Care of Bullet-related Injuries: A Cross-sectional Study of Instructions and Prescriptions Provided on Discharge from the Emergency Department.

INTRODUCTION: There are more than 80,000 emergency department (ED) visits for non-fatal bullet-related injuries (BRI) per year in the United States. Approximately half of these patients are discharged home from the ED. Our objective in this study was to characterize the discharge instructions, prescriptions, and follow-up plans provided to patients discharged from the ED after BRI. METHODS: This was a single-center, cross-sectional study of the first 100 consecutive patients who presented to an urban, academic, Level I trauma center ED with an acute BRI beginning on January 1, 2020. We queried the electronic health record for patient demographics, insurance status, cause of injury, hospital arrival and discharge timestamps, discharge prescriptions, and documented instructions regarding wound care, pain management, and follow-up plans. We analyzed data using descriptive statistics and chi-square tests. RESULTS: During the study period, 100 patients presented to the ED with an acute firearm injury. Patients were predominantly young (median age 29, interquartile range 23-38 years), male (86%), Black (85%), non-Hispanic (98%), and uninsured (70%). We found that 12% of patients did not receive any type of written wound care instruction, while 37% received discharge paperwork that included instructions to take both an NSAID and acetaminophen. Fifty-one percent of patients received an opioid prescription, with a range from 3-42 tablets (median 10 tablets). The proportion of patients receiving an opioid prescription was significantly higher among White patients (77%) than among Black patients (47%). CONCLUSION: There is variability in prescriptions and instructions provided to survivors of bullet injuries upon ED discharge at our institution. Our data indicates that standardized discharge protocols could improve quality of care and equity in the treatment of patients who have survived a BRI. Current variable quality in discharge planning is an entry point for structural racism and disparity.

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.

SAVE 2.0: Identifying and strengthening resident leadership skills through simulation based team training.

BACKGROUND: The "Surgery for Abdomino-thoracic ViolencE (SAVE)" animate lab engages surgical residents in the management of penetrating injuries in a team setting. Senior residents, representing postgraduate year (PGY) 3-5, assume the role of team leader and facilitate the junior residents, PGY1-2, in operative management of simulated penetrating wounds. Residents completed five scenarios with increasing level of difficulty within set time limits. Senior residents were evaluated on their team's ability to "SAVE" their patient within the time allotted, as well as their communication and leadership skills. METHODS: General, vascular, urology, and plastic surgery residents (n = 79) were divided into 25 teams of three to four residents by "resident scores" (R scores, the sum of the team members' PGY) to create balanced teams with comparable years of clinical experience. Residents completed assessments of their senior resident's leadership ability and style. RESULTS: Evaluation of a resident's desired learning style changed across PGY with junior residents preferring more hands-on guidance compared with senior residents preferring only verbal correction. Resident leadership evaluations demonstrated that team leaders of varied resident years achieved the highest scores. Greater differences in the mismatch between autonomy provided to and desired by junior residents correlated to greater junior resident discomfort in expressing their opinion, confidence, and leadership ratings of senior residents. However, greater autonomy mismatch also correlated to more rapid time to task completion. CONCLUSION: Different from our expectations, clinical experience alone did not define team leader success. Leadership is a powerful influence on the outcome of team performance and may be a skill, which can transcend overall clinical experience. A match between desired and provided resident autonomy and team cohesion may demonstrate a stronger effect on team success in stressful operative situations, such as trauma resuscitation. Enhancement of leadership skills early in residency training may represent an important focus for trauma surgery education.

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.

Anatomy of Gun Violence: Contextualized Curriculum to Train Surgical Residents in Both Technical and Non-Technical Skills in the Management of Gun Violence.

BACKGROUND: Gun violence (GV) is a complex public health issue, and the management of GV as a disease engages the surgeon in technical and nontechnical skills. The Anatomy of Gun Violence (AGV) curriculum was developed to teach surgical trainees these seemingly disparate skills, training residents to manage the multiple aspects of firearm injury. STUDY DESIGN: The AGV curriculum was delivered over 6 weeks in the 2017-2018 and 2018-2019 academic years (AY), and used multiple educational methods including didactic lectures, mock oral examinations, a Bleeding Control training session, a GV survivor's personal story, a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) training session, and the Surgery for Abdominal-thoracic ViolencE (SAVE) simulation lab. As surgical residents were involved over both AYs, components of the curriculum were available every other year to provide variety. As proof of concept, this novel curriculum was objectively evaluated by residents' improvement in knowledge and overall experience using pre- and post-surveys. RESULTS: Sixty surgical residents participated in the AGV curriculum in both AYs, with 41 and 36 residents completing the survey regarding their experiences with the curriculum. The curriculum was well received by residents overall in both AYs (median ± IQR 5 ± 0 and 5 ± 0.1, respectively), with the SAVE simulation lab being the most highly favored portion. Additionally, residents had an average 7.5% improvement in knowledge attributed to the curriculum, with a larger effect seen in the junior residents. CONCLUSIONS: This novel AGV curriculum created a well-received learning experience involving the technical and nontechnical skills necessary to care for GV victims. This comprehensive approach to GV may represent a unique opportunity to engage surgical trainees in both the treatment and prevention of firearm injury.

A comparison of the effects of clonidine and CNQX infusion into the locus coeruleus and the amygdala on naloxone-precipitated opiate withdrawal in the rat.

Both the locus coeruleus (LC) and the amygdala have been implicated in aspects of opiate dependence and withdrawal. The LC is known to be one of the most sensitive sites for precipitating withdrawal behaviors after local opiate antagonist infusions in morphine-dependent subjects. The amygdala is also known to mediate antagonist-induced withdrawal behaviors and aversive motivational states. The goal of the present study was to evaluate directly the ability of noradrenergic agonists and glutamatergic antagonists to attenuate naloxone-precipitated withdrawal behaviors when infused into the LC or the central nucleus of the amygdala (CeA). The alpha-2-noradrenergic agonists clonidine or ST-91 were infused into the CeA to compare the effects of noradrenergic activation in the CeA to the attenuation of withdrawal previously observed in rats infused with clonidine into the LC, since the LC and CeA are known to contain co-localized opiate and noradrenergic receptors. The effects of microinfusions of the non-NMDA excitatory amino acid antagonist 6-cyano-2,3-dihydroxy-7-nitroquinoxaline (CNQX) were also infused into the LC and CeA since opiate withdrawal is associated with increased glutamatergic transmission. Intra-CeA clonidine or ST-91 (2.4 microg/0.5 microl or 1.0 microl) produced significant reductions primarily in the occurrence of irritability. Conversely, intra-CeA or intra-LC infusions of CNQX (2.5 microg/0.5 microl) significantly attenuated naloxone-precipitated withdrawal, an effect similar to the attenuation previously observed after intra-LC clonidine infusions. These data demonstrate the specific behavioral effects of altering glutamatergic and noradrenergic neurotransmission in the LC or CeA during naloxone-precipitated opiate withdrawal. Elucidation of the neuroanatomical circuitry involved in opiate withdrawal should increase our understanding of the neuroadaptations associated with drug dependence and subsequent withdrawal behavior.

Opposite modulation of opiate withdrawal behaviors on microinfusion of a protein kinase A inhibitor versus activator into the locus coeruleus or periaqueductal gray.

Chronic opiate administration upregulates the cAMP pathway in the locus coeruleus (LC). This adaptation is thought to increase the electrical excitability of LC neurons and contribute to the dramatic increase in LC firing induced by opioid receptor antagonists in opiate-dependent animals. The goal of the present study was to evaluate directly a role of the cAMP pathway in opiate withdrawal behaviors by studying, in vivo, whether withdrawal is influenced by intra-LC infusion of compounds known to activate or inhibit protein kinase A (PKA). Infusions into amygdala or periaqueductal gray (PAG) were studied for comparison. In one series of experiments the effect of intra-LC, intra-amygdala, or intra-PAG infusions of the PKA inhibitor Rp-cAMPS on naloxone-precipitated withdrawal from morphine was examined. Intra-LC infusions of Rp-cAMPS significantly attenuated several prominent behavioral signs of morphine withdrawal. Intra-PAG infusions of Rp-cAMPS also significantly attenuated opiate withdrawal behaviors, although different behaviors were affected. In contrast, intra-amygdala infusions of Rp-cAMPS were without significant effect. In a second series of experiments the effect of intra-LC or intra-PAG infusions of the PKA activator Sp-cAMPS on behavior in nondependent drug-naive animals was determined. Sp-cAMPS infusions into either brain region induced a quasi-withdrawal syndrome, but the observed behaviors differed between the two groups. Analysis of the phosphorylation state of tyrosine hydroxylase, a well characterized substrate for PKA, confirmed the ability of Rp-cAMPS and Sp-cAMPS to inhibit and activate, respectively, PKA activity in vivo. Together, these data provide direct evidence for involvement of the cAMP-PKA system in the LC, as well as in the PAG, in opiate withdrawal and withdrawal-related behaviors.