Starting a Vascular Surgery Fellowship at a Rural Healthcare Center.

INTRODUCTION: In the United States, there is an anticipated critical shortage of vascular surgeons in the coming decades. The shortage is expected to be particularly pronounced in rural areas. Our institution serves a rural and underserved population in which the incidence and prevalence of cardiovascular disease continues to rise. Our institution maintains a general surgery residency and has all the required Accreditation Council for Graduate Medical Education (ACGME) rotations and educational infrastructure to support a vascular surgery fellowship. This study aims to analyze the vascular caseload at our institution to determine if we and other institutions with similar surgical volumes can support the creation of a 2-year vascular fellowship. METHODS: A single-site retrospective review of the number and type of vascular cases conducted at our institution between July 2016 and June 2021 was performed. The procedures were grouped into the following ACGME-defined categories: abdominal, cerebrovascular, complex, endovascular aneurysm repair, endovascular diagnostic or therapeutic, and peripheral. The total number and annual average for each category was obtained. Using the annual average, a 2-year estimate was calculated and compared to the ACGME minimum for each category. Our 2-year estimate was then compared to the national average for graduating vascular surgery fellows in order to generate a z-score for each category. RESULTS: In the specified period, 6100 total surgical procedures were performed by three vascular surgeons at our institution. Two thousand five hundred and seventy-eight of the 6100 procedures met at least one of the ACGME-defined category requirements. Our center greatly exceeded the requirements for each category except for abdominal. This is consistent with trends observed in most centers across the nation, which are seeing a decline in open repairs across all categories, especially in open abdominal repairs. Our center's vascular case volume shows no significant difference the national average in each ACGME category (P ≥ 0.05 for all). CONCLUSIONS: Despite our center's large vascular caseload and need for more vascular providers, there were not enough open abdominal cases performed to support the training of a vascular fellow. Given the continued decline in open aortic volume across the country, we anticipate that rural centers similar to our own will have difficulty establishing programs to train and recruit vascular surgeons. Flexibility in the abdominal category requirement or creation of open aortic fellowships may be necessary for smaller rural centers to train vascular surgeons and meet the future needs of the specialty.

Surgeon Perceptions and Variations in Surgical Morbidity and Mortality Conference: Report of a Survey from the American College of Surgeons Board of Governors.

OBJECTIVE: To highlight the evolution of surgical morbidity and mortality conferences (MMCs) from the early 20th century as a means of identifying surgeon error into current practices as identifying hospital-based system factors that contribute to adverse patient events. Further, to elucidate differences in the perception of MMCs between trainees and attending surgeons as well as differences in the structure of MMCs geographically and by institution type. DESIGN: We developed a survey that was distributed to current American College of Surgeon members through Survey Monkey. SETTING: Survey-based study. PARTICIPANTS: Current members of the American College of Surgeons, including Board of Governors, surgeons, and trainees. RESULTS: There were a total of 1,396 responses to the survey, 814 (58%) from surgical trainees and 582 (42%) from attending surgeons. Both surgical trainees and attending surgeons noted that the most common day for MMCs was Wednesday and that the most common time for MMCs was before 7:30 AM. Further, most surgical trainees and attending surgeons noted that there was no structured format to their institution's MMCs and that increased attending surgeon engagement would make MMCs more educational. Significant variations in MMCs existed across both geographic region and by institution type. CONCLUSION: The results from this survey highlight key aspects of MMCs that contribute to their educational value. Staff engagement was noted to be the most educational aspect of MMCs. While geographic and institutional differences will likely persist, efforts should be made to increase staff engagement at MMCs in addition to a more structured approach.

A novel decision tree approach based on transcranial Doppler sonography to screen for blunt cervical vascular injuries.

OBJECTIVES: Early detection and treatment of blunt cervical vascular injuries prevent adverse neurologic sequelae. Current screening criteria can miss up to 22% of these injuries. The study objective was to investigate bedside transcranial Doppler sonography for detecting blunt cervical vascular injuries in trauma patients using a novel decision tree approach. METHODS: This prospective pilot study was conducted at a level I trauma center. Patients undergoing computed tomographic angiography for suspected blunt cervical vascular injuries were studied with transcranial Doppler sonography. Extracranial and intracranial vasculatures were examined with a portable power M-mode transcranial Doppler unit. The middle cerebral artery mean flow velocity, pulsatility index, and their asymmetries were used to quantify flow patterns and develop an injury decision tree screening protocol. Student t tests validated associations between injuries and transcranial Doppler predictive measures. RESULTS: We evaluated 27 trauma patients with 13 injuries. Single vertebral artery injuries were most common (38.5%), followed by single internal carotid artery injuries (30%). Compared to patients without injuries, mean flow velocity asymmetry was higher for single internal carotid artery (P = .003) and single vertebral artery (P = .004) injuries. Similarly, pulsatility index asymmetry was higher in single internal carotid artery (P = .015) and single vertebral artery (P = .042) injuries, whereas the lowest pulsatility index was elevated for bilateral vertebral artery injuries (P = .006). The decision tree yielded 92% specificity, 93% sensitivity, and 93% correct classifications. CONCLUSIONS: In this pilot feasibility study, transcranial Doppler measures were significantly associated with the blunt cervical vascular injury status, suggesting that transcranial Doppler sonography might be a viable bedside screening tool for trauma. Patient-specific hemodynamic information from transcranial Doppler assessment has the potential to alter patient care pathways to improve outcomes.

Transcranial Doppler investigation of hemodynamic alterations associated with blunt cervical vascular injuries in trauma patients.

OBJECTIVES: Blunt cervical vascular injuries, often missed with current screening methods, have substantial morbidity and mortality, and there is a need for improved screening. Elucidation of cerebral hemodynamic alterations may facilitate serial bedside monitoring and improved management. Thus, the objective of this study was to define cerebral flow alterations associated with single blunt cervical vascular injuries using transcranial Doppler sonography and subsequent Doppler waveform analyses in a trauma population. METHODS: In this prospective pilot study, patients with suspected blunt cervical vascular injuries had diagnoses by computed tomographic angiography and were examined using transcranial Doppler sonography to define cerebral hemodynamics. Multiple vessel injuries were excluded for this analysis, as the focus was to identify hemodynamic alterations from isolated injuries. The inverse damping factor characterized altered extracranial flow patterns; middle cerebral artery flow velocities, the pulsatility index, and their asymmetries characterized altered intracranial flow patterns. RESULTS: Twenty-three trauma patients were evaluated: 4 with single internal carotid artery injuries, 5 with single vertebral artery injuries, and 14 without blunt cervical vascular injuries. All internal carotid artery injuries showed a reduced inverse damping factor in the internal carotid artery and dampened ipsilateral mean flow and peak systolic velocities in the middle cerebral artery. Vertebral artery injuries produced asymmetry of a similar magnitude in the middle cerebral artery mean flow velocity with end-diastolic velocity alterations. CONCLUSIONS: These data indicate that extracranial and intracranial hemodynamic alterations occur with internal carotid artery and vertebral artery blunt cervical vascular injuries and can be quantified in the acute injury phase by transcranial Doppler indices. Further study is required to elucidate cerebral flow changes resulting from a single blunt cervical vascular injury, which may guide future management to preserve cerebral perfusion after trauma.

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm.

BACKGROUND: The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members. METHODS: Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed. RESULTS: The algorithm is attached with detailed explanation of each step, supported by data if available. CONCLUSION: Blunt pancreatic trauma is rare and presents many treatment challenges.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm.

LEVEL OF EVIDENCE: Literature synthesis and expert opinion, Level V.

Pregnancy in trauma-A Western Trauma Association algorithm.

BACKGROUND: The Western Trauma Association has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations or scarcity of experience. Care of the pregnant trauma patient is one of these clinically complex situations that is based on physiologic data, standard trauma care, trauma care experience, and outcomes. METHODS: Review of multiple evidence- based guidelines, case reports, and expert opinion were compiled and reviewed. RESULTS: The algorithm is attached with detailed explanation of each step, supported by data if available. CONCLUSION: Resuscitative and trauma care of the mother is the utmost priority. STUDY TYPE: Algorithm, expert opinion, consensus. LEVEL OF EVIDENCE: Diagnostic Tests/Criteria; Level III.

Real-time infection prediction with wearable physiological monitoring and AI to aid military workforce readiness during COVID-19.

Infectious threats, like the COVID-19 pandemic, hinder maintenance of a productive and healthy workforce. If subtle physiological changes precede overt illness, then proactive isolation and testing can reduce labor force impacts. This study hypothesized that an early infection warning service based on wearable physiological monitoring and predictive models created with machine learning could be developed and deployed. We developed a prototype tool, first deployed June 23, 2020, that delivered continuously updated scores of infection risk for SARS-CoV-2 through April 8, 2021. Data were acquired from 9381 United States Department of Defense (US DoD) personnel wearing Garmin and Oura devices, totaling 599,174 user-days of service and 201 million hours of data. There were 491 COVID-19 positive cases. A predictive algorithm identified infection before diagnostic testing with an AUC of 0.82. Barriers to implementation included adequate data capture (at least 48% data was needed) and delays in data transmission. We observe increased risk scores as early as 6 days prior to diagnostic testing (2.3 days average). This study showed feasibility of a real-time risk prediction score to minimize workforce impacts of infection.

Evaluation and management of traumatic pneumothorax: A Western Trauma Association critical decisions algorithm.

ABSTRACT: This is a recommended algorithm of the Western Trauma Association for the management of a traumatic pneumothorax. The current algorithm and recommendations are based on available published prospective cohort, observational, and retrospective studies and the expert opinion of the Western Trauma Association members. The algorithm and accompanying text represents a safe and reasonable approach to this common problem. We recognize that there may be variability in decision making, local resources, institutional consensus, and patient-specific factors that may require deviation from the algorithm presented. This annotated algorithm is meant to serve as a basis from which protocols at individual institutions can be developed or serve as a quick bedside reference for clinicians. LEVEL OF EVIDENCE: Consensus algorithm from the Western Trauma Association, Level V.

Age: is it all in the head? Factors influencing mortality in elderly patients with head injuries.

BACKGROUND: Elderly patients, an increasing segment of the population, who sustain traumatic brain injury (TBI) are known to have worse outcomes, including higher mortality. This objective of this study was to examine the Crash Injury Research Engineering Network and to determine at what age motor vehicle crash fatalities from head injuries increased. METHODS: The Crash Injury Research Engineering Network database was queried from 1996 to 2009. Study inclusion criteria were adult vehicle occupants with TBI, with an Abbreviated Injury Scale score ≥2. The age at which mortality increased was calculated. Patients younger and older than this cutoff age were compared to determine differences in crash characteristics. The determined cutoff age was compared with one found in a larger, population-based database. RESULTS: There were 915 patients who met the study criteria. An increase in mortality was seen at age 60 years despite no difference in Injury Severity Score and a decrease in crash severity. Patients ≤60 years were more likely to have alcohol involved, to be in a rollover crash, and had higher crash speeds. Comparing the element of the crash attributed to the head injury, the patients >60 years were more likely to have struck the airbag, door, and seat. An analysis of the larger database revealed an increase in mortality at age 70 years. CONCLUSIONS: There was a higher mortality secondary to head injuries in those older than 60 years involved in motor vehicle crashes. Improved safety measures in vehicle design may decrease the number of head injuries seen in the older population.

Teaching breaking bad news using mixed reality simulation.

BACKGROUND: Our novel teaching approach involved having students actively participate in an unsuccessful resuscitation of a high fidelity human patient simulator with a gun shot wound to the chest, followed immediately by breaking bad news (BBN) to a standardized patient wife (SPW) portrayed by an actress. METHODS: Brief education interventions to include viewing a brief video on the SPIKES protocol on how to break bad news, a didactic lecture plus a demonstration, or both, was compared to no pretraining by dividing 553 students into four groups prior to their BBN to the SPW. The students then self-assessed their abilities, and were also evaluated by the SPW on 21 items related to appearance, communication skills, and emotional affect. All received cross-over training. RESULTS: Groups were equal in prior training (2 h) and belief that this was an important skill to be learned. Students rated the experience highly, and demonstrated marked improvement of self-assessed skills over baseline, which was maintained for the duration of the 12-wk clerkship. Additionally, students who received any of the above training prior to BBN were rated superior to those who had no training on several communication skills, and the observation of the video seemed to offer the most efficient way of teaching this skill in a time delimited curriculum. CONCLUSION: This novel approach was well received and resulted in improvement over baseline. Lessons learned from this study have enhanced our curricular approach to this vital component of medical education.

Association Between American Board of Surgery Initial Certification and Risk of Receiving Severe Disciplinary Actions Against Medical Licenses.

Importance: Board certification is used as a marker of surgeon quality and professionalism. Although some research has linked certification in surgery to outcomes, more research is needed. Objective: To measure associations between surgeons obtaining American Board of Surgery (ABS) certification and examination performance with receiving future severe disciplinary actions against their medical licenses. Design, Setting, and Participants: Retrospective analysis of severe license action rates for surgeons who attempted ABS certification based on certification status and examination performance. Surgeons who attempted to become certified were classified as certified or failing to obtain certification. Additionally, groups were further categorized based on whether the surgeon had to repeat examinations and whether they ultimately passed. The study included surgeons who initially attempted certification between 1976 and 2017 (n = 44 290). Severe license actions from 1976 to 2018 were obtained from the Federation of State Medical Boards, and certification data were obtained from the ABS database. Data were analyzed between 1978 and 2008. Main Outcomes and Measures: Severe license action rates were analyzed across certified surgeons and those failing to obtain certification, as well as across examination performance groups. Results: The final dataset included 36 197 men (81.7%) and 8093 women (18.3%). The incidence of severe license actions was significantly greater for surgeons who attempted and failed to obtain certification (incidence rate per 1000 person-years = 2.49; 95% CI, 2.13-2.85) than surgeons who were certified (incidence rate per 1000 person years = 0.77; 95% CI, 0.71-0.83). Adjusting for sex and international medical graduate status, the risk of receiving a severe license action across time was also significantly greater for surgeons who failed to obtain certification. Surgeons who progressed further in the certification examination sequence and had fewer repeated examinations had a lower incidence and less risk over time of receiving severe license actions. Conclusions and Relevance: Obtaining board certification was associated with a lower rate of receiving severe license actions from a state medical board. Passing examinations in the certification examination process on the first attempt was also associated with lower severe license action rates. This study provides supporting evidence that board certification is 1 marker of surgeon quality and professionalism.

Basilar skull fracture: a risk factor for transverse/sigmoid venous sinus obstruction.

In trauma practice, basilar skull fracture is an extremely common finding while transverse/sigmoid venous sinus thrombosis is generally considered quite a rare complication. During evaluation of cervical computed tomography (CT) angiography after trauma, we identified five patients in just three months with unexpected transverse/sigmoid venous sinus obstruction ipsilateral to a basilar skull fracture. This number represented a surprisingly high percentage of our neurosurgical trauma consults for the study period (31%). Three of the five patients were found to have sinus thrombosis: two with right transverse/sigmoid sinus thrombosis experienced significant neurological deficits and prolonged hospital courses even with anti-coagulation therapy; one patient with a left transverse/sigmoid sinus thrombosis had a good outcome with anti-coagulation therapy. The other two of the five patients had outflow obstruction, likely from focal epidural bleeding and extrinsic compression: one patient with partial obstruction in the right transverse-sigmoid junction, due to epidural bleeding, experienced a difficult recovery; one patient with a right sigmoid sinus obstruction presented and remained asymptomatic and experienced a benign hospital course. Two of the five patients had a posterior temporal hemorrhagic area ipsilateral to the affected sinus, suggesting that this finding may have represented hemorrhagic venous infarction rather than traumatic contusion. We propose that a basilar skull fracture in the region of temporal or occipital bone should be considered as a significant risk factor for the development of transverse/sigmoid venous sinus obstruction and may be an under-recognized and treatable cause of increased intracranial pressure. Failure to detect this complication may explain, in part, unexpected clinical outcomes.

Defining service and education: the first step to developing the correct balance.

BACKGROUND: Service and education activities have not been well defined or studied. The purpose of this study is to describe how attendings and residents categorize common resident activities on a service-education continuum. METHODS: A web-based survey was designed to categorize resident activities. A panel of residents and surgical educators reviewed the survey for content validity. Residents and attendings categorized 27 resident activities on a 5-point scale from 1 (pure service) to 5 (pure education). Data analysis was performed using SPSS ver.12. RESULTS: 125 residents and 71 attendings from eight residency programs participated. 66% of residents and 90% of attendings were male. On average, attendings had practiced 14.3 years. Residents' post-graduate year ranged from PGY-1 to PGY-6 (mean of 2.78). Attendings and residents agreed on the categorization of most activities. Residents felt more time should be devoted to pure education than did attendings. Forty percent of residents felt that more than half of their time was spent in pure service versus 10% of attendings. Twenty-five percent of residents and 23% of attendings were dissatisfied with the service-education balance. CONCLUSIONS: The Residency Review Committee mandates that education is the central purpose of the surgical residency without clearly defining the balance between education and service. Attendings and residents agree on the educational value of most activities and that the balance between education and service is acceptable. When compared with attendings, residents feel they need significantly more time in education. Adequate learning can be facilitated by the development of clear definitions of service and education and guidelines for the distribution of resident time.

Pregnancy is not a sufficient indicator for trauma team activation.

BACKGROUND: Trauma complicates 6% to 7% of all pregnancies. Adverse outcomes are rare when monitoring is normal and early warning signs absent. Trauma systems often use pregnancy as the sole criterion (PSC) for partial trauma team activation. This study compares outcomes of pregnant patients presenting with PSC versus other physiologic, mechanistic, or anatomic (OPMA) activation criteria. METHODS: Three hundred fifty-two consecutive obstetric partial trauma team activation patients (2000-2005) were grouped by length of gestation and evaluated for activation criteria and early maternal and fetal outcomes. Data were analyzed using descriptive statistics and analysis of variance. RESULTS: Patients ranged in age from 16 to 44 (mean age, 28 +/- 6.4) and in weeks gestation between 1 and 40 weeks (mean, 25 +/- 8 weeks). Eighty-two percent had been in vehicle crashes. One hundred eighty-eight (58%) were activated based on PSC and 137 on OPMA. No PSC patient had injuries sufficient to warrant trauma service admission. Ninety-four percent of all PSCs of <20 weeks were discharged home from the emergency department. There were no maternal mortalities. There were four fetal mortalities; two pregnancies were terminally compromised before the trauma event. No patient in the PSC group required admission to the trauma service. There were seven cases of abruption (2%) and 18 cases of vaginal bleeding or discharge (6%). No case of vaginal bleeding or abruption in the first 20 weeks was hypotensive at the scene or on arrival. CONCLUSION: In this study, pregnancy was not an independent predictor of the need for trauma team activation. Standard OPMA trauma activation criteria apply equally to pregnant and nonpregnant patients. These data provide support for more judicious allocation of scarce trauma systems resources.

Estimated height, weight, and body mass index: implications for research and patient safety.

BACKGROUND: Research suggests that weight influences patient care and outcomes. Health-care providers (HCPs) sometimes rely on patient self-reports or HCP estimates of height and weight. The purpose of this study was to determine the accuracy of self-reported height and weight and HCP estimations of height, weight, and body mass index (BMI) classification when compared with measured height, weight, and calculated BMI. STUDY DESIGN: Attending physicians, residents, and nurses provided height and weight estimates along with BMI categorizations for 110 trauma patients at a large, teaching hospital with a Level I trauma center. Patients provided reports of their heights and weights. Measured heights and weights were obtained with appropriate calibrated devices, and BMIs were calculated. Estimates and categorizations were then compared with measured and calculated values. RESULTS: HCPs were 41% and 53% accurate in estimating height and weight, respectively. Self-reports had higher accuracy (69% and 92%, respectively) but still resulted in a BMI misclassification of 32%. Twenty-two percent of patient self-reports were unobtainable. When HCPs attempted to categorize a patient into a BMI group, the accuracy was 56%. Functioning, calibrated instruments for measuring height and weight were frequently unavailable in relevant hospital locations. CONCLUSIONS: This study demonstrated that HCPs' estimates of height, weight, and BMI category are highly inaccurate. Patient self-reports are better, but are unavailable at times. Objective measurements with calibrated instruments are necessary for accuracy in research studies and for patient safety in clinical practice. Efforts to ensure the availability of calibrated instruments may be necessary in the hospital setting.

Combining high-fidelity human patient simulators with a standardized family member: a novel approach to teaching breaking bad news.

Our novel approach to teaching Breaking Bad News (BBN) involves having students actively participate in an unsuccessful resuscitation (mannequin) followed immediately by BBN to a standardized patient wife (SPW) portrayed by an actress. Thirty-nine 3(rd) year medical students completed a questionnaire and then were divided as follows: Group 1 (n=21) received little to no training prior to speaking with the SPW. Group 2 (n =18) received a lecture and practiced for 1 hour in small groups prior to the resuscitation and BBN. Both groups self assessed ability to BBN (p<.0002 & p<.00001), and ability to have a plan (p<.0004 & p <.0003) improved significantly over base line with greater improvement in group 2. Group 2 (pre-trained) students were rated superior by SPW's in several key areas. This novel approach to teaching BBN to 3(rd) year medical students was well received by the students and resulted in marked improvement of self assessed skills over baseline.