Trauma and Death in the Emergency Department: A Time to PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life).

BACKGROUND: Witnessing death can be difficult and emotionally draining for health care workers and presents a risk factor for burnout. The practice of a ritual pause at patient death to recognize the patient as a person, reflect, and acknowledge the health care team is an emerging intervention that has not been well studied in trauma. OBJECTIVE: This study aims to explore the effect of a team pause on trauma team member attitudes after emergency department patient death. METHODS: This is a pre- and postintervention study of the implementation of a Trauma PAUSE (Promoting Acknowledgment, Unity, and Sympathy at the End of Life) conducted from March 2018 to June 2020. RESULTS: A total of 466 participated in this study. Emergency department employee responses to the pre- (296 of 745 employees contacted responded) and postimplementation surveys (170 of 732 employees contacted responded) were compared. Although not statistically significant, responses to the postsurvey suggested an increased connection to patients and belief in the need for a moment of silence following a death. Employees who had participated in a PAUSE (57/170) reported improvements in internal conflict, feeling of emptiness, resilience, and ability to move on to the next task. Overall, 84.2% (48/57) of Trauma PAUSE participants were satisfied with the Trauma PAUSE. CONCLUSION: The Trauma PAUSE is a meaningful way to help trauma staff members find peace, maintain resiliency, and readily shift their focus to providing care to other patients.

The role of palliative care in acute trauma: When is it appropriate?

INTRODUCTION: We hypothesized that trauma providers are reticent to consider palliative measures in acute trauma care. METHODS: An electronic survey based on four patient scenarios with identical vital signs and serious blunt injuries, but differing ages and frailty scores was sent to WTA and EAST members. RESULTS: 509 (24%) providers completed the survey. Providers supported early transition to comfort care in 85% old-frail, 53% old-fit, 77% young-frail, and 30% young-fit patients. Providers were more likely to transition frail vs. fit patients with (OR = 4.8 [3.8-6.3], p < 0.001) or without (OR = 16.7 [12.5-25.0], p < 0.001) an advanced directive (AD) and more likely to transition old vs. young patients with (OR = 2.0 [1.6-2.6], p < 0.001) or without (OR = 4.2 [2.8-5.0], p < 0.001) an AD. CONCLUSIONS: In specific clinical situations, there was wide acceptance among trauma providers for the early institution of palliative measures. Provider decision-making was primarily based on patient frailty and age. ADs were helpful for fit or young patients. Provider demographics did not impact decision-making.

International Surgery Electives During General Surgery Residency: A 9-Year Experience at an Independent Academic Center.

OBJECTIVE: International experiences are an increasingly emphasized feature of general surgery residency programs. In 2008, an international elective (IE) was implemented for general surgery residents at our institution. This effort was augmented by the establishment of a pathway for formal approval of IEs by the American Board of Surgery and Accreditation Council for Graduate Medical Education in 2012. DESIGN: A retrospective review of Accreditation Council for Graduate Medical Education case logs was completed. IE operative volumes were compared to home institution general surgery service volumes. An electronic survey of IE participants was conducted to assess preresidency goals, prior international exposure, overall experience on IEs, and current or planned engagement with international experiences, volunteerism, or global philanthropy. SETTING: Independent Academic Medical Center. PARTICIPANTS: Fourteen general surgery residents who participated in IEs from 2008 to 2017. RESULTS: IE locations included the Dominican Republic (9), Ecuador (1), Ethiopia (3), and Nicaragua (1). IEs were a first-time international surgical experience for 10 (71%) residents. Nine (64%) reported that they would not or may not have participated in an IE during residency had established opportunities not been available. Ten residents had graduated at the time of this study and 3 of them have participated in international service. Median case volumes were 17 cases per week during IEs compared to 8 cases per week for residents on home institution rotations. Residents were exposed to a variety of first-time operations during IEs including open cholecystectomies, gynecologic procedures, thyroidectomies for goiter, and prostatectomies. CONCLUSIONS: Incorporation of IEs into our general surgery residency has demonstrated numerous benefits. IE participation provides valuable operative experience in both volume and variety, and can be especially impactful for those who may not have elected to pursue such opportunities independently. These experiences have the potential to empower general surgery residents to invest in similar practices and acts of generosity in their future careers.

An Unusual Subcutaneous Mass in an Otherwise Healthy Patient: A Case Report of Localized Histoplasmosis Diagnosed on Excisional Biopsy.

Patients are commonly referred to general surgery clinics for evaluation of soft-tissue masses of the trunk and extremities. The primary goal of surgical referral is to confirm the presence of a mass, to assess the need for additional imaging and/or testing, and to gauge amenability to surgical biopsy, whether incisional or excisional. This is a case of a 67-year-old woman who was referred to surgery clinic for a small soft-tissue mass near her left elbow that had increased in size and pain over the past year. The mass had been present for several years. After MRI imaging revealed a nonspecific process, an excisional biopsy was performed. Following a careful review of the patient's history, risk factors, and histological results, a diagnosis of localized subcutaneous Histoplasma capsulatum var. capsulatum infection was made. Without signs or symptoms of active, systemic disease, no further treatment was recommended. The patient was provided risk factor counseling for symptoms or signs of active histoplasmosis and outpatient follow-up. Histologically, most masses will return as benign and mesenchymal in origin. However, soft-tissue masses may arise from uncommon etiologies and a broad differential is needed to ensure appropriate management and recommendations.