Smartphone Use in the Management of Neurological Emergencies: A Simulation-Based Study.

BACKGROUND: Smartphone use in medicine is nearly universal despite a dearth of research assessing utility in clinical performance. We sought to identify and define smartphone use during simulated neuroemergencies. METHODS: In this retrospective review of a prospective observational single-center simulation-based study, participants ranging from subinterns to attending physicians and stratified by training level (novice, intermediate, and advanced) managed a variety of neurological emergencies. The primary outcome was frequency and purpose of smartphone use. Secondary outcomes included success rate of smartphone use and performance (measured by completion of critical tasks) of participants who used smartphones versus those who did not. In subgroup analyses we compared outcomes across participants by level of training using t-tests and χ2 statistics. RESULTS: One hundred and three participants completed 245 simulation scenarios. Smartphones were used in 109 (45%) simulations. Of participants using smartphones, 102 participants looked up medication doses, 52 participants looked up management guidelines, 11 participants looked up hospital protocols, and 13 participants used smartphones for assistance with an examination scale. Participants found the correct answer 73% of the time using smartphones. There was an association between participant level and smartphone use with intermediate participants being more likely to use their smartphones than novice or advanced participants, 53% versus 29% and 26%, respectively (p < 0.05). Of the intermediate participants, those who used smartphones did not perform better during the simulation scenario than participants who did not use smartphones (smartphone users' mean score [standard deviation] = 12.3 [2.9] vs. nonsmartphone users' mean score [standard deviation] = 12.9 (2.7), p = 0.85). CONCLUSIONS: Participants commonly used smartphones in simulated neuroemergencies but use didn't confer improved clinical performance. Less experienced participants were the most likely to use smartphones and less likely to arrive at correct conclusions, and thus are the most likely to benefit from an evidence-based smartphone application for neuroemergencies.

Surgical Science and the Evolution of Critical Care Medicine.

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Contributions of Surgical Critical Care Program Directors Society to the training of surgeons.

BACKGROUND: In 1986, Surgical Critical Care (SCC) was formally recognized as a specialty by the American Board of Surgery (ABS), however it took another two decades to develop a formal national training structure in SCC. In 2003, the program directors of SCC fellowships began to meet and the Surgical Critical Care Program Directors Society (SCCPDS) was officially formed in 2004, with recognition of the SCCPDS as a non-profit organization in 2008. Over the next several years, and in conjunction with other interested groups, such as the American Association for the Surgery of Trauma (AAST) and the Society of Critical Care Medicine (SCCM), SCCPDS created a formal curriculum, developed a unified system for the fellowship application process, and increased recruitment and match such that now approximately 1 in 6 general surgery graduates are pursuing training in SCC. In discussion with past and present leadership of SCCPDS, there are several ongoing initiatives to further improve the educational opportunities of the fellows and increase inclusion of other organizations and other specialties interested in SCC. The purpose of this article is to discuss the role of SCCPDS in the development and evolution of SCC and Acute Care Surgery (ACS) training. LEVEL OF EVIDENCE: Expert Opinion; Level V.

Developing a National Trauma Research Action Plan: Results from the postadmission critical care research gap Delphi survey.

INTRODUCTION: The 2016 National Academies of Science, Engineering and Medicine report included a proposal to establish a National Trauma Research Action Plan. In response, the Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma and burn care from prehospital care to rehabilitation as part of an overall strategy to achieve zero preventable deaths and disability after injury. The Postadmission Critical Care Research panel was 1 of 11 panels constituted to develop this research agenda. METHODS: We recruited interdisciplinary experts in surgical critical care and recruited them to identify current gaps in clinical critical care research, generate research questions, and establish the priority of these questions using a consensus-driven Delphi survey approach. The first of four survey rounds asked participants to generate key research questions. On subsequent rounds, we asked survey participants to rank the priority of each research question on a 9-point Likert scale, categorized to represent low-, medium-, and high-priority items. Consensus was defined as ≥60% of panelists agreeing on the priority category. RESULTS: Twenty-five subject matter experts generated 595 questions. By Round 3, 249 questions reached ≥60% consensus. Of these, 22 questions were high, 185 were medium, and 42 were low priority. The clinical states of hypovolemic shock and delirium were most represented in the high-priority questions. Traumatic brain injury was the only specific injury pattern with a high-priority question. CONCLUSION: The National Trauma Research Action Plan critical care research panel identified 22 high-priority research questions, which, if answered, would reduce preventable death and disability after injury. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

Ethical decision-making climate, moral distress, and intention to leave among ICU professionals in a tertiary academic hospital center.

BACKGROUND: Commentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave. METHODS: We performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave. RESULTS: Nurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/Pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower "intention to leave" scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = -0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and "intention to leave" were negatively correlated (r = -0.50, p < 0.001). CONCLUSIONS: Significant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care.

Emergency preservation and resuscitation for cardiac arrest from trauma.

Patients who suffer a cardiac arrest from trauma rarely survive. Surgical control of hemorrhage cannot be obtained in time to prevent irreversible organ damage. Emergency preservation and resuscitation (EPR) was developed to utilize hypothermia to buy time to achieve hemostasis and allow delayed resuscitation. Large animal studies have demonstrated that cooling to tympanic membrane temperature 10 °C during exsanguination cardiac arrest can allow up to 2 h of circulatory arrest and repair of simulated injuries with normal neurologic recovery. The Emergency Preservation and Resuscitation for Cardiac Arrest from Trauma (EPR-CAT) trial is testing the feasibility and safety of initiating EPR. Study subjects include patients with penetrating trauma who lose a pulse within 5 minutes of hospital arrival and remain pulseless despite standard care. EPR is initiated via an intra-aortic flush of ice-cold saline solution. Following hemostasis, delayed resuscitation and rewarming are accomplished with cardiopulmonary bypass. The primary outcome is survival to hospital discharge without significant neurologic deficits. If trained team members are available, subjects can undergo EPR. If not, subjects can be enrolled as concurrent controls. Ten EPR and 10 control subjects will be enrolled. If successful, EPR could save the lives of trauma patients who are currently dying from exsanguinating hemorrhage.

Quantitative analysis of intermuscular septa in the leg: implications for trauma surgery.

BACKGROUND: Compartment syndrome is the excess swelling within an inelastic compartment leading to excessive compartment pressure. Lower limb trauma has a high risk of compartment syndrome, which is typically mitigated using a two-incision fasciotomy. Our previous findings showed surgeons sometimes perform incomplete fasciotomies due to misidentifying the septum between the lateral and superficial posterior compartments as the septum between the anterior and lateral compartments. We conjectured this may be due to variability in the septal position between individuals leading to misinterpretation of the septal identity. METHODS: A retrospective analysis was performed using CT angiograms to analyze septal position between the anterior and lateral compartments of the leg of 100 patients randomly selected from the University of Maryland Shock Trauma Center database. RESULTS: Analysis of septal position showed that (1) as the septum progresses distally down the leg, the relative septum position shifts anteriorly; and that (2) there was considerable variability in the intermuscular septum position between individuals even when accounting for the anterior to posterior progression of septal position. DISCUSSION: This variability could lead to erroneous septal identification in individuals with a very anteriorly located septum during a leg fasciotomy with the classic initial incision being insufficiently anterior. We propose making the lateral initial incision 'two finger breadths posterior the tibia' rather than the traditional 'one finger breadth anterior' to the fibula. This moves the initial incision slightly anteriorly, uses the more readily palpable tibia, and makes the medial and lateral incisions symmetrical at 'two finger breadths' from the tibia, simplifying the procedure. LEVEL OF EVIDENCE: Level 3.

Seven-Year Follow-Up of an Online Critical Care Curriculum.

Background: In July of 2013, the University of Maryland launched MarylandCCProject.com. This free-access educational website delivers asynchronous high-quality multidisciplinary critical care education targeted at critical care trainees. The lectures, presented in real time on-site, are recorded and available on the website or as a podcast on iTunes or Android. Thus, the curriculum can be easily accessed around the world.Objective: We sought to identify the impact this website has on current and former University of Maryland critical care trainees.Methods: A 32-question survey was generated using a standard survey generation tool. The survey was e-mailed in the fall of 2019 to the University of Maryland Multi-Departmental Critical Care current and graduated trainees from the prior 7 years. Survey data were collected through December 2019. The questions focused on user demographics, overall experience with the website, scope of website use, and clinical application of the content. Anonymous responses were electronically gathered.Results: A total of 186 current trainees and graduates were surveyed, with a 39% (n = 72) response rate. Of responders, 76% (55) use the website for ongoing medical education. The majority use the website at least monthly. Most users (63%, n = 35) access the lectures directly through the website. All 55 current users agree that the website has improved their medical knowledge and is a useful education resource. Platform use has increased and includes users from around the world.Conclusion: Based on our current data, the MarylandCCProject remains a valuable and highly used educational resource, impacting patient care both during and after critical care fellowship training.

Cardiopulmonary Resuscitation and Rescue Therapies.

The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.

Pre-operative fluid resuscitation in the emergency general surgery septic patient: does it really matter?

OBJECTIVE: Emergency general surgery (EGS) patients presenting with sepsis remain a challenge. The Surviving Sepsis Campaign recommends a 30 mL/kg fluid bolus in these patients, but recent studies suggest an association between large volume crystalloid resuscitation and increased mortality. The optimal amount of pre-operative fluid resuscitation prior to source control in patients with intra-abdominal sepsis is unknown. This study aims to determine if increasing volume of resuscitation prior to surgical source control is associated with worsening outcomes. METHODS: We conducted an 8-year retrospective chart review of EGS patients undergoing surgery for abdominal sepsis within 24 h of admission. Patients in hemorrhagic shock and those with outside hospital index surgeries were excluded. We grouped patients by increasing pre-operative resuscitation volume in 10 ml/kg intervals up to > 70 ml/kg and later grouped them into < 30 ml/kg or ≥ 30 ml/kg. A relative risk regression model compared amounts of fluid administration. Mortality was the primary outcome measure. Secondary outcomes were time to operation, ventilator days, and length of stay (LOS). Groups were compared by quick Sequential Organ Failure Assessment (qSOFA) and SOFA scoring systems. RESULTS: Of the 301 patients included, the mean age was 55, 51% were male, 257 (85%) survived to discharge. With increasing fluid per kg (< 10 to < 70 ml/kg), there was an increasing mortality per decile, 8.8% versus 31.6% (p = 0.004). Patients who received < 30 mL/kg had lower mortality (11.3 vs 21%) than those who received > 30 ml/kg (p = 0.02). These groups had median qSOFA scores (1.0 vs. 1.0, p = 0.06). There were no differences in time to operation (6.1 vs 4.9 h p = 0.11), ventilator days (1 vs 3, p = 0.08), or hospital LOS (8 vs 9 days, p = 0.57). Relative risk regression correcting for age and physiologic factors showed no significant differences in mortality between the fluid groups. CONCLUSIONS: Greater pre-operative resuscitation volumes were initially associated with significantly higher mortality, despite similar organ failure scores. However, fluid volumes were not associated with mortality following adjustment for other physiologic factors in a regression model. The amount of pre-operative volume resuscitation was not associated with differences in time to operation, ventilator days, ICU or hospital LOS.

Conflict of interest disclosure in orthopaedic and general surgical trauma literature.

SIGNIFICANCE: Financial relationships between industry and physicians are a key aspect for the advancement of surgical practice and training, but these relationships also result in a conflict of interest with respect to research. Financial payments to physicians are public within the United States in the Open Payments Database, but the rate of accurate financial disclosure of payments has not previously been studied in trauma surgery publications. OBJECTIVE: To determine the rate of accurate financial disclosure in major surgical trauma journals compared with the Open Payments Database. MATERIALS AND METHODS: The names of all authors publishing in The Journal of Orthopaedic Trauma, Injury, and The Journal of Trauma and Acute Care Surgery between 2015 and 2018 were obtained from MEDLINE. Non-physicians, physicians outside of the United States, physicians without payments in the Open Payments Database, and physicians with payments types of only "Food and Drink" were excluded. Financial disclosure statements were obtained from the journal websites and manually compared against Open Payments Database entries the year prior to submission and during the year of submission up until 3 months prior to publication for each individual physician. Main outcomes were accuracy of disclosure published with each article, total amount of payments received (disclosure or undisclosed), surgical subspecialty of the reporting physician. Statistical comparisons were made using Chi-square testing with significance defined as p<0.05. RESULTS: Between 2015 and 2018, 5070 articles were published involving 28,948 authors. 2945 authors met inclusion criteria. 490 authors accurately disclosed their financial relationships with industry (16.6%). The median value of undisclosed payments was $22,140 [IQR $6465, $77,221] which was significantly less than the medial value of disclosed payment of $66,433 [IQR $24,624, $161,886], p<0.001 Orthopaedic surgeons disclosed at a higher rate (26.3%, 479/1818) than general surgeons (4.8%, 47/971), p<0.001. CONCLUSIONS: Physician-industry relationships are key for advancing surgical practice and providing training to physicians. These relationships are not inherently unethical, but there is consistently high inaccuracy of financial disclosure across multiple trauma surgery journals which may indicate the need for further education on financial disclosures during surgical training or active obtainment of publicly available financial disclosures by journals.

Procedural Telementoring in Rural, Underdeveloped, and Austere Settings: Origins, Present Challenges, and Future Perspectives.

Telemedicine is perhaps the most rapidly growing area in health care. Approximately 15 million Americans receive medical assistance remotely every year. Yet rural communities face significant challenges in securing subspecialist care. In the United States, 25% of the population resides in rural areas, where less than 15% of physicians work. Current surgery residency programs do not adequately prepare surgeons for rural practice. Telementoring, wherein a remote expert guides a less experienced caregiver, has been proposed to address this challenge. Nonetheless, existing mentoring technologies are not widely available to rural communities, due to a lack of infrastructure and mentor availability. For this reason, some clinicians prefer simpler and more reliable technologies. This article presents past and current telementoring systems, with a focus on rural settings, and proposes aset of requirements for such systems. We conclude with a perspective on the future of telementoring systems and the integration of artificial intelligence within those systems.

Enhanced Training Benefits of Video Recording Surgery With Automated Hand Motion Analysis.

BACKGROUND: Hand motion analysis by video recording during surgery has potential for evaluation of surgical performance. The aim was to identify how technical skill during open surgery can be measured unobtrusively by video recording during a surgical procedure. We hypothesized that procedural-step timing, hand movements, instrument use and Shannon entropy differ with expertise and training and are concordant with a performance-based validated individual procedure score. METHODS: Surgeon and non-surgeon participants with varying training and levels of expertise were video recorded performing axillary artery exposure and control (AA) on un-preserved cadavers. Color-coded gloves permitted motion-tracking and automated extraction of entropy data from recordings. Timing and instrument-use metrics were obtained through observational video reviews. Shannon entropy measured speed, acceleration and direction by computer-vision algorithms. Findings were compared with individual procedure score for AA performance RESULTS: Experts had lowest entropy values, idle time, active time and shorter time to divide pectoralis minor, using fewer instruments. Residents improved with training, without reaching expert levels, and showed deterioration 12-18 months later. Individual procedure scores mirrored these results. Non-surgeons differed substantially. CONCLUSIONS: Hand motion entropy and timing metrics discriminate levels of surgical skill and training, and these findings are congruent with individual procedure score evaluations. These measures can be collected using consumer-level cameras and analyzed automatically with free software. Hand motion with video timing data may have widespread application to evaluate resident performance and can contribute to the range of evaluation and testing modalities available to educators, training course designers and surgical quality assurance programs.

Development of Neurological Emergency Simulations for Assessment: Content Evidence and Response Process.

OBJECTIVE: To document two sources of validity evidence for simulation-based assessment in neurological emergencies. BACKGROUND: A critical aspect of education is development of evaluation techniques that assess learner's performance in settings that reflect actual clinical practice. Simulation-based evaluation affords the opportunity to standardize evaluations but requires validation. METHODS: We identified topics from the Neurocritical Care Society's Emergency Neurological Life Support (ENLS) training, cross-referenced with the American Academy of Neurology's core clerkship curriculum. We used a modified Delphi method to develop simulations for assessment in neurocritical care. We constructed checklists of action items and communication skills, merging ENLS checklists with relevant clinical guidelines. We also utilized global rating scales, rated one (novice) through five (expert) for each case. Participants included neurology sub-interns, neurology residents, neurosurgery interns, non-neurology critical care fellows, neurocritical care fellows, and neurology attending physicians. RESULTS: Ten evaluative simulation cases were developed. To date, 64 participants have taken part in 274 evaluative simulation scenarios. The participants were very satisfied with the cases (Likert scale 1-7, not at all satisfied-very satisfied, median 7, interquartile range (IQR) 7-7), found them to be very realistic (Likert scale 1-7, not at all realistic-very realistic, median 6, IQR 6-7), and appropriately difficult (Likert scale 1-7, much too easy-much too difficult, median 4, IQR 4-5). Interrater reliability was acceptable for both checklist action items (kappa = 0.64) and global rating scales (Pearson correlation r = .70). CONCLUSIONS: We demonstrated two sources of validity in ten simulation cases for assessment in neurological emergencies.

Mapping the increasing interest in acute care surgery-Who, why and which fellowship?

BACKGROUND: Interest in acute care surgery (ACS) has increased over the past 10 years as demonstrated by the linear increase in fellowship applicants to the different fellowships leading to ACS careers. It is unclear why interest has increased, whether various fellowship pathways attract different applicants or whether fellowship choice correlates with practice patterns after graduation. METHODS: An online survey was distributed to individuals previously registered with the Surgical critical care and Acute care surgery Fellowship Application Service. Fellowship program directors were also asked to forward the survey to current and former fellows to increase the response rate. Data collected included demographics, clinical interests and motivations, publications, and postfellowship practice patterns. Fisher's exact and Pearson's χ were used to determine significance. RESULTS: Trauma surgery was the primary clinical interest for all fellowship types (n = 273). Fellowship type had no impact on academic productivity or practice patterns. Most fellows would repeat their own fellowship. The 2-year American Association for the Surgery of Trauma-approved fellowship was nearly uniformly reported as the preferred choice among those who would perform a different fellowship. Career motivations were similar across fellowships and over time though recent trainees were more likely to consider predictability of schedule a significant factor in career choice. Respondents reported graduated progression to full responsibility, further exposure to trauma care and additional operative technical training as benefits of a second fellowship year. CONCLUSION: American Association for the Surgery of Trauma-approved 2-year fellows appear to be the most satisfied with their fellowship choice. No differences were noted in academic productivity or practice between fellowships. Future research should focus on variability in trauma training and operative experience during residency and in practice to better inform how a second fellowship year would improve training for ACS careers. LEVEL OF EVIDENCE: Descriptive, mixed methods, Level IV.

Emerging hemorrhage control and resuscitation strategies in trauma: Endovascular to extracorporeal.

This article reviews four emerging endovascular hemorrhage control and extracorporeal perfusion techniques for management of trauma patients with profound hemorrhagic shock including hemorrhage-induced traumatic cardiac arrest: resuscitative endovascular balloon occlusion of the aorta, selective aortic arch perfusion, extracorporeal life support, and emergency preservation and resuscitation. The preclinical and clinical studies underpinning each of these techniques are summarized. We also present an integrated conceptual framework for how these emerging technologies may be used in the future care of trauma patients in both resource-rich and austere environments.

Improving Postoperative Handoff in a Surgical Intensive Care Unit.

BACKGROUND: Evidence-based research demonstrates that postoperative formalized handoff improves communication and satisfaction among hospital staff members, leading to improved patient outcomes. OBJECTIVE: To improve postoperative patient safety in the surgical intensive care unit of a tertiary academic medical center. METHODS: A verbal and written formal reporting method was designed, implemented, and evaluated. The intervention created an admission "time-out," allowing the handoff from surgical and anesthesia teams to the intensive care unit team and bedside nurses to occur in a more structured manner. Before and 1 year after implementation of the intervention, nurses completed surveys on the quality of postoperative handoff. RESULTS: After the intervention, the proportion of nurses who reported receiving handoff from the surgical team increased from 20% to 60% (P < .001). More nurses felt satisfied with the surgical handoff (46% before vs 74% after the intervention; P < .001), and more nurses frequently felt included in the handoff process (42% vs 74%; P < .001). Nurses perceived improved communication with surgical teams (93%), anesthesia teams (89%), and the intensive care unit team (94%), resulting in a perception of better patient care (88%). CONCLUSION: After implementation of a systematic multidisciplinary handoff process, surgical intensive care nurses reported improved frequency and completeness of the postoperative handoff process, resulting in a perception of better patient care.