Defining and Measuring Decision-Making for the Management of Trauma Patients.

BACKGROUND: Effective management of trauma patients is heavily dependent on sound judgment and decision-making. Yet, current methods for training and assessing these advanced cognitive skills are subjective, lack standardization, and are prone to error. This qualitative study aims to define and characterize the cognitive and interpersonal competencies required to optimally manage injured patients. METHODS: Cognitive and hierarchical task analyses for managing unstable trauma patients were performed using qualitative methods to map the thoughts, behaviors, and practices that characterize expert performance. Trauma team leaders and board-certified trauma surgeons participated in semistructured interviews that were transcribed verbatim. Data were supplemented with content from published literature and prospectively collected field notes from observations of the trauma team during trauma activations. The data were coded and analyzed using grounded theory by 2 independent reviewers. RESULTS: A framework was created based on 14 interviews with experts (lasting 1-2 hours each), 35 field observations (20 [57%] blunt; 15 [43%] penetrating; median Injury Severity Score 20 [13-25]), and 15 literary sources. Experts included 11 trauma surgeons and 3 emergency physicians from 7 Level 1 academic institutions in North America (median years in practice: 12 [8-17]). Twenty-nine competencies were identified, including 17 (59%) related to situation awareness, 6 (21%) involving decision-making, and 6 (21%) requiring interpersonal skills. Of 40 potential errors that were identified, root causes were mapped to errors in situation awareness (20 [50%]), decision-making (10 [25%]), or interpersonal skills (10 [25%]). CONCLUSIONS: This study defines cognitive and interpersonal competencies that are essential for the management of trauma patients. This framework may serve as the basis for novel curricula to train and assess decision-making skills, and to develop quality-control metrics to improve team and individual performance.

Epidural analgesia for traumatic rib fractures is associated with worse outcomes: a matched analysis.

BACKGROUND: The optimal method of pain control for patients with traumatic rib fractures is unknown. The aim of this study was to determine the effect of epidural analgesia on respiratory complications and in-hospital mortality in patients with rib fractures. METHODS: Adult patients at a level I trauma center with ≥1 rib fracture from blunt trauma were included (2004-2013). Those with a blunt-penetrating mechanism, traumatic brain injury, or underwent a laparotomy or thoracotomy were excluded. Patients who were treated with epidural analgesia (EPI) were compared with those were not treated with epidural analgesia (NEPI) using coarsened exact matching. Primary outcomes were respiratory complications (pneumonia, deep vein thrombosis/pulmonary embolus, and respiratory failure) and 30-d in-hospital mortality. Secondary outcomes were total hospital and intensive care unit length of stay, and duration of ventilator support. RESULTS: About 1360 patients (EPI: 329 and NEPI: 1031) met inclusion criteria (mean age: 54.2 y; standard deviation [SD]: 19.7; 68% male). The mean number of rib fractures was 4.8 (SD: 3.3; 21% bilateral) with a high total burden of injury (mean Injury Severity Score: 19.9 [SD: 8.9]). The overall incidence of respiratory complications was 13% and mortality was 4%. After matching, 204 EPI patients were compared with 204 NEPI patients, with no differences in baseline characteristics. EPI patients experienced more respiratory complications (19% versus 10%, P = 0.009), but no differences in 30-d mortality (5% versus 2%, P = 0.159), duration of mechanical ventilation (EPI: 148 h [SD: 167] versus NEPI: 117 h [SD: 187], P = 0.434), or duration of intensive care unit length of stay (6.5 d [SD: 7.6] versus 5.8 d [SD: 9.1], P = 0.626). Hospital stay was higher in the EPI group (16.6 d [SD: 19.6] vs 12.7 d [SD: 15.2], P = 0.026). CONCLUSIONS: Epidural analgesia is associated with increased respiratory complications without providing mortality benefit after traumatic rib fractures. Alternate analgesic strategies should be investigated to treat these severely injured patients.

The effect of in vitro tracheal occlusion on branching morphogenesis in fetal lung explants from the rat nitrofen model of congenital diaphragmatic hernia.

BACKGROUND/PURPOSE: Fetal tracheal occlusion (TO) has been investigated as a treatment option for lung hypoplasia secondary to congenital diaphragmatic hernia. Tracheal occlusion has been shown to accelerate lung growth, but its effect on bronchial branching is unknown. In this study, we characterize the effects of in vitro TO on bronchial branch development in fetal lung explants derived from the nitrofen rat model of congenital diaphragmatic hernia. METHODS: Rat dams were gavaged nitrofen on gestational day 9.5, and fetal lungs were harvested for explant culture on gestational day 14 (term, 22 days). Four experimental groups were investigated, with TO performed ex vivo using cautery: control, control + TO, nitrofen, and nitrofen + TO. Explants were incubated for 72 hours. Representative photographs were taken at 0, 24, 48, and 72 hours from the time of culture, and the number of distal branches was counted for each explant. The Student t test was used to compare distal branch measurements. RESULTS: A minimum of 12 fetal lung explants were cultured for each group. By 24 hours, all explants undergoing TO had more branch iterations than explants that did not. Moreover, TO in nitrofen-exposed explants increased bronchial branching to control levels by 24 hours in culture. CONCLUSION: Our results suggest that TO at day 14 increases branching in normal and nitrofen-exposed lung explants. In addition, TO increases airway branching in nitrofen-exposed explants to control levels suggesting that early TO reverses the lung hypoplasia seen in this model.

Effect of hospital case volume on outcome in congenital diaphragmatic hernia: the experience of the Canadian Pediatric Surgery Network.

PURPOSE: Despite advances in neonatal care of congenital diaphragmatic hernia (CDH), a significant variation exists in the mortality rates reported by individual centers. Center experience (reflected by case volume) may contribute to this variation in outcome. The aim of the study was to determine whether CDH mortality is affected by hospital case volume. METHODS: The CDH cases were abstracted from a disease-specific, 16-hospital, national network. Thirteen hospitals participated in this study. Anonymized hospitals were categorized as either high (>6 cases) or low-volume (

Spindle epithelial tumor with thymus-like elements of the thyroid: a multi-institutional case series and review of the literature.

BACKGROUND/PURPOSE: Spindle epithelial tumor with thymus-like elements (SETTLE) is a rare tumor of the thyroid observed in children and adolescents. We present a case series of 3 patients with SETTLE, focusing on the clinical and pathologic features of this rare tumor. METHODS: Three male patients presented at ages 4.5, 6.5, and 7 years with a right thyroid mass. All were treated by standard hemithyroidectomy. None had evidence of distant metastases at presentation. The diagnosis of SETTLE was confirmed at the time of the initial operation in 2 of the 3 patients. RESULTS: All patients had uneventful postoperative courses. Two patients remain disease-free 4 and 7 years postresection, respectively. One patient presented 10 years after resection with shortness of breath and hemoptysis secondary to multiple bilateral parenchymal lung metastases. This patient received chemotherapy against the epithelial components of the tumor with a 25% response based on imaging studies. CONCLUSION: Spindle epithelial tumor with thymus-like elements is rare tumor that should be suspected if spindle elements are observed in the resected thyroid specimen. Because these patients may present with delayed metastases, follow-up is recommended. However, chemotherapy against specific tumor elements is only marginally effective.