Ethical considerations in embedding a surgeon in a military or civilian tactical team.

Tactical emergency medical services (TEMS) bring immediate medical support to the inner perimeter of special weapons and tactics team activations. While initially envisioned as a role for an individual dually trained as a police officer and paramedic, TEMS is increasingly undertaken by physicians and paramedics who are not police officers. This report explores the ethical underpinnings of embedding a surgeon within a military or civilian tactical team with regard to identity, ethically acceptable actions, triage, responsibility set, training, certification, and potential future refinements of the role of the tactical police surgeon.

Evaluation of Swallow Function Post-Extubation: Is It Necessary to Wait 24 Hours?

BACKGROUND: Post-extubation dysphagia is associated with an increased incidence of nosocomial pneumonias, longer hospitalizations, and higher re-intubation rates. The purpose of this study was to determine if it is necessary to delay swallow evaluation for 24 hours post-extubation. METHODS: A prospective investigation of swallowing was conducted at 1, 4, and 24 hours post-extubation to determine if it is necessary to delay swallow evaluation following intubation. Participants were 202 adults from 5 different intensive care units (ICU). RESULTS: A total of 166 of 202 (82.2%) passed the Yale Swallow Protocol at 1 hour post-extubation, with an additional 11 (177/202; 87.6%) at 4 hours, and 8 more (185/202; 91.6%) at 24 hours. Only intubation duration ≥4 days was significantly associated with nonfunctional swallowing. CONCLUSIONS: We found it is not necessary to delay assessment of swallowing in individuals who are post-extubation. Specifically, the majority of patients in our study (82.2%) passed a swallow screening at 1 hour post-extubation.

Integrated assessment and consultation for the preoperative patient.

Assessment of the presurgical patient requires interdisciplinary cooperation over the continuum of documentation and optimization of existing disorders, determination of patient resilience and reserve, and planning for subsequent interventions and care. For many patients, evident or suspected morbidities or anticipated surgical disturbance warrant specialty consultation. There may be uncertainty as to the optimal processes for a given patient, a limitation attributable to myriad factors, not the least of which is that there is often a paucity of evidence that is directly relevant to a given patient in a given setting. The present article discusses these limitations and describes a framework for documentation, optimization, risk assessment, and planning, as well as a uniform grading of existing morbidities and anticipated perioperative disturbances for patients requiring integrated assessment and consultation.

Integrated assessment and consultation for the preoperative patient.

Assessment of the presurgical patient requires interdisciplinary cooperation over the continuum of documentation and optimization of existing disorders, determination of patient resilience and reserve, and planning for subsequent interventions and care. For many patients, evident or suspected morbidities or anticipated surgical disturbance warrant specialty consultation. There may be uncertainty as to the optimal processes for a given patient, a limitation attributable to myriad factors, not the least of which is that there is often a paucity of evidence that is directly relevant to a given patient in a given setting. The present article discusses these limitations and describes a framework for documentation, optimization, risk assessment, and planning, as well as a uniform grading of existing morbidities and anticipated perioperative disturbances for patients requiring integrated assessment and consultation.

Emergency and urgent surgery.

Patients presenting with general surgical emergencies are hypovolemic, and require early aggressive resuscitative efforts. Although these efforts may safely be accomplished preoperatively in a select subset of patients, it is often the combined task of surgeons, anesthesiologists, and internists to optimize these critically ill patients in the intraoperative and postoperative period. Early surgical consultation and intervention can be lifesaving. This article presents the current state of emergency surgical care in the United States and the approach to the patient with an emergency surgical illness. The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all health care providers, the patient, and his or her family. In addition to aggressive resuscitation, life-threatening general surgical conditions often require specific diagnostic and therapeutic interventions.

Emergency and urgent surgery.

Patients presenting with general surgical emergencies are hypovolemic, and require early aggressive resuscitative efforts. Although these efforts may safely be accomplished preoperatively in a select subset of patients, it is often the combined task of surgeons, anesthesiologists, and internists to optimize these critically ill patients in the intraoperative and postoperative period. Early surgical consultation and intervention can be lifesaving. This article presents the current state of emergency surgical care in the United States and the approach to the patient with an emergency surgical illness. The aggressiveness of the surgical intervention is patient- and disease-specific and requires frequent and open communication between all health care providers, the patient, and his or her family. In addition to aggressive resuscitation, life-threatening general surgical conditions often require specific diagnostic and therapeutic interventions.

Postoperative considerations for patients with obesity and sleep apnea.

Sleep apnea and obesity are prevalent and often coexisting conditions that challenge medical, anesthetic, and surgical treatment. It is essential to possess knowledge of the magnitude of the sleep disorder as well as concomitant medical comorbidities. Management of obese patients requires a thorough preoperative evaluation and appraisal of anesthetic and operative risks. Postoperatively, these patients can present an additional challenge.

Intermittent cardiac troponin-I screening is an effective means of surveillance for a perioperative myocardial infarction.

OBJECTIVE: Several studies suggest that cardiac troponin-I (cTn-I) is a more sensitive indicator of cardiac injury compared with other biochemical markers of injury, but the strategy with the highest diagnostic yield (true positive and true negative) for perioperative surveillance is unknown. The authors undertook a prospective evaluation of the perioperative incidence of myocardial infarction (MI) and evaluated surveillance strategies for the diagnosis of MI. DESIGN: Prospective, cohort study. SETTING: Two university hospitals. PARTICIPANTS: Four hundred sixty-seven high-risk patients requiring noncardiac surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The diagnosis of myocardial injury was determined by cardiac protein markers combined with either postoperative changes on 12-lead electrocardiography or 1 of 3 clinical symptoms consistent with MI (chest pain, dyspnea, requirement for hemodynamic support). A receiver operating characteristic curve evaluating troponin in the diagnosis of MI revealed a value of 2.6 ng/mL as having the highest sensitivity and specificity. The sensitivity and specificity of cTn-I value > or =2.6 ng/mL, troponin > or =1.5 ng/mL, total creatine kinase (CK) > or =170 IU/L with MB > or =5%, and CK-MB > or =8 ng/mL were compared. Surveillance strategies were determined on a subset of patients (n = 257). The incidence of MI was 9.0% by cTn-I > or =2.6 ng/mL criteria, 19% by cTn-I > or =1.5 ng/mL, 13% by CK-MB mass, and 2.8% by CK-MB%. The specificity of cTn-I > or =2.6 ng/mL as an indicator of MI was 98%, and its positive predictive value (PPV) was 85%. Cardiac troponin-I > or =2.6 ng/mL had equal specificity but greater PPV than the cTn-I > or =1.5 ng/mL (specificity 98% and PPV 79%). If surveillance of cTn-I > or =2.6 ng/mL was used to detect MI, then the strategy with the highest diagnostic yield was surveillance on postoperative days 1, 2, and 3. CONCLUSIONS: Perioperative cardiac injury continues to occur frequently after noncardiac surgery, as detected by cTn-I. Serial monitoring of cardiac troponin-I on postoperative days 1, 2, and 3 provides the strategy with the highest diagnostic yield for surveillance of MI.

Clinical practice guidelines for the maintenance of patient physical safety in the intensive care unit: use of restraining therapies--American College of Critical Care Medicine Task Force 2001-2002.

OBJECTIVE: To develop clinical practice guidelines for the use of restraining therapies to maintain physical and psychological safety of adult and pediatric patients in the intensive care unit. PARTICIPANTS: A multidisciplinary, multispecialty task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM), the Society of Critical Care Medicine (SCCM), and the American Association of Critical Care Nurses (AACN). EVIDENCE: The task force members reviewed the published literature (MEDLINE articles, textbooks, etc.) and provided expert opinion from which consensus was derived. Relevant published articles were reviewed individually for validity using the Cochrane methodology (http://hiru.mcmaster.ca/cochrane/ or www.cochrane.org). CONSENSUS PROCESS: The task force met as a group and by teleconference to identify the pertinent literature and derive consensus recommendations. Consideration was given to both the weight of scientific information within the literature and expert opinion. Draft documents were composed by a task force steering committee and debated by the task force members until consensus was reached by nominal group process. The task force draft then was reviewed, assessed, and edited by the Board of Regents of the ACCM. After steering committee approval, the draft document was reviewed and approved by the SCCM Council. CONCLUSIONS: The task force developed nine recommendations with regard to the use of physical restraints and pharmacologic therapies to maintain patient safety in the intensive care unit.