Moral dilemmas faced by hospitals in time of war: the Rambam Medical Center during the second Lebanon war.

Rambam Medical Center, the only tertiary care center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethical dilemmas to the hospital management. An ambiguous situation arose that required routine patient care in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of the moral dilemmas faced, the policy they chose to follow, and offer a retrospective critical reflection in this paper. The hospital's first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medical care such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats.

[The encounter between literature and medicine--from theory to practice].

The relationship between literature and medicine has existed from Ancient Greece to the 19th century. However, in the last two centuries, the scientific achievements in medicine, along with the dominance of the biological model in medical education, have weakened this relationship. In the last quarter of the 20th century "Literature and Medicine" has made a comeback in an effort to restore the humanistic component to medical education. "Literature and Medicine" is a subdiscipline of literary studies and a part of "medical humanities". It focuses on issues such as; the physician, the patient, doctor-patient communication, empathy, ethics and life perspective. The growing interest in "Literature and Medicine" is evident not only in undergraduate medical education, but also in many publications in medical journals, and in the increasing number of literature and medicine groups for health care professionals. A "Literature and Medicine" group for physicians and other health care providers has been active for 4 years in the Faculty of Medicine at the Technion in Haifa. So far, the group has read and discussed about thirty literary works. The participants stress how this activity enhances exposure to literature, generates a commitment to reading and leads to a better understanding of literary texts.

Surgical site infection rates following cardiac surgery: the impact of a 6-year infection control program.

BACKGROUND: To evaluate the impact of an infection control program on surgical site infections (SSIs) complicating cardiac operations. METHODS: Prospective cohort study of patients undergoing cardiac operations. Interventions included prospective surveillance, povidone-iodine scrub showers, depilation before surgery, administration of preoperative antibiotic prophylaxis in the operating room, and postdischarge follow-up. Logistic regression models were fitted to assess infection rates over time, adjusting for factors known to affect SSI rates. RESULTS: The overall SSI rate for 2051 procedures was 10.4%. Rates of superficial and deep incisional SSIs remained unchanged over the study period. The rates of all organ/space infections, mediastinitis, and SSIs because of methicillin-resistant Staphylococcus aureus during the first 2 years were 3.25%, 2.22%, and 1.48%, respectively, and they decreased to 1.17%, 0.73%, and 0.73%, respectively, by the end of 2002 (P = .01, P = .01, and P = .09, respectively). The adjusted odds ratios for these 3 types of infection at the end of 2002 compared with December 31, 1998, were 0.19 (95% confidence interval [95% CI]: 0.07-0.48), 0.20 (95% CI: 0.06-0.66), and 0.28 (95% CI: 0.08-0.97), respectively. CONCLUSION: We observed significant reductions in organ/space infection rates, particularly mediastinitis. These differences remained significant when adjusted for potential confounding variables.

Skeletonized versus pedicled internal mammary artery: impact of surgical technique on post CABG surgery pain.

OBJECTIVE: Recent evidence suggests that coronary artery bypass graft (CABG) surgery often results in chronic chest wall pain, termed: 'post CABG pain syndrome' (PCP). Direct injury to intercostal nerves during the surgical procedure was presumed to underlie this syndrome. The aim of this study was to investigate the effect of two harvesting techniques of the internal mammary artery (IMA)-skeletonization (S-LIMA) and pedicle (P-LIMA) on the occurrence and incidence of PCP. METHODS: A mailed questionnaire enquiring about the presence and characteristics of PCP was sent to all 482 patients who had undergone CABG in our institution in the years 1999-2000. A randomly chosen subgroup of IMA patients reporting PCP were summoned for evaluations of pain localization and intensity, thermal and tactile sensitivity, and disability assessment using recognized tests and indices. RESULTS: Of the 380 responders (S-LIMA: 221, P-LIMA: 125, veins only V-34) 169 (44%) reported having PCP. Its prevalence was similar between the two IMA groups (S-LIMA: 45%, P-LIMA: 50%) but significantly lower in the V group (18%, P=0.003). Physical assessment in the subgroup of 43 IMA patients (S-LIMA: 22, P-LIMA: 21) performed 40.2+/-8.7 months after surgery confirmed equal occurrence of mostly left and midline chest wall neuropathic pain in both IMA groups. No significant differences were found between the two groups in respect to indices of pain intensity, thermal and tactile sensitivity and disability. CONCLUSIONS: PCP is a prevalent finding in post CABG patients. The skeletonization technique of IMA harvesting although causing significantly less inner chest wall trauma does not appear to reduce the occurrence of PCP. This finding may imply that ischemic injury rather than direct mechanical injury to the intercostal nerves is the putative mechanism underlying PCP.

Minimal dissection and continuous retrograde cardioplegia for aortic valve replacement in patients with a patent left internal mammary artery bypass graft.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with previous coronary artery bypass grafting (CABG) and a patent pedicled internal mammary artery (IMA) is often complicated by a need to dissect and clamp the IMA to achieve optimal myocardial protection. Eliminating this need may simplify and facilitate surgery; hence, a new surgical technique for use in these patients is described. METHODS: Five patients with previous CABG and functioning IMA who required AVR between January 1998 and October 2002 were studied. In all patients, the IMA was neither dissected nor clamped. Myocardial protection comprised an initial bolus of antegrade cardioplegia, followed by continuous retrograde infusion of tepid non-diluted oxygenated blood, supplemented with cardioplegic drugs to maintain cardiac arrest. The systemic and myocardial temperature was 30-32 degrees C. RESULTS: All patients underwent surgery as planned, and there was no operative mortality or myocardial infarction. One patient sustained a minor stroke. None of the IMA was injured. CONCLUSION: In patients requiring AVR, it is both possible and reasonable to leave the IMA undissected and unclamped. Limited experience suggests that this new technique provides adequate myocardial protection, while keeping surgery both simple and safe.

An automatic sutureless coronary anastomotic device: initial results of an animal study.

BACKGROUND: The efficacy and long-term patency of a new distal anastomotic device (DAD) for the creation of rapid, sutureless end-to-side venous or arterial coronary artery bypass graft anastomoses were tested in a sheep model. METHODS: The DAD was used on the beating hearts of 34 sheep to create 20 anastomoses between saphenous veins (n = 9) or internal mammary arteries (n = 11) and various coronary arteries. Fourteen conventional hand-sutured anastomoses (7 veins; 7 internal mammary arteries) served as controls. The sheep were sacrificed 1 day, 1 week, and 1, 3, and 6 months after surgery. RESULTS: The immediate patencies of all anastomoses were proven by the rates and pattern of flow. There were no significant differences between the DAD and suture anastomosis groups in presacrifice pulsatility index and occlusion rate. The histomorphometric studies showed complete intimal bridging over the DAD with no significant differences between DAD and suture anastomoses with respect to tissue response, mural injury, inflammation, and adventitial fibrosis. CONCLUSIONS: The DAD enables the creation of rapid, efficient, and sutureless venous or arterial coronary anastomoses. The long-term results of histomorphometric studies show that the results with the DAD are comparable with those of conventional hand-sutured anastomoses.

Effect of preoperative antibiotic prophylaxis on surgical site infections complicating cardiac surgery.

OBJECTIVE: To evaluate the effect of an optimized policy for antibiotic prophylaxis on surgical site infection (SSI) rates in cardiac surgery. DESIGN: Prospective cohort study. SETTING: Tertiary medical center in Israel. METHODS: SSIs were recorded during a 10-year study period and ascertained through routine surveillance using the National Healthcare Safety Network (NHSN) methodology. Multivariable analyses were conducted to determine which significant covariates, including the administration of preoperative prophylaxis, affected these outcomes. RESULTS: A total of 2,637 of 3,170 evaluated patients were included, and the overall SSI rate was 8.4%. A greater than 50% reduction in SSI rates was observed in the last 4 years of the study. Overall and site-specific infection rates were similar for patients receiving cefazolin or vancomycin. SSIs developed in 206 (8.1%) of the 2,536 patients who received preoperative prophylaxis (within 2 hours of the first incision) compared with 14 (13.9%) of 101 patients who received antibiotic prophylaxis at a different time (P = .04; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.0-3.3). After accounting for covariates, preoperative hospital stay (5 days or more), an NHSN risk category (2 or 3), age (60 years or more), surgeon's role, and the period of measurement were significantly associated with SSIs. Emergency surgery, age, surgeon's role, and nonpreoperative prophylaxis were found to be independent predictors of superficial SSI. CONCLUSIONS: We observed a progressive and significant decrease in SSI rates after the implementation of an infection control program that included an optimized policy of preoperative prophylaxis in cardiac surgery.

Decision-support information system to manage mass casualty incidents at a level 1 trauma center.

Mass casualty incidents are probably the greatest challenge to a hospital. When such an event occurs, hospitals are required to instantly switch from their routine activity to conditions of great uncertainty and confront needs that exceed resources. We describe an information system that was uniquely designed for managing mass casualty events. The web-based system is activated when a mass casualty event is declared; it displays relevant operating procedures, checklists, and a log book. The system automatically or semiautomatically initiates phone calls and public address announcements. It collects real-time data from computerized clinical and administrative systems in the hospital, and presents them to the managing team in a clear graphic display. It also generates periodic reports and summaries of available or scarce resources that are sent to predefined recipients. When the system was tested in a nationwide exercise, it proved to be an invaluable tool for informed decision making in demanding and overwhelming situations such as mass casualty events.

An academic medical center under prolonged rocket attack--organizational, medical, and financial considerations.

The Rambam Medical Center, the major academic health center in northern Israel, serving a population of two million and providing specialized tertiary care, was exposed to an unprecedented experience during the Second Lebanon War in the summer of 2006. For more than one month, it was subjected to continuous rocket attacks, but it continued to provide emergency and routine medical services to the civilian population and also served the military personnel who were evacuated from the battlefront. To accomplish the goals of serving the population while itself being under fire, the Rambam Medical Center had to undertake major organizational decisions, which included maximizing safety within the hospital by shifting patients and departments, ensuring that the hospital was properly fortified, managing the health professional teams' work schedules, and providing needed services for the families of employees. The Rambam Medical Center's Level I trauma center expertise included multidisciplinary teams and extensive collaborations; modern imaging modalities usually reserved for peacetime medical practice were frequently used. The function of the hospital teams during the war was efficient and smooth, based on the long-term actions taken to prepare for disasters and wartime conditions. Routine hospital services continued, although at 60% of normal occupancy. Financial losses incurred were primarily due to the decrease in revenue-generating activity. The two most important components of managing the hospital under these conditions are (1) the ability to arrive at prompt and meaningful decisions with respect to the organizational and medical hospital operations and (2) the leadership and management of the professional staff and teams.

CorLink sutureless aortic anastomotic device: results of an animal study.

BACKGROUND: The CorLink Automated Anastomotic Device (AD) was developed to create a sutureless vein-to-aorta anastomosis without the need to clamp the aorta. This study examined the effectiveness and safety of this device in an animal model. MATERIALS AND METHODS: Forty-seven vein-to-aorta anastomoses using the AD and 27 control hand-sutured anastomoses were constructed in 28 sheep. The distal part of these grafts were connected either to the main pulmonary artery (40 AD, 20 control), or to the sheep's brachiocephalic trunk (7 AD, 7 control). Procedural details focusing on deployment, leakage, and early patency rates were examined. Sheep were sacrificed after periods ranging from 1 to 180 days. Specimens were examined grossly and histologically. RESULTS: All but three attempts to construct an anastomosis were successful (2 AD, 1 control). All anastomoses were patent immediately after their construction. There was no difference between control and AD anastomoses in respect to flow rates at the end of operation and before sacrifice. No metal breaks were detected. Fourteen of the 47 AD anastomoses and 6 of the control anastomoses (29.8% versus 22.2% P = ns) were occluded at autopsy. Histological findings characteristic of the healing process, were evenly distributed between AD and control anastomoses in both models. Intimal thickening was found in a notable number of anastomoses, but without any significant difference between the AD and control sutured (44.7% versus 40.7% P = ns). CONCLUSIONS: The AD proved safe and effective for the construction of proximal vein-to-aorta anastomoses as compared to control hand-sutured anastomoses.

Colchicine for the prevention of postpericardiotomy syndrome.

BACKGROUND: Postpericardiotomy syndrome (PPS) is a troublesome complication of cardiac surgery, occurring in 10-45% of cases. Accepted modalities of treatment include nonsteroidal anti-inflammatory drugs, corticosteroids, and pericardiectomy in severe cases. The optimal method for prevention of PPS has not been established. Recent trial data have shown that colchicine is efficient in the secondary prevention of recurrent episodes of pericarditis. The aim of the present study was to evaluate the possible benefit of colchicine for the primary prevention of PPS in patients after cardiac surgery. To the best of our knowledge, this is the first study addressing this issue. PATIENTS AND METHODS: A prospective, randomized, double-blind design was used. The initial study group included 163 patients who underwent cardiac surgery in two centers in Israel between October 1997 and September 1998. On the 3rd postoperative day, the patients were randomly assigned to receive colchicine (1.5 mg/day) or placebo for 1 month. All were evaluated monthly for the first 3 postoperative months for development of PPS. RESULTS: 52 of the 163 patients were excluded because of postoperative complications, noncompliance, or gastrointestinal side effects of treatment. Of the 111 patients who completed the study, 47 (42.3%) received colchicine and 64 (57.7%) placebo. There was no statistically significant difference between the groups in clinical or surgical characteristics. PPS was diagnosed in 19 patients (17.1%), 5/47 cases (10.6%) in the colchicine group and 14/64 (21.9%) in the placebo group. The difference showed a trend toward statistical significance (p < 0.135). CONCLUSIONS: Colchicine may be efficacious for the prevention of PPS in patients after cardiac surgery. Further evaluations in larger clinical trials are warranted.