Practical Bioethics for the Humanitarian Surgeon: The Development, Implementation and Assessment of an Ethics Curriculum for Residents Participating in Humanitarian Missions.

BACKGROUND: Humanitarian surgeons face many ethical challenges. Despite increasing resident participation during humanitarian activities, minimal literature exists describing premission ethics training. METHODS: A systematic literature review was conducted to identify publications on humanitarian surgery. A 3-tiered review was performed assessing for ethical conflicts and guidelines. A Humanitarian Ethics Curriculum (HEC) was developed based on these findings and administered to residents prior to a humanitarian mission. Postmission essays were assigned to describe an ethical dilemma they encountered. The HEC's value was evaluated by identifying the ACGME core competencies represented in the essays. RESULTS: 49 eligible publications were identified. Several areas of consensus were found. Controversies identified included: trainee involvement, surgical innovation, and operating on patients with dismal prognosis. All residents stated that the HEC was vital. 61% of ethical dilemmas involved surgical patients. Core competencies emphasized included systems-based practice, patient care, professionalism, interpersonal/communication skills, and medical knowledge. CONCLUSIONS: There is consensus regarding ethical principles that surgeons should follow during humanitarian activities. However, areas of controversy persist. Premission HEC should be administered to residents participating in humanitarian missions.

Giant Anterior Tibial Artery Pseudoaneurysm Successfully Treated on the USNS Mercy.

The need for an experienced vascular surgeon in the combat setting is not questioned; however, there is a paucity of literature exploring the utility of vascular surgery during an elective humanitarian mission. We herein present a case of a post-traumatic pseudoaneurysm of the anterior tibial artery treated in the context of a humanitarian mission during Pacific Partnership 2015 aboard the United States Naval Ship Mercy. This case report demonstrates the necessity and unique opportunities for vascular surgeons to participate in humanitarian surgery.

A decade of pelvic vascular injuries during the Global War on Terror.

BACKGROUND: Pelvic vascular injuries (PVIs) rarely occur in isolation and are often associated with significant morbidity. The purpose of this study was to examine the incidence, trends, and early outcomes of PVIs sustained in combat. METHODS: The Department of Defense Trauma Registry was queried to identify all patients treated with PVIs during the first 10 years of Operation Enduring Freedom. Patient demographics, mechanism of injury, type of vascular injury, in-theater complications, and early clinical outcomes were examined. RESULTS: From 2003 to 2012, 143 patients (99% male) sustained a PVI in Afghanistan. During this period, there was a persistent increase in the percentage of patient visits (0.4% in 2003 to 2.0% in 2012). The mean Injury Severity Score (ISS) was 24. Sixty-six percent of patient injuries were secondary to explosions. Improvised explosive devices (IEDs) encountered by dismounted personnel accounted for 47% of all injuries and were associated with a significantly higher ISS (28) compared with all other mechanisms of injury (P < .01). There were 85 (43%) arterial and 112 (57%) venous PVIs. The most frequent arterial injury was the common iliac artery. Injury to the femoral vein was associated with a higher median transfusion requirement. One patient died in combat theater. Injuries from IEDs had higher rates of coagulopathy, acidosis, and hypothermia compared with other mechanisms of injury (P = .03). Forty-two patients (29%) sustained early infectious complications. Injuries from explosions were also associated with a significantly higher rate of infectious complications compared with other mechanisms of injury (P < .01). CONCLUSIONS: PVIs have occurred with increasing frequency during Operation Enduring Freedom. Despite a persistently low mortality, complication and infection rates remain high, particularly when injuries are secondary to explosions. IEDs are associated with higher ISS and complication rates. Future studies must continue to focus on the prevention and treatment of PVIs sustained in combat, particularly those caused by explosions.

Frailty in trauma: A systematic review of the surgical literature for clinical assessment tools.

BACKGROUND: Elderly trauma patients have outcomes worse than those of similarly injured younger patients. Although patient age and comorbidities explain some of the difference, the contribution of frailty to outcomes is largely unknown because of the lack of assessment tools developed specifically to assess frailty in the trauma population. This systematic review of the surgical literature identifies currently available frailty clinical assessment tools and evaluates the potential of each instrument to assess frailty in elderly patients with trauma. METHODS: This review was registered with PROSPERO (the international prospective register of systematic reviews, registration number CRD42014015350). Publications in English from January 1995 to October 2014 were identified by a comprehensive search strategy in MEDLINE, EMBASE, and CINAHL, supplemented by manual screening of article bibliographies and subjected to three tiers of review. Forty-two studies reporting on frailty assessment tools were selected for analysis. Criteria for objectivity, feasibility in the trauma setting, and utility to predict trauma outcomes were formulated and used to evaluate the tools, including their subscales and individual items. RESULTS: Thirty-two unique frailty assessment tools were identified. Of those, 4 tools as a whole, 2 subscales, and 29 individual items qualified as objective, feasible, and useful in the clinical assessment of trauma patients. The single existing tool developed specifically to assess frailty in trauma did not meet evaluation criteria. CONCLUSION: Few frailty assessment tools in the surgical literature qualify as objective, feasible, and useful measures of frailty in the trauma population. However, a number of individual tool items and subscales could be combined to assess frailty in the trauma setting. Research to determine the accuracy of these measures and the magnitude of the contribution of frailty to trauma outcomes is needed. LEVEL OF EVIDENCE: Systematic review, level III.

Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers.

BACKGROUND: Venous thromboembolism (VTE) remains a significant cause of morbidity and mortality in trauma. Controversy exists regarding the use of lower extremity duplex ultrasound screening and surveillance (LEDUS). Advocates cite earlier diagnosis and treatment of deep venous thrombosis (DVT) to prevent clot propagation and pulmonary embolism (PE). Opponents argue that LEDUS identifies more DVT (surveillance bias) but does not reduce the incidence of PE. We sought to determine the magnitude of surveillance bias associated with LEDUS and test the hypothesis that LEDUS does not decrease the incidence of PE after injury. METHODS: We compared data from two Level 1 trauma centers: Scripps Mercy Hospital, which used serial LEDUS, and Christiana Care Health System, which used LEDUS only for symptomatic patients. Beginning in 2013, both centers prospectively collected data on demographics, injury severity, and VTE risk for patients admitted for more than 48 hours. Both centers used mechanical and pharmacologic prophylaxis based on VTE risk assessment. RESULTS: Scripps Mercy treated 772 patients and Christiana Care treated 454 patients with similar injury severity and VTE risk. The incidence of PE was 0.4% at both centers. The odds of a DVT diagnosis were 5.3 times higher (odds ratio, 5.3; 95% confidence interval, 2.5-12.9; p < 0.0001) for patients admitted to Scripps Mercy than for patients admitted to Christiana Care. Of the 80 patients who developed DVT, PE, or both, 99% received prophylaxis before the event. Among those who received pharmacologic prophylaxis, the VTE rates between the two centers were not statistically significantly different (Scripps Mercy, 11% vs. Christiana Care, 3%; p = 0.06). CONCLUSION: The odds of a diagnosis of DVT are increased significantly when a program of LEDUS is used in trauma patients. Neither pharmacologic prophylaxis nor mechanical prophylaxis is completely effective in preventing VTE in trauma patients. VTE should not be considered a "never event" in this cohort. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III; therapeutic study, level III.

Attenuation of cardiovascular stress with sympatholytics does not improve survival in patients with severe isolated traumatic brain injury.

BACKGROUND: Studies have shown improved survival after traumatic brain injury (TBI) with the administration of sympatholytics, including ß-blockers and clonidine, which is thought to attenuate the cardiovascular stress response. However, the use of sympatholytics has not been studied in patients with isolated severe TBI (ISTBI). We hypothesized that ISTBI patients receiving sympatholytics who demonstrated a reduction in cardiovascular stress would have improved outcomes compared with similarly injured patients without these cardiovascular changes. METHODS: We reviewed the medical records of 338 ISTBI patients (head Abbreviated Injury Scale [AIS] score > 3 and associated injury AIS score < 1) admitted to a Level I trauma center from 2010 through 2014. All patients were managed according to Brain Trauma Foundation guidelines. Demographic, clinical, and survival probability data were gathered. The primary outcome was inpatient mortality. Cardiovascular stress was assessed using the rate-pressure product (RPP = systolic blood pressure × heart rate / 100) calculated both before and after sympatholytic administration. Associations between independent variables and mortality were adjusted for total hospital length of stay. RESULTS: Among ISTBI patients, observed mortality was 6% (n = 20), while predicted mortality by Trauma and Injury Severity Score (TRISS) was 11% (n = 38). Administration of sympatholytics was associated with reduction in RPP in univariate analysis (p = 0.035). After adjusting for length of stay, neither receipt of ß-blockers nor reduction in RPP was associated with survival. Mean reduction in RPP among survivors was not different from that among nonsurvivors (-4.0% vs. -11.9%, p = 0.148). In addition, RPP reduction among patients who received sympatholytics occurred at the same rate in survivors as nonsurvivors (67% vs. 68%, p = 0.894). Severity of head injury, intraventricular hemorrhage, and any intracranial operative intervention were significantly associated with mortality. CONCLUSION: Although sympatholytic administration is associated with a significant decrease in RPP, the survival benefit seen in patients with multiple injuries with TBI is not observed among ISTBI patients. Further research on the role of sympatholysis in the management of ISTBI is warranted. LEVEL OF EVIDENCE: Therapeutic study, level IV.

A pulseless limb poorly predicts an arterial injury in combat trauma.

BACKGROUND: A pulseless limb is considered a hard sign of an arterial injury after penetrating trauma in the civilian population. However, the reliability of this finding has never been examined in combat trauma. The purpose of this study was to examine the reliability of the pulseless limb in the combat trauma population. Reasons for false positive physical examination findings were also identified. METHODS: The Joint Theater Trauma Registry identified all patients who presented to a military treatment facility (MTF) in Kandahar, Afghanistan, with a penetrating extremity injury over a 2-year period. Patients found to have a pulse deficit on initial physical examination were followed, and the results of the subsequent computed tomographic angiogram or arteriogram recorded. Patient demographics, injury patterns, and physiological data were examined. Standard statistical analysis was performed. RESULTS: From 2011 to 2012, 644 patients were treated at a single MTF for lower extremity penetrating injuries. The most common mechanisms of injury were explosions (62%) and gunshot wounds (20%). Of the 577 patients with complete medical records, 448 patients (78%) presented with palpable pulses, 115 patients (20%) presented with a pulseless limb, and 14 (2%) presented with hard signs of vascular injury. Of those with a pulseless limb and abnormal ankle-brachial index (ABI) or no ABI obtained who underwent further radiologic imaging, 38 patients (77%) had no arterial injury identified. Compared with those with a palpable pulse, patients with a pulseless limb without an arterial injury were more likely to have a higher Injury Severity Score (ISS), lower hematocrit, lower pH, greater base deficit, higher heart rate, more frequent use of tranexamic acid, and received greater volumes of packed red blood cells, plasma, and crystalloids. CONCLUSIONS: Our results demonstrate that a pulseless limb is a poor predictor of arterial injury and should not be considered a hard sign of vascular injury in the combat population. Variables including a high ISS, anemia, acidosis, and need for resuscitation products, each a surrogate for injury severity, may contribute to the decreased accuracy of the physical examination in our troops. This may translate into unnecessary immediate exploration or other interventions in patients who present with more significant injuries from the battlefield. Future studies must continue to focus on improved algorithms for diagnostic accuracy of extremity vascular injuries in this population.