Application of an external fixator vascular compressor (EFVC) in the critically injured trauma patient: a novel damage control technique.

Methods of controlling hemorrhage in penetrating abdominal injuries are varied, ranging from electrocautery, ligation, laparotomy sponge packing, angiography, hemostatic agents, and direct manual pressure. Unfortunately, traditional methods are sometimes unsuccessful due to the location or nature of the hemorrhage, and manual pressure cannot be held indefinitely. We describe a novel damage control technique for hemorrhage control in these situations, followed by three cases where an external fixator vascular compressor (EFVC) was used to hold continual pressure. Three patients are presented to a Level 1 trauma center following multiple ballistic injuries, all requiring emergent exploratory laparotomy. The first had a two-pin iliac crest EFVC placed during repeat exploratory laparotomy to control bleeding. The second patient had a supra-acetabular EFVC placed during initial exploratory laparotomy after emergent embolization failed to control bleeding from the L3 vertebral body. The third patient had a two-pin iliac crest EFVC placed at initial exploratory laparotomy due to uncontrollable bleeding from the sacral venous plexus and internal iliac veins. Of the three patients, two stabilized and survived, while one passed away due to multi-organ failure. We describe a novel damage control technique that may be a useful means of temporarily stemming intraabdominal bleeding that is otherwise recalcitrant to traditional hemostatic methods. Additionally, we provided a limited case series of patients who have undergone this technique to illustrate its utility and versatility. This technique is simple, fast, effective, and adaptable to a variety of circumstances that may be encountered in patients with intraabdominal bleeding recalcitrant to conventional hemorrhage control.

Surgical Versus Endovascular Aortic Aneurysm Repair: Evidence to Guide the Optimal Approach for the Individual Patient.

The choice between an open surgical and an endovascular approach for abdominal aortic aneurysm (AAA) repair remains an individualized clinical decision. As the technology and applications of endovascular aortic aneurysm repair (EVAR) continue to evolve, so does the literature investigating its outcomes. Multiple high-quality, randomized controlled trials comparing EVAR to open surgical repair (OSR) have now been published with long-term follow-up. Experience with ruptured aneurysms and the use of complex endografts is growing as well. This review is an up-to-date compilation of pertinent clinical trials for practitioners placed in the context of individual patient considerations to guide the choice of an optimal approach to the management of AAAs.

Update on the status of infrarenal AAA devices.

There are a variety of endografts currently available for endovascular repair of abdominal aortic aneurysms. Aneurysms of increasing anatomic complexity are being repaired with devices that are either newly approved or redesigned relative to the initial published experience with infrarenal endovascular aortic aneurysm repair (EVAR). This article describes the contemporary devices approved for infrarenal EVAR in the United States and includes an up-to-date compilation of the data addressing outcomes specific to each device.

A National Longitudinal Survey of Medical Students' Intentions to Practice Among the Underserved.

PURPOSE: To explore students' intentions to practice in medically underserved areas. METHOD: In January 2011, 960 third-year medical students from 24 MD-granting U.S. medical schools were invited to participate in a survey on their intention to practice in a medically underserved area. A follow-up survey was sent to participants in September 2011. Covariates included student demographics, medical school characteristics, environmental exposures, work experiences, sense of calling, and religious characteristics. RESULTS: Adjusted response rates were 564/919 (61.4%, first survey) and 474/564 (84.0%, follow-up survey). Among fourth-year medical students, an estimated 34.3% had an intention to practice among the underserved. In multivariate logistic regression modeling, predictors for intentions to practice among the underserved included growing up in an underserved setting (odds ratio [OR] range: 2.96-4.81), very strong sense of calling (OR range: 1.86-3.89), and high medical school social mission score (in fourth year: OR = 2.34 [95% confidence interval (CI), 1.31-4.21]). International experience was associated with favorable change of mind in the fourth year (OR = 2.86 [95% CI, 1.13-7.24]). High intrinsic religiosity was associated with intentions to practice primary care in underserved settings (in fourth year: OR = 2.29 [95% CI = 1.13-4.64]). CONCLUSIONS: Growing up in medically underserved settings, work experience in religiously affiliated organizations, very strong sense of calling, and high medical school social mission score were associated with intentions to practice in underserved areas. Lack of formative educational experiences may dissuade students from considering underserved practice.