Surgeon as Double Agent: Perception of Conflicting Expectations of Patient Care and Stewardship of Resources.

BACKGROUND: Physicians must satisfy 2 competing expectations: advocate for patients and serve as stewards of resources. No guidelines exist for surgeons on resolving this conflict. We surveyed surgeons' perceptions about these dual obligations. STUDY DESIGN: We conducted our study at 2 large university hospitals in 3 distinct steps, each built on the previous one. First, we surveyed 40 surgery residents and medical students using a 10-question assessment tool as the quantitative portion of our analysis. Next, a focus group of attending surgeons was surveyed to identify themes for the qualitative part of our study. Based on these, 5 attending surgeons from varying specialties were interviewed in a semi-structured format. We used the Wilcoxon signed rank test for quantitative analysis and content analysis to report our qualitative findings. RESULTS: Students and residents did not think that they faced resource allocation decisions; however, they observed attending surgeons face them regularly (p = 0.0003). Attending surgeons from various specialties agreed that they thought they were obligated to both provide excellent care and serve as a steward of resources. All surgeons agreed these obligations can conflict. Individual practices varied with all erring on the side of patient care. Concern about being an outlier in one's section was a greater motivator to alter practice than was fear of litigation. No surgeon thought that patients had an adequate understanding of surgeons' dual agency. CONCLUSIONS: Surgeons balance the responsibilities of patient care and stewardship of resources with great variability. Diverse practices likely add to inequalities in healthcare delivery and increase mistrust. Surgeons' social contract with patients calls for transparent strategies to address their dual agency.

Resident Education in End-of-Life Communication and Management: Assessing Comfort Level to Enhance Competence and Confidence.

OBJECTIVES: Our primary objective was to understand residents' baseline comfort with end-of-life (EOL) communication and management and to compare this with their comfort after completion of their surgical intensive care unit (SICU) rotation. We also evaluated the association between prior training with perceived level of comfort with EOL issues, and whether the resident believed in the concept of a "better death." DESIGN, SETTING, PARTICIPANTS: As a quality improvement initiative, we conducted surveys of trainees before and after their rotation in the Yale New Haven Hospital SICU. Prerotation and postrotation surveys were administered to all residents who rotated during the 2016-2017 academic year and the first half of 2017-2018. The survey consisted of 34 questions querying residents on their level of training in EOL care, their comfort with management and discussions in different EOL domains, and their beliefs about what measures would have improved their ability to provide EOL care. Residents surveyed were from general surgery, emergency medicine, or anesthesia departments. RESULTS AND CONCLUSIONS: Our study demonstrates that there is a significant correlation between resident comfort with EOL communication and experience providing EOL care. However, concepts in medicolegal aspects of palliative care could be taught through formal didactics, and structured training may allow residents the opportunity to reflect on the importance of a "better death."

Using the Rothman index to predict early unplanned surgical intensive care unit readmissions.

BACKGROUND: The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS: This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS: A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION: An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

The use of magnetic resonance imaging in the diagnosis of suspected appendicitis in pregnancy: shortened length of stay without increase in hospital charges.

IMPORTANCE: Making an accurate diagnosis of appendicitis in pregnancy is critical for maternal and fetal outcomes. OBJECTIVE: To determine whether magnetic resonance (MR) imaging in pregnant patients with suspected appendicitis improves outcomes, minimizes length of stay (LOS), and lowers hospital charges. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review at a university tertiary referral center of all pregnant patients seen with abdominal pain and suspected appendicitis who were followed up through delivery during an 11-year period. MAIN OUTCOMES AND MEASURES: Time to operation, LOS, complications, nontherapeutic exploration, fetal outcomes, and hospital charges. RESULTS: Seventy-nine patients were included in this study, 34 of whom had pathology-confirmed appendicitis. Thirty-one patients underwent MR imaging. A trend toward fewer operations (odds ratio [OR], 0.45; 95% CI, 0.18-1.16; P = .07) was observed in the MR imaging group. Seven nontherapeutic explorations were performed in the non-MR imaging group and 1 nontherapeutic exploration in the MR imaging group (OR, 0.44; 95% CI, 0.08-2.32; P = .13). Patients in the MR imaging group were more frequently discharged from the emergency department (OR, 0.35; 95% CI, 0.13-0.94; P = .04) and had shorter LOS (33.7 vs 64.8 hours, P < .001). Gestational age, time to operation, and the presence of perforated appendicitis were similar between groups. No patient discharged without operation returned with appendicitis in either group. On multivariable analysis, the receipt of MR imaging (P < .001) and the absence of operative intervention (P = .001) were associated with shorter LOS. The mean hospital charges were similar in those with vs without appendicitis. One fetal loss occurred in the non-MR imaging group. CONCLUSIONS AND RELEVANCE: Magnetic resonance imaging in pregnant patients with suspected appendicitis does not affect clinical outcomes or hospital charges. It allows safe discharge from the emergency department and improves resource use.

Appendiceal endometriosis in a pregnant woman presenting with acute perforated appendicitis.

Endometriosis is a common disease in women of childbearing age and is defined as the presence of endometrial glands and stroma in organs outside of the uterine cavity. Appendiceal endometriosis is very uncommon and accounts for a small fraction of all cases of extrapelvic endometriosis. Cases of that which occur during pregnancy are extremely rare with an incidence that ranges between 3 and 8 deliveries per 10 000. This makes the diagnosis extremely difficult and represents a challenge in the management of the patient. In this report we describe the case of a pregnant woman who underwent ileocecectomy for perforated appendicitis stemming from endometriosis and subsequent pre-term delivery of a 31-week-old fetus.

Compared to conventional ventilation, airway pressure release ventilation may increase ventilator days in trauma patients.

BACKGROUND: Airway pressure release ventilation (APRV) is used both as a rescue therapy for patients with acute lung injury and as a primary mode of ventilation. Unlike assist-control volume (ACV) ventilation that uses spontaneous breathing trials, APRV weaning consists of gradual decreases in supporting pressure. We hypothesized that the APRV weaning process increases total ventilator days compared with those of spontaneous breathing trials-based weaning. METHODS: A retrospective review of a Level I trauma center's database identified trauma admissions from January 1, 2007, to December 31, 2010, which required mechanical ventilation for more than 24 hours and survived. Demographics, injuries, in-hospital complications, ventilation mode(s), and total ventilator days were abstracted. RESULTS: A total of 362 patients fulfilled study entry criteria; 53 patients with more than one ventilator mode change were excluded. Seventy-five patients were successfully liberated from mechanical ventilation on APRV and 234 on ACV. The APRV and ACV groups, respectively, were similar in age (46.1 vs. 44.6 years) and sex (72% vs. 73% male) but differed in Injury Severity Score (20.8 vs. 17.5; p = 0.03). Patients on APRV had higher rates of abdominal compartment syndrome (6.7% vs. 0.8%, p = 0.003) and were more likely to have a higher chest Abbreviated Injury Scale (AIS) score ≥3 (57.3% vs. 30.8%, p < 0.001). Ventilator days were significantly greater in the APRV group (19.6 vs. 10.7 days, p < 0.001). Multiple regression was performed to adjust for the clinical differences between the two groups, identifying APRV as an independent predictor for increased number of ventilator days (B = 6.2 ± 1.5, p < 0.001) in addition to male sex, abdomen AIS score of 3 or higher, spine AIS score of 3 or higher, acute renal failure, and sepsis. CONCLUSION: APRV is frequently used for patients who are more severely injured or who develop in-hospital complications such as pneumonia. However, after controlling for potential confounding factors in a multiple regression model, the APRV mode itself seems to increase ventilator days.

Development of a computed tomography-based scoring system for necrotizing soft-tissue infections.

BACKGROUND: Necrotizing soft-tissue infections (NSTIs) are associated with significant morbidity and mortality, but a definitive nonsurgical diagnostic test remains elusive. Despite the widespread use of computed tomography (CT) as a diagnostic adjunct, there is little data that definitively correlate CT findings with the presence of NSTI. Our goal was the development of a CT-based scoring system to discriminate non-NSTI from NSTI. METHODS: Patients older than 17 years undergoing CT for evaluation of soft-tissue infection at a tertiary care medical center over a 10-year period (2000-2009) were included. Abstracted data included comorbidities and social history, physical examination, laboratory findings, and operative and pathologic findings. NSTI was defined as soft-tissue necrosis in the dictated operative note or the accompanying pathology report. CT scans were reviewed by a radiologist blinded to clinical and laboratory data. A scoring system was developed and the area under the receiver operating characteristic curve was calculated. RESULTS: During the study period, 305 patients underwent CT scanning (57% men; mean age, 47.4 years). Forty-four patients (14.4%) evaluated had an NSTI. A scoring system was retrospectively developed (table). A score >6 points was 86.3% sensitive and 91.5% specific for the diagnosis of NSTI (positive predictive value, 63.3%; negative predictive value, 85.5%). The area under the receiver operating characteristic curve was 0.928 (95% confidence interval, 0.893-0.964). The mean score of the non-NSTI group was 2.74. CONCLUSIONS: We have developed a CT scoring system that is both sensitive and specific for the diagnosis of NSTIs. This system may allow clinicians to more accurately diagnose NSTIs. Prospective validation of this scoring system is planned.

The status of massive transfusion protocols in United States trauma centers: massive transfusion or massive confusion?

BACKGROUND: Massive transfusion protocol (MTP) utilization and makeup is unknown. STUDY DESIGN AND METHODS: A Web-based survey was sent to members of the Eastern Association for the Surgery of Trauma and published in the American Association for the Surgery of Trauma newsletter. Comparisons were made with chi-square and logistic regression. RESULTS: A total of 186 surgeons and 59 center directors responded. To avoid bias, directors' responses are reported. Sixty percent annually admit more than 1500 patients. Sixty-seven percent had in-house attending coverage and 85% had a MTP. Presence of a MTP was not predicted by institution size, level, residency status, or admissions. Sixty-five percent of MTPs had been in place less than 5 years with 18% less than 1 year. Designs varied: 23% had one batch of components, 25% had two or three, 41% had more than three, and 11% did not use batches. Only 62% of first batches contained fresh-frozen plasma (FFP). In the second batch 98% had FFP. All third boxes had FFP. A ratio of FFP : red blood cells (RBCs) of less than 1 in the first batch predicted a ratio less than 1 in the second batch (p = 0.013). Twenty-seven percent had blood stored in the emergency department and 14% in the operating room. Twenty-four percent of MTPs autoactivate and 80% are trauma surgeon activated, 66% by the anesthesia staff, 32% by other surgeons, and 17% by the blood bank. Trauma surgeons activate the MTP most. CONCLUSION: Most centers have a MTP. Protocols are variable and new, and half have a 1:1 FFP : RBC ratio. Protocols with fewer initial units of FFP compared to RBCs maintain this.

Contrast-induced nephropathy in elderly trauma patients.

BACKGROUND: Computed tomography (CT) is the gold standard for the identification of occult injuries, but the intravenous (IV) contrast used in CT scans is potentially nephrotoxic. Because elderly patients have decreased renal function secondary to aging and chronic disease, we sought to determine the rate of acute kidney injury (AKI) in elderly trauma patients exposed to IV contrast. METHODS: Medical records of patients older than 55 years evaluated at a level-one trauma center between January 2003 and July 2008 were reviewed. Contrast was nonionic, isosmolar, and administered in standard volumes. Groups were based on administration of contrast. AKI was defined as a 25% relative or 0.5 mg/dL absolute increase in serum creatinine within 72 hours of presentation [corrected]. RESULTS: During the study period 1,371 patients older than 55 years were evaluated, and 1,152 met the inclusion criteria. CT was performed on 1,071 patients (96%); 71% of this group received IV contrast. There was no significant difference between the contrast and noncontrast groups in terms of baseline characteristics. Criteria for AKI were satisfied in 2.1% of all patients, including 1.9% the contrast group versus 2.4% in the noncontrast group. AKI diagnosed within 72 hours of patient presentation was an independent risk factor for in-hospital mortality and prolonged length of stay. CONCLUSIONS: IV contrast media in elderly trauma patients is not associated with an increased risk of AKI. Development of AKI within 72 hours of admission is associated with mortality and increased length of stay.

Blunt cerebrovascular injuries: does treatment always matter?

BACKGROUND: Blunt cerebrovascular injuries (BCVI) have become an increasingly recognized entity. Stroke as a result of these injuries can have devastating consequences. Optimal screening criteria, diagnostic imaging, and therapy for BCVIs have not been elucidated. Our institution began to apply liberal screening criteria using a whole-body scanning protocol with multidetector computed tomographic (WB-MDCT) scans to diagnose these injuries. The purpose of this study is to describe a single institution's large experience in patients with BCVI in an effort to provide insight into the diagnosis and management of these injuries. METHODS: All patients with a BCVI admitted to the R Adams Cowley Shock Trauma Center during a 30-month period were included in this study. Choice of diagnostic evaluation and treatment regimens were at the discretion of the treating attending physician. Review of medical records and all relevant radiographic studies were retrospectively performed for the purposes of this study. RESULTS: During the study period, there were 12,667 patients admitted to the R Adams Cowley Shock Trauma Center. There were 147 patients identified with 200 carotid or vertebral artery injuries. The incidence of BVCI was 1.2%. Mortality was 13%. Anatomic injury risk factors for BCVI (major facial fractures, skull base fractures, cervical spine fractures or spinal cord injury, or traumatic brain injury) were found in only 78%. Major thoracic injury was found in 63% of patients with carotid artery injuries and cervical spine fractures or spinal cord injury was found in 74% of patients with vertebral artery injuries. The initial screening test employed was a WB-MDCT in 96% of patients of which 84% detected a BCVI. Treatments included endovascular therapy (22%), antiplatelet medications (36%), anticoagulation (10%), and combination therapy with antiplatelet agents and anticoagulation (18%). Thirty percent received no therapy, primarily due to contraindications from concomitant injuries. There were 18 (12%) patients who had a stroke. Of these patients, 8 (44%) had evidence of infarction at admission, 6 were diagnosed within 72 hours, and 4 were diagnosed after 1 week. Stroke-related mortality was 50%, whereas clinical follow-up after hospital discharge demonstrated only one patient with disability as a result of infarction. Of 10 patients who did not have stroke at admission, 3 were fully treated, 5 had specific contraindications to therapy, and 2 had no or false-negative imaging before infarction. Stroke rates for untreated patients were 25.8% and patients treated with any therapy had a stroke rate of 3.9% (p = 0.0003). Radiographic follow-up >1 month after injury demonstrated improvement in over 50% of patients. CONCLUSIONS: BCVIs are not infrequent after blunt trauma. These injuries occur even in the absence of classically described risk factors. Liberal screening with WB-MDCT incorporates detection of these injuries into the initial diagnostic evaluation. Stroke occurs in a substantial number of patients and carries a very high mortality. However, nearly one third of patients with BCVI are not candidates for therapy. Treatment does reduce the risk of infarction in patients with BCVI, but strokes, when they occur, are not preventable.