resident education on the proper techniques of pre-operative antiseptic surgical prep. METHODS: An 18-question anonymous survey was created using the Qualtrics platform. The survey was distributed to members of the Association of Program Directors in Surgery listserv over a 2-month period. Responses were compiled and data analysis was performed. RESULTS: The survey response rate was 30% (n = 85/280). 81% of respondents reported that surgery residents are responsible for performing pre-operative skin prep at their institutions. The same proportion (81%) reported that they feel surgical skin prep techniques are an important component of surgical resident education. However, only 42% reported that their residents are provided formal education regarding proper skin prep techniques and only 6% reported that their residents are required to take a written or practical proficiency exam. 42% of respondents felt that formal skin prep education for residents is likely to affect the rate of surgical site infections. CONCLUSIONS: Surgical residents commonly perform pre-operative skin preparation. However, few residents receive formal education or evaluation of these skills. Given the importance of pre-operative skin preparation in reducing SSIs and the potential for patient harm if performed incorrectly, the results from this study raise the question of whether formal surgical resident education regarding pre-op skin prep should be more widely adopted and standardized.

Computed tomography angiography in the "no-zone" approach era for penetrating neck trauma: A systematic review.

BACKGROUND: Penetrating neck trauma (PNT) continues to present a diagnostic dilemma. Practice guidelines advocate the use of computed tomography angiography (CTA) for suspected vascular or aerodigestive injuries in all neck zones. There is also an evolving evidence of "no-zone" approach where the decision to obtain a CTA is guided by physical examination findings and clinical presentation. The aim of this systematic review was to examine existing literature on the diagnostic accuracy of CTA as an integral component of the no-zone approach in stable patients with PNT. METHODS: We performed a systematic review using an electronic search of three databases (PubMed, Medline, Cochrane Review) from 2000 to 2017. RESULTS: A total of 5 prospective and 8 retrospective studies were included. The sensitivity of CTA ranged from 83% to 100%; specificity, from 61% to 100%; positive predictive value, from 30% to 100%; and negative predictive value, from 90% to 100%. Three studies reported high sensitivity and specificity for the detection of vascular injuries but low specificity for aerodigestive tract injuries. When stratified by clinical presentation, CTA had a sensitivity of 89.5% to 100% and specificity of 61% to 100% in stable patients presenting with soft signs (SSs). In a combined group of stable patients with either hard signs (HSs) or SSs, the sensitivity of CTA was 94.4% to 100% and the specificity was 96.7% to 100%. Among patients presenting with HSs, the sensitivity of CTA was 78.6% to 90% and the specificity was 100%. CONCLUSIONS: This is the first systematic review to examine the role of CTA in PNT. In combination with physical examination, CTA demonstrated a reliable high sensitivity and specificity for detecting injuries in PNT in stable patients with SSs of injury and select patients with HSs of injury. These results support the management of PNT using no-zone approach based on physical examination and the use of CTA in stable patients. LEVEL OF EVIDENCE: Systematic review, level IV.

A Structured Quality Improvement Educational Curriculum Increases Surgical Resident Involvement in QI Processes.

OBJECTIVE: Patient safety and quality improvement (QI) processes are vitally important to healthcare systems. Training and experience in QI processes are mandated by the Accreditation Council for Graduate Medical Education (ACGME) for general surgery residents. The execution and efficacy of these training programs in residencies have thus far been inconsistent. The purpose of this study was to assess the effectiveness of our surgical residency's QI educational program. METHODS: We instituted a formalized QI educational program for all residents in our academic general surgery residency program from 2018 to 2019. The curriculum included didactics, online educational resources, peer-group collaboration, and faculty mentorship. Residents performed a self-assessment survey of their knowledge, skill, and comfort levels with QI processes before and after the program using a 10-point Likert scale. The number of QI projects conducted, presented, and subsequently prepared for publication was enumerated. The ACGME resident survey program results regarding resident involvement in QI processes before and after program implementation were compared. RESULTS: After 1 year of the program, residents demonstrated significant increases in average self-assessed knowledge of QI processes (6.4 vs. 4.0, p < 0.05), knowledge of local QI resources (5.4 vs. 3.3, p < 0.05), and confidence in their ability to develop and implement a QI project (6.3 vs. 3.9, p < 0.05). The average number of QI projects each resident participated in the year preceding the program vs. during the program increased from 0.4 to 1.8 (p < 0.05). Ten of 26 residents (38%) reported no direct involvement in a QI project the preceding year before the QI program implementation, while 26/26 (100%) of residents reported direct involvement in at least 1 QI project during the implementation year. Residency program ACGME survey results regarding resident participation in QI increased from 86% (just below the national average of 87%) before the development of the QI program to 97% after program implementation. CONCLUSION: Implementation of a formalized, structured quality improvement education program for surgery residents significantly increased residents' participation in QI projects, as well as increasing their confidence in their knowledge and skillset to perform QI processes. The residency program's ACGME resident survey results regarding resident involvement in QI also improved during program implementation.

Correlation of ride sharing service availability and decreased alcohol-related motor vehicle collision incidence and fatality.

BACKGROUND: Alcohol-related motor vehicle collisions (AR-MVCs) account for ~30% of all US traffic fatalities. Ride-sharing services (RSS) have existed since 2010, but few studies to date have investigated their impact on AR-MVCs. We hypothesized that the availability of RSS would be correlated with a decrease in AR-MVCs at an urban Level I trauma center. METHODS: A retrospective chart review was conducted of all AR-MVC trauma activations at a Level I trauma center from 2012 to 2018. Additional data were gathered from regional governmental traffic and law enforcement databases, including crash incidence, fatalities, and demographics. Data were compared pre- and post-RSS and analyzed using an unpaired t test with p less than 0.05 considered significant. RESULTS: There were 1,474 patients in AR-MVCs during the study period. There was a significant decrease in the annual average proportion of MVCs that were AR-MVCs pre- vs. post-RSS (39% vs. 29%, p = 0.02) as well as a decrease in the average annual incidence of fatal AR-MVCs (11.6 vs. 5, p = 0.02). Subset analysis showed a decrease in AR-MVC incidence in 18- to 29-year-olds (12.7% vs. 7.5%; p = 0.03), which was also demonstrated by data from a local law enforcement database. Availability of RSS was also correlated with a decreased proportion of nighttime AR-MVCs (14.7% vs. 7.6%, p = 0.03) and decreased number of driving while intoxicated (1198.0 ± 78.5 vs. 612.8 ± 137.6, p = <0.01). CONCLUSION: We found that the incidence of both total AR-MVCs and fatal AR-MVCs presenting to our trauma center decreased after the introduction of RSS. Ride-sharing services may play a role in preventing AR-MVCs. Further research is needed to correlate AR-MVC incidence with granular proprietary RSS usage data and to account for any confounding factors. Future studies may identify ways to better utilize RSS availability as a targeted intervention for certain demographic groups to prevent AR-MVCs. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Impact of trauma center volume on major vascular injury: An analysis of the National Trauma Data Bank (NTDB).

BACKGROUND: The association of procedure volume and improved outcomes has been established with infrequently performed elective operations. However, effect of trauma center volume on outcomes in emergency surgery has not been defined. We hypothesized that high volume centers (HVC) would provide better outcomes for operative major vascular injuries (MVI) than low volume centers (LVC). METHODS: The NTDB was queried from 2010 to 2014. Patients with MVI were identified and HVC were compared to LVC. HVC were defined as >480 patients per year with ISS≥15. RESULTS: There were 37,125 patients with MVI, with 16,461 (44.3%) managed operatively. Of these, 15,965 (97%) underwent surgery at HVC and 496 (3%) at LVC. There was no difference in shunt utilization, however, HVC were more likely to utilize endovascular repair (31.0% vs. 21.9%, p < 0.001). Rates of death, amputation, and compartment syndrome were similar. HVC were more likely to develop pneumonia or sepsis. On logistic regression, HVC was not associated with survival (OR: 0.90, 95%CI: 0.60-1.34, p = 0.60). Variables associated with mortality for HVC and LVC included thoracic arterial injury (OR: 1.57, 95%CI: 1.27-1.94, p < 0.001), penetrating mechanism (OR:1.84, 95%CI: 1.57-2.15, p < 0.001), and open repair (OR: 1.95, 95%CI: 1.69-2.26, p < 0.001). Lower ISS (OR: 0.29, 95%CI: 0.24-0.34, p < 0.001) and higher presenting blood pressure (OR: 0.99, 95%CI: 0.99-1.00, p < 0.001) were associated with survival. CONCLUSIONS: Although LVC may have less proficiency with endovascular techniques, trauma center volume does not influence survival in emergency surgery for MVI.

Burnout and its relationship with perceived stress, self-efficacy, depression, social support, and programmatic factors in general surgery residents.

BACKGROUND: Burnout affects surgical residents' well-being. OBJECTIVE: We sought to identify factors associated with burnout among surgery residents. METHODS: An electronic/anonymous survey was sent to surgical residents at 18 programs, consisting of demographic/programmatic questions and validated scales for burnout, depression, perceived stress, self-efficacy, and social support. Residents were grouped into quartiles based off burnout, and predictors were assessed using univariate and multivariate analyses. RESULTS: 42% of residents surveyed completed it. Burnout was associated with depression, higher perceived stress/debt, fewer weekends off, less programmatic social events, and residents were less likely to reconsider surgery if given the chance. Low burnout was associated with lower depression/stress, higher social support/self-efficacy, more weekends off per month, program mentorship, lower debt, and residents being more likely to choose surgery again if given the chance. On multivariate analysis, higher depression/perceived stress were associated with burnout, and lower burnout scores were associated with lower stress/higher self-efficacy. CONCLUSIONS: Burnout in surgery residents is associated with higher levels of depression and perceived stress. The addition of programmatic social events, limiting weekend work, and formal mentoring programs may decrease burnout.

Bicycle lanes: Are we running in circles or cycling in the right direction?

BACKGROUND: The number of urban bicyclists has grown exponentially across the United States. Bike lanes were created to promote a safe environment for both motorist and cyclists, but few studies have specifically addressed the outcomes of these interventions. The aim of this study was to analyze the effect of bike lanes on bicycle usage and safety in a major urban city. METHODS: A retrospective chart review of consecutive adult trauma patients presenting at an urban Level I trauma center due to motor vehicle versus bicycle collisions from January 1, 2007, to January 28, 2017, was performed. Cohorts were stratified into prebicycle and postbicycle lane implementation for analysis. RESULTS: Bicycle use during the study period increased almost three fold (1,672 vs. 6,060, p < 0.0001). There was also a spike in the percent of yearly bicyclists as trauma patients during the 10-year period (0.7% vs. 1.5%, p < 0.05). A total of 184 patients brought to the trauma center were identified. Significant differences between the prebike lane and postbike lane groups were identified for average Injury Severity Score (12.7 ± 1.7 vs. 8.0 ± 0.6 p = 0.0134), Glasgow Coma Scale score on arrival (12.6 ± 0.7 vs. 13.9 ± 0.2, p = 0.0171), proportion of head and face injuries (59.4% to 38.8%, p = 0.047), and patients requiring surgical intervention (100% to 55.9%, p < 0.0001). CONCLUSION: As bicycle lanes become increasing popular in US cities, it is important to review the success of this intervention on improving safety. Preliminary results from this study suggest that the implementation of urban bike lanes improved bicyclist safety. Further studies should focus on specific injury prevention programs, which could help to target areas such as helmet use and riding a bicycle while impaired to help improve overall safety. LEVEL OF EVIDENCE: Prognostic and epidemiological, level IV.

Pediatric firearm incidents: It is time to decrease on-scene mortality.

BACKGROUND: Previous epidemiological studies on pediatric firearm mortality have focused on overall mortality rather than on-scene mortality. Despite advances in trauma care, the number of potentially preventable deaths remains high. This study used the National Emergency Medical Services Information Systems database to characterize patterns of on-scene mortality in order to identify patients who may benefit from changes to prehospital care practices. METHODS: National Emergency Medical Services Information Systems database was searched for all pediatric firearm incidents from 2010 to 2015. Data on demographics, anatomic location of injury, intent and location of incident, and on-scene mortality were analyzed using Student's t test for continuous variables and χ test for categorical variables. A linear regression model was used to calculate independent predictors of mortality. RESULTS: Sixteen thousand eight hundred eight patients were identified, with a mortality rate of 6.1%. Most mortalities suffered cardiac arrest on-scene; 72.6% of these were prior to Emergency Medical Services (EMS) arrival, which carried a significantly higher mortality rate than arrest after EMS arrival. No difference was seen in anatomic location of injury in those who arrested before and after EMS arrival. Compressible injuries were most common with the lowest mortality. Noncompressible injuries together accounted for 25.8% of injuries and 23.5% of mortalities. CONCLUSION: To our knowledge, this is the largest study of on-scene mortality in pediatric firearm injury. Cardiac arrest prior to EMS arrival was a considerable source of on-scene mortality; significantly more of these patients died than those who arrested after EMS arrival. The mortality of compressible injuries was very low, implying that use of compression and tourniquets have been effective in stopping life-threatening extremity bleeding. Noncompressible injury mortality could be decreased with education of bystanders and more aggressive on-scene intervention. Through the evaluation of on-scene mortality specifically, this study offers insight into potential areas of focus to improve prehospital care of pediatric gunshot victims. LEVEL OF EVIDENCE: Therapeutic/Care management, level IV.

Effect of Community and Academic Surgical Rotation Sites on Medical Student Performance Outcomes and Career Choices.

OBJECTIVE: We hypothesize that students exposed to both academic and community surgery clerkship sites will have higher National Board of Medical Examiners Subject Exam in Surgery (NBME SES) scores and be more likely to pursue a career in a surgical specialty. DESIGN: The NBME surgery subject exam scores and National Resident Matching Program (NRMP) results were collected for all medical students rotating through the surgery clerkship over 4 years. Permutations of sites were analyzed against exam scores and match rates into surgical and nonsurgical specialties. SETTING: This study was performed at the Tulane University School of Medicine, in New Orleans, Louisiana, United States of America. PARTICIPANTS: Data for a total of 910 students rotating through the surgery clerkship over a period of 4 years was collected and analyzed. RESULTS: There was no statistical difference in NBME subject exam scores (p = 0.44) or match rates into a surgical specialty (p = 0.13) as stratified by site placement. Average NBME surgery subject exam scores were higher for those pursuing a surgical specialty (p < 0.001). CONCLUSIONS: The combination of sites experienced during the surgery clerkship did not affect NBME surgery subject exam scores nor lead to a tendency to match into a surgical specialty.