Building trauma capability: using geospatial analysis to consider military treatment facilities for trauma center development.

Background: The Military Health System must develop and sustain experienced surgical trauma teams while facing decreased surgical volumes both during and between deployments. Military trauma resources may enhance local trauma systems by accepting civilian patients for care at military treatment facilities (MTFs). Some MTFs may be able to augment their regional trauma systems by developing trauma center (TC) capabilities. The aim of this study was to evaluate the geographical proximity of MTFs to the continental US (CONUS) population and relative to existing civilian adult TCs, and then to determine which MTFs might benefit most from TC development. Methods: Publicly available data were used to develop a list of CONUS adult civilian level 1 and level 2 TCs and also to generate a list of CONUS MTFs. Census data were used to estimate adult population densities across zip codes. Distances were calculated between zip codes and civilian TCs and MTFs. The affected population sizes and reductions in distance were tabulated for every zip code that was found to be closer to an MTF than an existing TC. Results: 562 civilian adult level 1 and level 2 TCs and 33 military medical centers and hospitals were identified. Compared with their closest civilian TCs, MTFs showed mean reductions in distance ranging from 0 to 30 miles, affecting populations ranging from 12 000 to over 900 000 adults. Seven MTFs were identified that would offer clinically significant reductions in distance to relatively large population centers. Discussion: Some MTFs may offer decreased transit times and improved care to large adult populations within their regional trauma systems by developing level 1 or level 2 TC capabilities. The results of this study provide recommendations to focus further study on seven MTFs to identify those that merit further development and integration with their local trauma systems. Level of evidence: IV.

Social Work Evaluations Among Pediatric Patients Transferred for Burn Care.

INTRODUCTION: Regionalization efforts aim to improve healthcare by designating specialty centers for a geographic area. Regionalization may play a role in determining patient treatment plans and outcomes. We hypothesize that these factors may be influenced by race, socioeconomics, insurance, and longitudinal follow-up. METHODS: Retrospective review of 81 patients ages 0-18 years evaluated at our Level 2 Trauma Center between February 2016-December 2020 who met criteria for transfer to a Regional Burn Center. RESULTS: 67% of patients were transferred to the Regional Burn Center. There was no difference in the percentage of transferred patients with respect to age, race, ethnicity, insurance type, or rurality of home address. Secondary analysis showed that 57.4% of children were transferred without evaluation by social work. Five patients' injuries were due to non-accidental trauma (NAT); two of these patients were transferred without social work evaluations. 28% of those transferred had documented involvement of Child Protective Services (CPS). Of the 31 transferred patients without social work evaluation, 67% had incomplete or missing notes from the burn center, including 100% of those subsequently confirmed to be due to NAT. Only 32% of patients received follow-up at our institution. CONCLUSION: We identified no differences in transfer percentages with respect to race, ethnicity, or insurance type. Secondary analysis demonstrated a significant gap in care regarding access to records and social work involvement. As NAT and social concerns are common amongst children with burns, we propose policies to ensure that these concerns are not overlooked during regionalization efforts.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Peer review and its ethical implications.

Peer review is an essential tool for institutions and providers to meet the modern goals of safety and quality in health care. It is a mechanism that leads to a just culture within a health care institution whereby errors and complications are considered products of the system rather than isolated actions by an individual. The benefits and potential drawbacks of peer review are outlined in this review with a special emphasis on the interface between peer review and principles of medical ethics. It is argued that peer review, in the ideal setting, is founded upon the principles of beneficence and justice, and to varying levels on non-maleficence and autonomy.

Single Versus Double Anatomic Site Intraosseous Blood Transfusion in a Swine Model of Hemorrhagic Shock.

BACKGROUND: Blood transfusion via single site intraosseous access is a critical modality when caring for a trauma victim that lacks intravascular access. Flow rates and potential clinical complications when utilizing two sites of intraosseous access are not well known. MATERIALS AND METHODS: Anesthetized adult female Yorkshire swine (Sus scrofa; n = 48; 76.7 ± 1.75kg; range 66-90kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to treatment groups: single sited humerus, single sited sternum, dual sited humerus or dual sited humerus and sternum. Flow rates, hemolysis, physiologic measurements, biochemical variables, and pulmonary histologic inflammation and occlusion were contrasted between groups. RESULTS: Dual sited intraosseous transfusion flow rates (128ml/min, 95% CI 123-132) were double the flow rates of single sites (65ml/min, 95% CI 60-70), P < .0001.Single sited humeral flow rates were greater than sternal flow rates, with respective averages of 74ml/min and 55ml/min, though not reaching statistical significance (P < 0.17). There was no significant elevation of plasma free hemoglobin in any group after transfusion as compared to baseline (P = 0.7). Groups did not significantly differ in vitals or biochemical variables. Most pulmonary specimens had some intraparenchymal fat embolism, however no animals had evidence of occlusive intra-arterial fat embolism. CONCLUSIONS: Dual anatomic site, pressure bag driven, intraosseous blood transfusion approximately doubles flow rates without evidence of clinical complications or hemolysis. Further research using a survivability model is needed to characterize long-term complications from pressurized IO transfusions.

Universal Healthcare Coverage Does Not Ensure Adherence to Initial Colorectal Cancer Screening Guidelines.

INTRODUCTION: Colorectal cancer is the second leading cause of cancer deaths in the USA, and screening tests are underutilized. The aim of this study was to determine the proportion of individuals at average risk who utilized a recommended initial screening test in a universal healthcare coverage system. MATERIALS AND METHODS: This is a retrospective cohort study of active duty and retired military members as well as civilian beneficiaries of the Military Health System. Individuals born from 1960 to 1962 and eligible for full benefits on their 50th birthday were evaluated. Military rank or rank of benefits sponsor was used to determine socioeconomic status. Adherence to the U.S. Preventive Services Task Force guidelines for initial colorectal cancer screening was determined using "Current Procedural Terminology" and "Healthcare Common Procedure Coding System" codes for colonoscopy, sigmoidoscopy, fecal occult blood test, and fecal immunohistochemistry test. Average risk individuals who obtained early screening ages 47 to 49 were also identified. RESULTS: This study identified 275,665 individuals at average risk. Of these, 105,957 (38.4%) adhered to screening guidelines. An additional 19,806 (7.2%) individuals were screened early. Colonoscopy (82.7%) was the most common screening procedure. Highest odds of screening were associated with being active duty military (odds ratio [OR] 3.63, 95% confidence interval [CI] 3.43 to 3.85), having highest socioeconomic status (OR 2.37, 95% CI 2.31 to 2.44), and having managed care insurance (OR 4.36, 95% CI 4.28 to 4.44). CONCLUSIONS: Universal healthcare coverage does not ensure initial colorectal cancer screening utilization consistent with guidelines no does it eliminate disparities.

Comparison of 10- versus 14-gauge angiocatheter for treatment of tension pneumothorax and tension-induced pulseless electrical activity with hemorrhagic shock: Bigger is still better.

BACKGROUND: Little is known regarding the effect of hemorrhagic shock on the diagnosis and treatment of tension pneumothorax (tPTX). Recently, the Tactical Combat Casualty Care guidelines included the 10-gauge angiocatheter (10-g AC) as an acceptable alternative to the 14-g AC. This study sought to compare these two devices for decompression of tPTX and rescue from tension-induced pulseless electric activity (tPEA) in the setting of a concomitant 30% estimated blood volume hemorrhage. METHODS: Following a controlled hemorrhage, carbon dioxide was insufflated into the chest to induce either tPTX or tPEA. Tension pneumothorax was defined as a reduction in cardiac output by 50%, and tPEA was defined as a loss of arterial waveform with mean arterial pressure less than 20 mm Hg. The affected hemithorax was decompressed using a randomized 14-g AC or 10-g AC while a persistent air leak was maintained after decompression. Successful rescue from tPTX was defined as 80% recovery of baseline systolic blood pressure, while successful return of spontaneous circulation following tPEA was defined as a mean arterial pressure greater than 20 mm Hg. Primary outcome was success of device. RESULTS: Eighty tPTX and 50 tPEA events were conducted in 38 adult Yorkshire swine. There were no significant differences in the baseline characteristics between animals or devices. In the tPTX model, the 10-g AC successfully rescued 90% of events, while 14-g AC rescued 80% of events (p = 0.350). In the tPEA model, the 10-g AC rescued 87% of events while the 14 AC rescued only 48% of events (p = 0.006). CONCLUSION: The 10-g AC was vastly superior to the 14-g AC for return of spontaneous circulation following tPEA in the setting of 30% hemorrhage. These findings further support the importance of larger caliber devices that facilitate rapid recovery from tPTX, particularly in the setting of polytrauma. LEVEL OF EVIDENCE: Therapeutic, level II.

From far and wide: Geographic distance to pediatric surgical care across Canada.

PURPOSE: Canada is the second largest country in the world, with most of the population located in the southern-most portion of its geography. We sought to define the relative distribution of pediatric surgeons to potential pediatric patients using data from the Canadian census. METHODS: The 2011 Canadian Census and a convenience sample of current Canadian pediatric surgeons were used to calculate straight-line distances between pediatric surgeon postal code centroids and census dissemination block centroids. RESULTS: Currently, there are 74 practicing pediatric surgeons in Canada; 493,345 populated census blocks were identified, and 7,752,075 children were enumerated. The median (IQR) kilometers to the closest pediatric surgeon was 27.99 (11.35, 85.47) kilometers, and 22.7% of Canadian children lived more than 100 km from care. Nearly 13% of children lived greater than 200 km from the nearest pediatric surgeon. CONCLUSION: More than 1.7 million Canadian children, nearly one quarter of all Canadian children, live greater than 100 km from the closest pediatric surgeon. This identifies a disparate group of patients who do not have an equal access-to-care as compared to others in the country. LEVEL OF EVIDENCE: Level IV.

Safety of Pressurized Intraosseous Blood Infusion Strategies in a Swine Model of Hemorrhagic Shock.

BACKGROUND: Current guidelines support intraosseous access for trauma resuscitation when intravenous access is not readily available. However, safety of intraosseous blood transfusions with varying degrees of infusion pressure has not been previously characterized. MATERIALS AND METHODS: Adult female Yorkshire swine (Sus scrofa; n = 36; mean (M): 80 kg, 95% CI: 78-82 kg) were cannulated and then bled approximately 30% total blood volume. Swine were randomly assigned to proximal humerus intraosseous blood infusion with either Rapid Infuser, or Pressure Bag, or Push-Pull methods (n = 12 each). Flow rates, infusion pressures, vitals, biochemical variables, and pulmonary and renal tissue pathology were contrasted between groups. RESULTS: Flow rates were greater for the Push-Pull strategy than Pressure Bag (96.5 mL/min versus 72.6 mL/min, P = 0.02) or Rapid Infuser (96.5 mL/min versus 60 mL/min, P = 0.002) strategies. The pressures generated during the Push-Pull transfusion (3058 mmHg) were greater than the other strategies (≤360 mmHg). After the observation period, plasma-free hemoglobin levels were higher in the Push-Pull strategy than in the Rapid Infuser (40 mg/dL versus 12 mg/dL, P = 0.02) or Pressure Bag (40 mg/dL versus 12 mg/dL, P = 0.01). Groups did not significantly differ in vitals, biochemical variables, or tissue pathology. CONCLUSIONS: Push-Pull conferred the highest flow rates, but with higher infusion pressures and evidence of intravascular hemolysis. Rapid Infuser and Pressure Bag infusions had no increase from baseline in plasma-free hemoglobin. Pressure Bag infusion was noted to confer an advantage in flow rates over Rapid Infuser. Intraosseous blood transfusion with pressure bags can safely bridge toward central access in the early phases of trauma resuscitation.

Evaluation of disparity in care for perforated appendicitis in a universal healthcare system.

PURPOSE: Racial and socioeconomic disparities have been reported in the management of appendicitis. Perforated appendicitis (PA) is used as an index for barriers to care due to delays in treatment. This study evaluates the effect of racial and socioeconomic differences on the likelihood of PA in a universally insured national healthcare system. METHODS: A retrospective review of pediatric patients enrolled in TRICARE who underwent appendectomy during a 5-year period was performed. Logistic regression was used to examine the association between ethnicity, age, gender, parent, or guardian marital status and deployment status of the active duty parent, type of facility, and type of admission with the odds of perforated appendicitis. RESULTS: A total of 3124 children met inclusion criteria. One-third of children carried the diagnosis of PA. Increased odds of PA was associated with younger age of patient among children of military personnel with enlisted ranks and senior officer ranks. CONCLUSION: In a universal healthcare system, no disparities across race with regard to presentation of appendicitis were identified. Increased odds of perforated appendicitis were observed in younger patients, but this was demonstrated in families of both high and low socioeconomic status. Universal coverage does appear to eliminate some barriers to healthcare.

Blunt versus penetrating trauma: Is there a resource intensity discrepancy?

BACKGROUND: The rising cost of healthcare requires responsible allocation of resources. Not all trauma centers see the same types of patients. We hypothesized that patients with blunt injuries require more resources than patients with penetrating injuries. METHODS: This was a retrospective analysis of all highest-level activation trauma patients at our busy urban Level I Trauma Center over five years. Data included demographics, injuries, hospital charges, and resources used. A p value < 0.05 was significant. RESULTS: 4578 patients were included (2037 blunt and 2541 penetrating). Blunt patients were more severely injured, more often admitted, required more radiographic studies, had longer hospital, intensive care unit, and mechanical ventilation days, and therefore, higher hospital charges. CONCLUSIONS: Within one center, patients with blunt injuries required more resources than those with penetrating injuries. Understanding this pattern will allow trauma systems to better allocate limited resources based on each center's mechanism of injury distribution.

A Reusable Perfused Human Cadaver Model for Surgical Training: An Initial Proof of Concept Study.

OBJECTIVES: Today's surgical trainees have less exposure to open vascular and trauma procedures. Lightly embalmed cadavers may allow a reusable model that maximizes resources and allows for repeat surgical training over time. METHODS: This was a three-phased study that was conducted over several months. Segments of soft-embalmed cadaver vessels were harvested and perfused with tap water. To test durability, vessels were clamped, then an incision was made and repaired with 5-0 polypropylene. Tolerance to suturing and clamping was graded. In a second phase, both an arterial-synthetic graft and an arterial-venous anastomosis were performed and tested at 90 mmHg perfusion. In the final phase, lower extremity regional perfusion was performed and vascular control of a simulated injury was achieved. RESULTS: Seven arteries and six veins from four cadavers were explanted. All vessels accommodated suture repair over 6 weeks. There was minor leaking at all previous clamp sites. In the anastomotic phase, vessels tolerated grafting, clamping, and perfusion without tearing or leaking. Regional perfusion provided a life-like training scenario. CONCLUSIONS: Explanted vessels of soft-embalmed cadavers show adequate durability over time with realistic vascular surgery handling characteristics. This shows promise as initial proof of concept for a reusable perfused cadaver model. Further study with serial regional and whole-body perfusion is warranted.

Geographic distance to pediatric surgical care within the continental United States.

PURPOSE: Geographic proximity to pediatric surgical care has not been evaluated using the Decennial Census nor have racial, ethnic, gender, or urbanization variations been reported. This study's aim is to describe proximity of children living in the continental U.S. to a pediatric surgeon with respect to these variations. METHODS: The 2010 American Pediatric Surgical Association member file and the 2010 Decennial Census were used to calculate straight-line distances between pediatric surgeons' zip code centroids and census block centroids. RESULTS: In 2010, 716 practicing pediatric surgeons were identified, 6,182,882 populated Census blocks were identified, and 73,690,271 children were enumerated. Of white non-Hispanic children, 30.1% lived greater than 40 miles from care. Of Native American children, 40.5% lived more than 60 miles from care. Among children 0-5 years of age, the median (IQR) miles to closest pediatric surgeon was 14.2 (6.2, 39.6), and 3,010,698 of these children lived more than 60 miles from care. CONCLUSION: More than 10 million children lived greater than 60 miles from a pediatric surgeon in 2010. Racial, ethnic, age, and urbanization variations in proximity to pediatric surgeons were present. This method is feasible to describe distance-to-care with the upcoming 2020 Decennial Census and may benefit future allocation of pediatric surgeons. LEVEL OF EVIDENCE: IV.

Larger-Caliber Alternative Devices for Decompression of Tension Hemopneumothorax in the Setting of Hemorrhagic Shock.

BACKGROUND: The 14-gauge (14G) angiocatheter (AC) has an unacceptably high failure rate in treatment of tension pneumothorax (tPTX). Little is known regarding the interplay among hemorrhage, hemothorax (HTX), and tPTX. We hypothesized that increased hemorrhage predisposes tension physiology and that needle decompression fails more often with increased HTX. METHODS: This is a planned secondary analysis of data from our recent comparison of 14G AC with 10-gauge (10G) AC, modified 14G Veress needle, and 3mm laparoscopic trocar conducted in a positive pressure ventilation tension hemopneumothorax model using anesthetized swine. Susceptibility to tension physiology was extrapolated from volume of carbon dioxide (CO2) instilled and time required to induce 50% reduction in cardiac output. Failures to rescue and recover were compared between the 10% and 20% estimated blood volume (EBV) HTX groups and across devices. RESULTS: A total of 196 tension hemopneumothorax events were evaluated. No differences were noted in the volume of CO2 instilled nor time to tension physiology. HTX with 10% EBV had fewer failures compared with 20% HTX (7% versus 23%; p = .002). For larger-caliber devices, there was no difference between HTX groups, whereas smaller-caliber devices had more failures and longer time to rescue with increased HTX volume as well as increased variability in times to rescue in both HTX volume groups. CONCLUSION: Increased HTX volume did not predispose tension physiology; however, smaller-caliber devices were associated with more failures and longer times to rescue in 20% HTX as compared with 10% HTX. Use of larger devices for decompression has benefit and further study with more profound hemorrhage and HTX and spontaneous breathing models is warranted.

The non-visualized appendix and secondary signs on ultrasound for pediatric appendicitis in the community hospital setting.

BACKGROUND: Secondary signs of appendicitis on ultrasound may aid with diagnosis in the setting of a non-visualized appendix (NVA). This role has not been shown in the community hospital setting. MATERIALS AND METHODS: All right lower quadrant ultrasounds performed in children for clinical suspicion of appendicitis over a 5-year period in a single community hospital were evaluated. Secondary signs of inflammation including free fluid, ileus, fat stranding, abscess, and lymphadenopathy were documented. Patients were followed for 1 year for the primary outcome of appendicitis. These data were analyzed to determine the utility of secondary signs in the diagnosis of acute appendicitis when an NVA is reported. RESULTS: Six hundred and seventeen ultrasounds were reviewed; 470 of these had an NVA. Of NVAs, 47 (10%) of patients were diagnosed with appendicitis. Sensitivity and specificity of having at least one secondary were 38.3% and 80%, respectively. The positive and negative predictive values of having at least one secondary sign were 17.3% and 92%, respectively. CONCLUSION: These data suggest that the absence of secondary signs has a strong negative predictive value for appendicitis in the community hospital setting; however, the full utility of secondary signs may be limited in this setting.

Group C strep mediastinitis.

This case is significant to the practice of emergency medicine because it represents the development of an uncommon and potentially fatal mediastinal infection from a commonly encountered and appropriately treated community respiratory pathogen. Most published reports on mediastinitis are those that are status-post cardiothoracic surgery. In our report, we discuss a case of a healthy, young individual who developed this morbid entity from extension of a simple respiratory infection where Group C Streptococcus has been isolated as the causative organism, which to our knowledge has not been previously reported. Further, this report outlines how a community acquired pneumonia progressed to a life threatening illness despite proper initial treatment per local and national guidelines.

Bigger is better: Comparison of alternative devices for tension hemopneumothorax and pulseless electrical activity in a Yorkshire swine model.

BACKGROUND: Tension pneumothorax is a cause of potentially preventable death in prehospital and battlefield settings and 14-gauge angiocatheter (14G AC) decompression remains the current treatment standard, despite its high incidence of failure. Traumatic pneumothorax is often associated with hemothorax, but 14G AC has no proven efficacy for associated hemothorax. We sought to compare the 14G AC to three alternative devices for treatment of tension hemopneumothorax (t-H/PTX) in a positive-pressure ventilation swine model. METHODS: Our tension model was modified to incorporate a persistent air leak and pleural blood. Tension physiology was achieved with escalating carbon dioxide insufflation via transdiaphragmatic trocar, and 10% estimated blood volume was instilled into each chest. Intervention was randomized between 14G AC, 10-gauge angiocatheter (10G AC), modified Veress-type needle (mVN), and 3-mm laparoscopic trocar (LT). After recovery, serial tension-induced pulseless electrical activity (PEA) events were induced and decompressed. Success of rescue, time to rescue, and physiologic data were recorded. RESULTS: One hundred ninety-five t-H/PTX and 88 PEA events were conducted in 25 swine. Laparoscopic trocar and 10G AC were more successful and had faster median time to rescue for t-H/PTX compared with 14G AC, whereas mVN performed comparably. Following PEA, 14G AC and mVN succeeded at rescue only 50% and 57% of the time, whereas 10G AC and LT had 100% success at return of spontaneous circulation. Time to successful return of circulation following PEA did not differ between devices; however, there was a noticeable difference in the rate of meaningful hemodynamic recovery following PEA favoring LT and 10G AC. There were no significant injuries noted. CONCLUSIONS: While mVN performed comparably to 14G AC, both have unacceptable failure rates. Ten-gauge AC and LT performed superiorly in both t-H/PTX and PEA. We believe there is now ample evidence supporting replacement of the 14G AC with 10G AC in current treatment recommendations.