Management of High Grade Splenic Injuries in Rural America.

BACKGROUND: Rural surgeons face unique challenges when managing patients with high-grade (III-V) blunt splenic injury (BSI) given limited access to interventional radiology and blood products. Patients therefore may require transfer for splenic artery embolization (SAE) when resuscitation may still be ongoing. This study aims to evaluate current resource utilization in a rural trauma population with limited access to SAE and blood products. METHODS: Retrospective analysis of adult patients with high-grade BSI at one Level 1 trauma center and two Level 2 trauma centers was performed. Patients were evaluated for resources used after transfer to the regional trauma center. Primary outcomes measured were SAE, operative management (OM), and blood product utilization. Secondary outcomes measured included injury severity score (ISS) and mortality. RESULTS: Final analysis included 134 transferred patients. 16% underwent SAE, 16% underwent OM, and 69% were treated successfully with nonoperative and non-procedural management (NOM). 52% of the SAE patients had sustained a grade III splenic injury, 38% grade IV, and 10% grade V. 84% of patients required <3 units of packed red blood cells (PRBC) and 57% of patients required none. 80% of transferred patients required <3 total units of all combined blood products. DISCUSSION: The majority of patients with BSI transferred to a tertiary trauma center from a rural facility were successfully managed without SAE and required minimal transfusion of blood products. In the absence of other injuries necessitating transfer to a tertiary trauma center, rural surgeons should consider management of high grade splenic injuries at their home institution.

Initial and Ongoing Training of the Rural Surgeon.

Over the last 2 decades, rural locations have realized a steady decrease in surgical access and direct care. Owing to societal expectations for equal general and subspecialty surgical care in urban or rural areas, the ability to attract, train, and hold onto the rural surgeon has come into question. Our current general surgery training curriculum has been reevaluated as to its relevance for rural surgery and several alternatives to the traditional surgical training model have been proposed. The authors discuss and evaluate current and proposed methods for surgical training curriculums and methods for rural surgeon retention through continuing education models.

Massive transfusion associated with a hemolytic transfusion reaction: necessary precautions for prevention.

CASE REPORT: A 45-year-old male presented in severe hypovolemic shock after a thoracoabdominal gunshot wound. The massive transfusion protocol (MTP) was activated and the patient was taken to the operating room. His major injuries included liver, small bowel, and right common iliac vein. Hemorrhage was stopped and a damage control laparotomy was completed. He received a total of 113 blood products. During his postoperative course he received a group B blood transfusion on Hospital Days 2 and 7 based on incorrect blood typing late in his massive transfusion and repeat testing on Day 4. RESULTS: He succumbed to multiple organ failure on Day 8. MTPs are standard in most trauma centers during which universal donor red blood cells are initially used. As hemorrhage is controlled, the patient undergoes a complete type and cross according to blood banking protocols. These typing results are used to continue transfusions once the MTP is no longer needed. In contacting other blood banks servicing Level I trauma centers, the policy of when to switch from universal donor blood to crossmatched blood is variable. CONCLUSION: Our case illustrates a potential blood typing problem that had a disastrous outcome. We identified changes in policy that will make MTPs safer.

Analysis of Academic Medical Center Graduate Medical Education Websites for Policies Regarding Restrictive Covenants in Non-ACGME Fellowships.

BACKGROUND: The topic of restrictive covenants in fellowships that are not approved by the Accreditation Council for Graduate Medical Education (ACGME) has not been studied. OBJECTIVE: To investigate the presence of institutional polices at academic medical centers regarding restrictive covenants in non-ACGME fellowships. METHODS: The graduate medical education (GME) office website of 132 academic medical centers was evaluated and searched for the following as of June 1, 2017: presence of any ACGME residency or fellowship, presence of any non-ACGME fellowship, presence of GME policies and procedures, presence of a restrictive covenant policy, and if that policy applies to non-ACGME fellowships. RESULTS: A total of 96 academic medical centers had non-ACGME fellowships. Of these, 56 prohibit restrictive covenants in non-ACGME fellowships because of either their GME policy or state law. Seven academic medical centers have a GME policy that allows restrictive covenants in non-ACGME fellowships. Two academic medical centers clearly state that fellows in a certain subspecialty fellowship will be required to sign a restrictive covenant. CONCLUSIONS: GME policies at academic medical centers that allow restrictive covenants in non-ACGME fellowships are very uncommon. The practice of having fellows sign a restrictive covenant in a non-ACGME fellowship is in conflict with an American Medical Association ethics statement, ACGME institutional requirement IV.L, and the rules of the San Francisco Match.

Association between Pre-Operative Cefazolin Dose and Surgical Site Infection in Obese Patients.

BACKGROUND: A fixed dose of cefazolin results in serum concentrations that decrease as body mass increases. Current national guidelines suggest a pre-operative cefazolin dose of two grams may be insufficient for patients ≥120 kg; thus a three gram dose is recommended. These recommendations, however, are based on pharmacokinetic rather than outcome data. We evaluate the efficacy of pre-operative cefazolin two gram and three gram doses as measured by the rate of surgical site infection (SSI). PATIENTS AND METHODS: We conducted a retrospective review of adult patients ≥100 kg who were prescribed cefazolin as surgical prophylaxis between September 1, 2012 and May 31, 2013 at an academic medical center. Patients were excluded if cefazolin was prescribed but not administered, had a known infection at the site of surgery, or inappropriately received cefazolin prophylaxis based on surgical indication. The SSIs were identified by documentation of SSI in the medical record or findings consistent with the standard Centers for Disease Control and Prevention definition. Inpatient and outpatient records up to 90 days post-operative were reviewed for delayed SSI. RESULTS: Four hundred eighty-three surgical cases were identified in which pre-operative cefazolin was prescribed. Forty-seven patients were excluded leaving a total of 436 patients for final analysis: 152 in the cefazolin two gram group and 284 in the three gram group. Baseline demographics were similar between groups with a mean follow-up duration of 77 days for both groups. Unadjusted SSI rates were 7.2% and 7.4% (odds ratio [OR] 0.98, p = 0.95), for the two gram and three gram groups, respectively. When differences in follow-up between groups were considered and logistic regression was adjusted with propensity score, there remained no difference in SSI rates (OR 0.87, 95% confidence interval 0.36-2.06, p = 0.77). CONCLUSION: In otherwise similar obese surgical patients weighing ≥100 kg, the administration of a pre-operative cefazolin two gram dose is associated with a similar rate of SSI compared with patients who received a three gram dose.

Clinical significance of computed tomography contrast extravasation in blunt trauma patients with a pelvic fracture.

INTRODUCTION: Blunt pelvic fractures can be associated with major pelvic bleeding. The significance of contrast extravasation (CE) on computed tomography (CT) is debated. We sought to update our experience with CE on CT scan for the years 2009-2014 to determine the accuracy of CE in predicting the need for angioembolization. METHODS: This is a retrospective review of the trauma registry and our electronic medical record from a Level I trauma center. Patients seen from July 1, 2009, to September 7, 2014, with blunt pelvic fractures and contrast-enhanced CT were included. Standard demographic, clinical, and injury data were obtained. Patient records were queried for CE, performance of angiography, and angioembolization. Positive patients were those where CE was associated with active bleeding requiring angioembolization. All other patients were considered negative. RESULTS: There were 497 patients during the study time period with blunt pelvic fracture meeting inclusion criteria, and 75 patients (15%) had CE. Of those patients with CE, 30 patients (40%) underwent angiography, and 17 patients (23%) required angioembolization. The sensitivity, specificity, positive predictive value, and negative predictive value of CE on CT were 100%, 87.9%, 22.7%, and 100%, respectively. Two patients without CE underwent angiography but did not undergo embolization. Patients with CE had higher mortality (13 vs. 6%, p < 0.05) despite not having higher ISS scores. CONCLUSIONS: This study reinforces that CE on CT pelvis with blunt trauma is common, but many patients will not require angioembolization. The negative predictive value of 100% should be reassuring to trauma surgeons such that if a modern CT scanner is used, and there is no CE seen on CT, then the pelvis will not be a source of hemorrhagic shock. All of these findings are likely due to both increased comfort with observing CEs and the increased sensitivity of modern CT scanners. LEVEL OF EVIDENCE: Therapeutic/care management study, level IV.

Role of the Open Abdomen in Critically Ill Patients.

An open abdomen is common used in critically ill patients to temporize permanent abdominal closure. The most common reason for leaving the abdomen open by reopening a laparotomy, not closing, or creating a fresh laparotomy is the abdominal compartment syndrome. The open abdomen technique is also used in damage control operations and intra-abdominal sepsis. Negative pressure wound therapy may be associated with better outcomes than other temporary abdominal closure techniques. The open abdomen is associated with many early and late complications, including infections, gastrointestinal fistulas, and ventral hernias. Clinicians should be vigilant regarding the development of these complications.

Predicting academic performance in surgical training.

INTRODUCTION: During surgical residency, trainees are expected to master all the 6 competencies specified by the ACGME. Surgical training programs are also evaluated, in part, by the residency review committee based on the percentage of graduates of the program who successfully complete the qualifying examination and the certification examination of the American Board of Surgery in the first attempt. Many program directors (PDs) use the American Board of Surgery In-Training Examination (ABSITE) as an indicator of future performance on the qualifying examination. Failure to meet an individual program's standard may result in remediation or a delay in promotion to the next level of training. Remediation is expensive in terms of not only dollars but also resources, faculty time, and potential program disruptions. We embarked on an exploratory study to determine if residents who might be at risk for substandard performance on the ABSITE could be identified based on the individual resident's behavior and motivational characteristics. If such were possible, then PDs would have the opportunity to be proactive in developing a curriculum tailored to an individual resident, providing a greater opportunity for success in meeting the program's standards. METHODS: Overall, 7 surgical training programs agreed to participate in this initial study and residents were recruited to voluntarily participate. Each participant completed an online assessment that characterizes an individual's behavioral style, motivators, and Acumen Index. Residents completed the assessment using a code name assigned by each individual PD or their designee. Assessments and the residents' 2013 ABSITE scores were forwarded for analysis using only the code name, thus insuring anonymity. Residents were grouped into those who took the junior examination, senior examination, and pass/fail categories. A passing score of ≥70% correct was chosen a priori. Correlations were performed using logistic regression and data were also entered into a neural network (NN) to develop a model that would explain performance based on data obtained from the TriMetrix assessments. RESULTS: A total of 117 residents' TriMetrix and ABSITE scores were available for analysis. They were divided into 2 groups of 64 senior residents and 53 junior residents. For each group, the pass/fail criteria for the ABSITE were set at 70 and greater as passing and 69 and lower as failing. Multiple logistic regression analysis was complete for pass/fail vs the TriMetrix assessments. For the senior data group, it was found that the parameter Theoretical correlates with pass rate (p < 0.043, B = -0.513, exp(B) = 0.599), which means increasing theoretical scores yields a decreasing likelihood of passing in the examination. For the junior data, the parameter Internal Role Awareness correlated with pass/fail rate (p < 0.004, B = 0.66, exp(B) = 1.935), which means that an increasing Internal Role Awareness score increases the likelihood of a passing score. The NN was able to be trained to predict ABSITE performance with surprising accuracy for both junior and senior residents. CONCLUSION: Behavioral, motivational, and acumen characteristics can be useful to identify residents "at risk" for substandard performance on the ABSITE. Armed with this information, PDs have the opportunity to intervene proactively to offer these residents a greater chance for success. The NN was capable of developing a model that explained performance on the examination for both the junior and the senior examinations. Subsequent testing is needed to determine if the NN is a good predictive tool for performance on this examination.

Laparoscopic repair of a traumatic intrapericardial diaphragmatic hernia.

INTRODUCTION: Intrapericardial diaphragmatic hernia is a rare injury. We present a case of an intrapericardial diaphragmatic hernia from blunt trauma. In this report we will review the current literature and also describe the first report of a primary laparoscopic repair of the defect. CASE DESCRIPTION: A 38-year-old unrestrained male passenger had blunt chest and abdominal trauma from a motor vehicle collision. Two months later, on a computed tomography scan, he was found to have an intrapericardial diaphragmatic hernia. The defect was repaired primarily through a laparoscopic approach. DISCUSSION: Symptoms of intrapericardial diaphragmatic hernia are chest pain, upper abdominal pain, dysphagia, and dyspnea. Chest computed tomography is the most useful diagnostic test to define the defect. Even when the injury is diagnosed late, laparoscopy can be used for primary and patch repair.

Heparin-induced thrombocytopenia.

This article deals with heparin-induced thrombocytopenia. It discusses the pathophysiology of the disease, as well as the diagnostic challenges and therapeutic management. The incidence of the disease and screening recommendations are reviewed. The article also emphasizes the importance of correct diagnosis and treatment options. This article is intended for surgeons in all specialties and levels of training.

A case study of a multiply injured patient.

Initial evaluation of severely injured patients requires an organized, rapid, and thorough evaluation of the patient where life-threatening injuries are identified and treated simultaneously. A case study provides the basis for discussion of the management of the multiply injured trauma patient. The ultimate goal in rehabilitation of a multiply injured patient is to return each patient to as much independent function and ability to contribute to society as possible.