Racial disparities in triage of adolescent patients after bullet injury.

BACKGROUND: While pediatric trauma centers (PTCs) and adult trauma centers (ATCs) exhibit equivalent trauma mortality, the optimal care environment for traumatically injured adolescents remains controversial. Race has been shown to effect triage within emergency departments (EDs) with people of color receiving lower acuity triage scores. We hypothesized that African-American adolescents were more likely triaged to an ATC than a PTC compared with their White peers. METHODS: Institutional trauma databases from a neighboring, urban Level I PTC and ATC were queried for gunshot wounds in adolescents (15-18 years) presenting to the ED from 2015 to 2017. The PTC and ATC were compared in terms of demographics, services, and outcomes. Results were analyzed using univariate analysis and logistic regression. RESULTS: Among 316 included adolescents, 184 were treated in an ATC versus 132 in a PTC. Patients at the PTC were significantly more likely to be younger (16.1 vs. 17.5 years; p < 0.001), White (16% vs. 5%; p = 0.001), and privately insured (41% vs. 30%; p = 0.002). At each age, the proportion of Whites treated at the PTC exceeded the proportion of African-Americans. At the PTC, patients were more likely to receive inpatient and outpatient social work follow-up (89% vs. 1%, p < 0.001). Adolescents treated at the PTC were less likely to receive opioids (75% vs. 56%, p = 0.001) at discharge and to return to ED within 6 months (25% vs. 11%, p = 0.005). On multivariate logistic regression, African-American adolescents were less likely to be treated at a PTC (odds ratio, 0.30; 95% confidence interval, 0.10-0.85; p = 0.02) after controlling for age and Injury Severity Score. CONCLUSION: Disparities in triage of African-American and White adolescents after bullet injury lead to unequal care. African-Americans were more likely to be treated at the ATC, which was associated with increased opioid prescription, decreased social work support, and increased return to ED. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

The impact of retained bullet fragments on outcomes in patients with gunshot wounds.

BACKGROUND: Nationally, 115,000 non-fatal firearm injuries occurred in 2017, with many such victims possessing retained bullet fragments (RBFs); however, the impact of RBFs has not been well studied. METHODS: An institutional trauma database from an urban, level one trauma center was queried for patients presenting with gunshot wounds (GSWs) to the ED in 2017. GSWs were stratified by the presence or absence of RBFs. Groups were compared using t-tests, chi-squared, and logistic regression. RESULTS: Of 674 patients with GSWs who met inclusion criteria, 394 had RBFs versus 280 with no RBFs. Patients with RBFs were more likely admitted from the ED (57.4% vs. 41.8%, p < 0.001), had significantly higher rates of return to the ED within six months (30.7% vs. 18.6%, p < 0.001), and higher rates of subsequent GSW in the next year (5.1% vs. 1.8%, p = 0.03). On return to ED, 17.6% of those with a RBF had symptoms associated with their RBF. CONCLUSION: RBFs may represent an unrecognized risk factor for both repeat ED visits and subsequent bullet injury.

COVER: A Curriculum in the Management of Soft Tissue Injury and Infection for Junior Surgery Residents.

BACKGROUND: While wound management is a common task for practicing surgeons, there is a paucity of dedicated education on soft tissue management during residency training. OBJECTIVE: The COVER (Causes of soft tissue injury, Obstacles to closure, Vacuums and stitches, Epithelialization, Rationale for wound care) curriculum was developed to engage junior surgery residents in the management of soft tissue injury and infection. METHODS: Junior surgery residents participated in the COVER lab during academic years 2018-2020. Residents applied appropriate surgical management and wound care to cadaveric models of soft tissue injury and infection. Assessments included a pre-/post-curriculum and pre-/post-lab multiple choice questionnaire and survey. RESULTS: All eligible residents (n = 45, 27) participated in the COVER lab for both academic years. Postgraduate year (PGY)-1s, PGY-2s, and PGY-3s showed improvement in wound management knowledge with an average increase in score of 17%, 8%, and 18%, respectively. They also showed a change in their self-reported perceived ability to achieve primary soft tissue closure with confidence levels 22%, 20%, and 16%, respectively. This was again seen in perceived ability to manage soft tissue injuries and infections (28%, 28%, and 23%, respectively). There was a significant increase in performing new wound management skills (PGY-1 mean 51.3%, PGY-2 33.5%, PGY-3 20%; ANOVA, P = .0001). CONCLUSIONS: The COVER curriculum provides a systematic approach to soft tissue injury and infection. Residents showed a significant increase in both soft tissue knowledge as well as confidence in ability to perform wound management.

Difficult conversations: Navigating intimate partner violence with standardized patients.

BACKGROUND: One in three women in the US experience intimate partner violence (IPV) in their lifetime. There are minimal opportunities for medical students to learn about responding to IPV. METHODS: Students participated in a learning intervention about recognizing and addressing IPV, followed by a standardized patient session. Students filled out a seven-question survey before and after the session, which assessed comfort addressing IPV, discussing resources, and practicing trauma-informed care. Responses were compared using the Mann-Whitney U test. RESULTS: Sixteen medical students participated, response rate of 100%. The median score for comfort recognizing signs of IPV increased from 2 to 3 (p < 0.01); for asking patients about IPV, from 1 to 3.5 (p < 0.01); in knowledge of IPV resources, from 1 to 3 (p < 0.01); in preparedness to practice trauma informed care, from 2 to 3.5 (ns). Comfort addressing IPV improved from 1 to 3 (p < 0.01). CONCLUSION: After the session, student preparedness and comfort addressing IPV increased. The learning intervention addressed information not in standard medical curricula. This module can be easily adapted to any medical school curricula.

A Multi-Modal Approach to Closing Exploratory Laparotomies Including High-Risk Wounds.

Background Laparotomy incisions with contamination have a high incidence of surgical site infection (SSI). One strategy to reduce SSI has been to allow these wounds to heal by secondary intention; however, this results in an ongoing need for wound care after discharge. Methods A prospectively maintained Acute and Critical Care Surgery database was queried for patients who underwent exploratory laparotomy during 2008-2018. Patients were stratified into two groups: 2008-2015 (no protocol [NP]) and 2016-2018 (closure protocol [CP]). CP patients were operated on by a single surgeon utilizing a multi-modal high-risk incisional closure protocol, which included dilute chlorhexidine lavage, closed suction drains for incisions deeper than 3 centimeters, and incisional negative-pressure wound therapy (iNPWT). The CDC (Centers for Disease Control and Prevention) guidelines were used to determine wound classification and SSI based on chart review. Groups were compared using univariate and multivariate analysis. Results A total of 139 patients met the study criteria. The overall SSI rate, including superficial and deep space infections, was no different in NP versus CP (21.6 vs. 24.1%; p=0.74). The rate of superficial SSI was similar between NP and CP (11.8 vs. 8.4%; p=0.53). Rates of wound closure at discharge were higher in the CP group than the NP group across wound classes, with the greatest difference among dirty wounds (50.0% NP vs. 94.9% CP; p<0.01). CP significantly increased the likelihood of wound closure (OR=179.2; p<0.001) even after controlling for body mass index, wound classification, ASA (American Society of Anesthesiologists) status, and initially open abdomen. Conclusions By addressing both tissue factors and bacterial burden through the use of a multi-modal high-risk incisional closure protocol involving iNPWT, all wounds can be considered for closure without increasing the risk of SSI.

Hybrid Use of Negative Pressure Therapy in the Management of Partial Wound Closure After Girdlestone Procedure.

In a patient with septic arthritis and pressure ulcers requiring bilateral Girdlestone pseudoarthroplasty, hybrid open and closed incisional negative pressure therapy (ciNPT) is used to manage a closed surgical incision confluent with a large, open wound. Hybrid open and ciNPT facilitates both the healing of the primary closure as well as preparation of the wound bed for skin grafting. ciNPT can be used in partially closed wounds in combination with traditional NPT of the open portion of the wound to allow for more successful closure in wounds under tension.

Firearm laws and illegal firearm flow between US states.

BACKGROUND: Considerable variation in firearm legislation exists. Prior studies show an association between stronger state laws and fewer firearm deaths. We hypothesized that firearms would flow from states with weaker laws to states with stronger laws based on proximity and population. METHODS: Crime gun trace data from 2015 to 2017 was accessed from the Bureau of Alcohol, Tobacco, Firearms and Explosives and compared with the count and composition of firearm legislation in 2015 among the contiguous 48 states. Additional independent variables included population, median household income, distance, and presence or absence of a shared border. We used Exponential Random Graph Models to identify predictors of traced firearm transfers between origin and destination states. RESULTS: After controlling for network structure, firearm laws in origin states were associated with fewer traced firearm transfers (incidence rate ratio [IRR], 0.88; 95% confidence interval [CI], 0.83-0.93; p < 0.001). Conversely, more firearm laws in destination states were associated with more traced firearm transfers (IRR, 1.10; 95% CI, 1.06-1.15; p < 0.001). Larger population at the origin was associated with increased transfers (IRR, 1.38; 95%CI, 1.27-1.50; p < 0.001), as was larger population at the destination state (IRR, 1.45; 95% CI, 1.35-1.56; p < 0.001). Greater distance was associated with fewer transfers (for each 1,000 km; IRR, 0.35; 95% CI, 0.27-0.46; p < 0.001), and transfers were greater between adjacent states (IRR, 2.49; 95% CI, 1.90-3.27; p < 0.001). CONCLUSION: State firearm legislation has a significant impact on gun trafficking even after controlling for network structure. States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state. LEVEL OF EVIDENCE: Epidemiologic, level III.

Stop the bleed: The impact of trauma first aid kits on post-training confidence among community members and medical professionals.

INTRODUCTION: Bystander training to control life-threatening hemorrhage is an important intervention to decrease preventable trauma deaths. We asked if receiving a trauma first aid (TFA) kit in addition to Bleeding Control (BC) 1.0 training improves self-reported confidence among community members (CM) and medical professionals (MP). METHODS: Anonymous pre- and post-course surveys assessed exposure to severe bleeding, BC knowledge, and willingness to intervene with and without TFA kits. Surveys were compared using chi-squared tests. RESULTS: 80 CM and 60 MP underwent BC training. Both groups demonstrated improved confidence in their ability to stop severe bleeding after the class; however, post-class confidence was significantly modified by receiving a TFA kit. After training, CM confidence was 36.1% without versus 57.0% with a TFA kit(p = 0.008) and MP confidence was 53.8% without versus 87.6% with a TFA kit(p = 0.001). CONCLUSION: Receiving a TFA kit was significantly associated with increased post-training confidence among CM and MP. SUMMARY: Stop the Bleed training improves confidence in stopping severe bleeding among both medical professionals and community members. By providing participants with a trauma first aid kit, post-class confidence improves significantly regardless of medical training.

Blunt splenic injury during colonoscopy: Is it as rare as we think?

BACKGROUND: Post colonoscopy blunt splenic injury (PCBSI) is a rarely reported and poorly recognized event. We analyzed cases of PCBSI managed at our hospital and compared them to existing literature. METHODS: We identified 5 patients admitted with PCBSI through chart review. RESULTS: There were 5 cases of PCBSI identified from April 2016-July 2017. Four of the patients were older than 65 years, three had prior surgeries, and all were women. CT scans showed splenic laceration in 4 cases, hemoperitoneum in 4 cases, and left pleural effusion in 2 cases. Three patients were treated with coil embolization, 1 had open splenectomy, and 1 was observed. CONCLUSIONS: Although blunt splenic injury is an infrequently reported complication of colonoscopy, it can result in high-grade injury requiring transfusion and invasive treatment due to significant hemorrhage. As previously reported, we demonstrate a high rate of PCBSI in women over 55 with a history of prior abdominal surgery. These data suggest that a high index of suspicion for splenic injury post-colonoscopy should be present in this population.

Combination of Girdlestone Pseudoarthroplasty and Negative Pressure Wound Therapy with Instillation and Dwell in the Treatment of Invasive Osteomyelitis of the Proximal Femur.

Osteomyelitis is a progressively destructive invasive infection of the bone that can result in both localized and systemic illness. This includes an acute suppurative infection, generalized weakness, a failure to thrive, a pathological fracture, and non-healing ulcers. When chronic osteomyelitis develops, therapeutic options are limited, as antimicrobial agents cannot penetrate the necrotic bone, and repeated surgical debridement may be needed. Re-establishing full thickness coverage of the wounds and ulcers associated with osteomyelitis is challenging due to factors such as ongoing pressure injury, malnutrition, and resistant microorganisms. Classically, Girdlestone pseudoarthroplasty has been used to manage a resistant and invasive infection of the acetabular cavity and proximal femur, but it is now rarely employed because of the morbidity of removing the femoral head and leaving a wound to heal by secondary intention. Negative pressure wound therapy with instillation and dwell (NPWTi-d) offers a powerful adjunct to the management of complex infections and wound healing. In this case series of invasive osteomyelitis of the proximal femur in non-ambulatory patients, we demonstrate that the combination of the Girdlestone and negative pressure wound therapy with instillation and dwell allows for delayed closure within a week of the initial procedure, with favorable outcomes and no recurrence of osteomyelitis. The case log of a single surgeon was analyzed retrospectively over an 18-month period. The case series includes all patients who underwent the Girdlestone procedure for invasive osteomyelitis of the femoral head after failed antibiotic management, were non-ambulatory, and were greater than age 18. A total of 10 patients with 11 Girdlestone operations were found. Patients were predominantly male. The average age was 40 years. All patients were treated with NPWTi-d and then underwent a delayed primary or partial closure on an average of 4.5 days after the initial debridement. All four patients with no pre-existing pressure ulceration of the greater trochanter underwent primary closure without wound complication. Of the remaining patients with pre-operative ulcers of the greater trochanter, three were closed successfully or completely healed secondarily and four had substantial wound healing and reduction in size in the post-operative time period. All but one patient who had pre-operative ulcers of the ipsilateral ischium also had a noted improvement of ulcer dimensions in the postoperative follow-up period. Two patients developed new pressure ulcers on the contralateral side and two patients had a worsening of their pre-existing contralateral pressure ulcers more than 30 days post-operatively. No patient had a recurrence of their osteomyelitis. During the same time period, one patient refused surgical intervention and died secondary to overwhelming sepsis. Girdlestone pseudoarthroplasty is a radical therapy for refractory invasive osteomyelitis. While it has been historically associated with prolonged or failed wound healing, combining this surgery with negative pressure wound therapy with instillation and dwell allows for the successful eradication of infection. In addition, this facilitates wound healing and closure, providing a powerful alternative to the challenge of refractory invasive osteomyelitis of the hip, an ultimately life-threatening infection.