Beyond Trauma: High-Volume Critical Care Medicine in a Military Medical Center-Based Military-Civilian Partnership.

INTRODUCTION: Critical Care Internal Medicine (CCIM) is vital to the U.S. Military as evidenced by the role CCIM played in the COVID-19 pandemic response and wartime operations. Although the proficiency needs of military surgeons have been well studied, this has not been the case for CCIM. The objective of this study was to compare the patient volume and acuity of military CCIM physicians working solely at Military Treatment Facilities (MTFs) with those at MTFs also working part-time in a military-civilian partnership (MCP) at the University Medical Center of Southern Nevada (UMC). MATERIALS AND METHODS: We analyzed FY2019 critical care coding data from the Military Health System and UMC comparing the number of critical care encounters, the number of high-acuity critical care encounters, and the Abilities/Activity component of the Knowledge, Skills, and Abilities/Clinical Activity (KSA) score. This analysis was restricted to critical care encounters defined by Current Procedural Terminology codes for critical care (99291 and 99292). A critical care encounter was considered high acuity if the patient had ICD-10 codes for shock, respiratory failure, or cardiac arrest or had at least three codes for critical care in the same episode. RESULTS: The five AF CCIM physicians in the MCP group performed 2,019 critical care encounters in 206 days, with 63.1% (1,273) being defined as high acuity. The total number of MTF critical care encounters was 16,855 across all providers and services, with 28.9% (4,864) of encounters defined as high acuity. When limited to CCIM encounters, MTFs had 6,785 critical care encounters, with 32.0% being high acuity (2,171). Thus, the five AF CCIM physicians, while working 206 days at the UMC, equated to 12.0% (2,019/16,855) of the total critical care MTF encounters, 27.2% (1,273/4,684) of the total high-acuity MTF critical care encounters, and 29.8% (2,019/6,785) of the MTF CCIM encounters, with 58.6% (1,273/2,171) of the MTF CCIM high-acuity encounters.The USAF CCIM physicians in the MCP group performed 454,395 KSAs in 206 days, with a KSA density per day of 2,206. In the MTF group, CCIM providers generated 2,344,791 total KSAs over 10,287 days, with a KSA density per day of 227.9. Thus, the five CCIM physicians at the UMC accounted for 19.38% of the MTF CCIM KSAs, with a KSA density over 10 times higher (2,206 vs. 227.9). CONCLUSIONS: The volume and acuity of critical care at MTFs may be insufficient to maintain CCIM proficiency under the current system. Military-civilian partnerships are invaluable in maintaining clinical proficiency for military CCIM physicians and can be done on a part-time basis while maintaining beneficiary care at an MTF. Future CCIM expeditionary success is contingent on CCIM physicians and team members having the required CCIM exposure to grow and maintain clinical proficiency.Limitations of this study include the absence of off-duty employment (moonlighting) data and difficulty filtering military data down to just CCIM physicians, which likely caused the MTF CCIM data to be overestimated.

BIG Kids: Application of a modified brain injury guideline in a pediatric trauma center.

BACKGROUND: Brain Injury Guidelines (BIG) were developed to stratify traumatic brain injuries (TBIs) by severity to decrease unnecessary CT imaging and neurosurgical consultation in low-risk cases. This study evaluated the potential effect of a modified pediatric BIG (pBIG) algorithm would have on resource utilization. METHODS: Isolated TBIs (<18 years) were queried from our Pediatric Trauma Registry from 2017 to 2020. Injuries were classified as mild (pBIG 1), moderate (pBIG 2), or severe (pBIG 3) based on neurologic status, skull fractures, size, and the number of bleeds. Modifications from the institutional adult algorithm were upgrading <4 mm epidural hematomas to pBIG 2 and eliminating interfacility transfer as a pBIG 2 criteria. The proposed pBIG 1 and 2 care plans do not include routine repeat CTs or neurosurgical consultation. RESULTS: A total of 314 children with a mean age of 4.9 years were included. Skull fractures (213, 68%) and subdural hematomas (162, 52%) were the most common injuries. 89 (28%) children had repeat head CTs (2 (7%) pBIG 1, 26 (25%) pBIG 2, 61 (34%) pBIG 3). Neurosurgical consultation was obtained in 306 (98%), with 50 (16%) requiring intervention (1 (1%) pBIG 2 and 49 (27%) pBIG 3). Following the proposed pBIG would decrease neurosurgical consults to 181 (58%) and repeat CTs to 63 (20%). Following the algorithm, 91 (29%) kids would have been admitted to a higher level of care and 45 (14.3%) to a lower level. CONCLUSIONS: Implementation of our pBIG algorithm would decrease neurosurgery consults (40% reduction) and repeat head CTs (29% reduction).

The Las Vegas military-civilian partnership: An origin story and call to action.

ABSTRACT: Military-civilian partnerships (MCPs) in urban American trauma centers have existed for more than 60 years to assist in the development and maintenance of wartime skills of military medical professionals. In the last 5 years, MCPs have gained congressional support, and their number and variety have grown substantially. The historical impact of these flagship trauma MCPs is well documented, with bidirectional benefit in the advancement of trauma care during the wars in Iraq and Afghanistan both deployed and stateside, and the future aim of MCPs lies primarily in mitigating the "peacetime effect." The majority of data regarding MCPs; however, focus on trauma care and are biased toward surgeons specifically. The Las Vegas (LV) MCP began in 2002 with the similar goal of sustaining Air Force (AF) expeditionary medical skills by embedding AF medics from nearby Nellis Air Force Base (AFB) into University Medical Center of Southern Nevada (UMC), the only Level 1 Trauma Center in Nevada. Over nearly 20 years, the LV-MCP has evolved into an innovative market-based collaboration composed of numerous relationships and programs that are designed to develop and sustain critical skills for military medical personnel in all aspects of expeditionary medicine. This includes AF medical personnel providing care to federal beneficiaries as well as civilian patients in a variety of medical settings. The partnership's central coordinating authority, the Office of Military Medicine-Las Vegas (OMM-LV), brings together military and civilian organizations with distinct and intersecting missions to support the greater LV population and the DoD mission of readiness. The LV-MCP is presented here as a model for the future of MCPs within the integrated local and national trauma and medical systems.

Hepatic Pseudoaneurysm Incidence After Liver Trauma.

BACKGROUND: Posttraumatic hepatic artery pseudoaneurysm is a potentially devastating complication after complex liver injury. Increasing computed tomography (CT) use may lead to more frequent identification of posttraumatic hepatic complications. This study was designed to determine the rate of hepatic pseudoaneurysm after traumatic liver injury. METHODS: We conducted a retrospective review of patients at an urban level 1 trauma center over 5 y (2012-2016). Injury characteristics, patient management, and complications were extracted from trauma registry data and chart review. RESULTS: Six hundred thirty-four hepatic injuries (11 no grade/no CT, 159 grade I, 154 grade II, 165 grade III, 93 grade IV, and 52 grade V) were identified from our trauma registry. No patient with a grade I or II injury had a subsequent bleeding complication. Eighteen patients had a documented hepatic pseudoaneurysm: grade III n = 3 (1.8%), grade IV n = 6 (6.5%), grade V n = 9 (17.3%). The median time to pseudoaneurysm identification was 6.5 d. Seven pseudoaneurysms were found on asymptomatic surveillance CT-angiography on average 5 d after injury. Eleven patients were symptomatic at the time of CT-angiography performed at a median of 9 d after admission. Of the 11 symptomatic patients, four were in hemorrhagic shock, and two died from hepatic-related complications. CONCLUSIONS: The incidence of hepatic artery pseudoaneurysm increases with higher grade liver injury. Aggressive surveillance for hepatic pseudoaneurysm with interval CT-angiography 5-7 d postinjury may be warranted, especially for grade IV and V injuries.

Micronutrient Needs of the Elderly.

Older adults are becoming a significant percentage of the world's population. A multitude of factors, from the normal aging process to the progression of chronic disease, influence the nutrition needs of this very diverse group of people. Appropriate micronutrient intake is of particular importance but is often suboptimal. Here we review the available data regarding micronutrient needs and the consequences of deficiencies in the ever growing aged population.

Pyloric stenosis after gastroschisis closure.

Hypertrophic pyloric stenosis is a very common surgical problem in infants. It occurs most often in otherwise well babies with normal gestation and birth history. Rarely, pyloric stenosis has been described in babies with history of prior abdominal surgery. Below we discuss the management of hypertrophic pyloric stenosis in a child who remained hospitalized, recovering from repair of a congenital abdominal wall defect.

Cardiopulmonary bypass after severe blunt hepatic injury: management of multi-system blunt trauma in an adolescent.

A 16-year-old adolescent male sustained combined injuries to the tricuspid valve and liver. This injury is exceptional due to the mechanism and the circumstances in which it took place: a flying pumpkin thrown from a sport utility vehicle. An echocardiogram demonstrated a flail chordal apparatus associated with the posterior leaflet of the tricuspid valve, creating substrate for severe tricuspid regurgitation with preserved right heart function. He was treated with non-operative management for the liver injury; he remained hemodynamically stable and was discharged home. He underwent successful repair of the tricuspid valve 17 days following the initial injury necessitating systemic anticoagulation and was discharged home two days later. The patient recovered fully without residual valvular pathology or hepatic sequelae.