Incidence of rescue surgical airways after attempted orotracheal intubation in the emergency department: A National Emergency Airway Registry (NEAR) Study.

BACKGROUND: Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE: We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS: We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS: Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION: Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

Outcomes of the Main Residency Match for Applicants With Disability.

This cohort study assesses match rates of US applicants with and without disability into specialty residence programs.

Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study.

OBJECTIVE: To describe the association between mistreatment, burnout, and having multiple marginalized identities during undergraduate medical education. DESIGN: Cross sectional survey and retrospective cohort study. SETTING: 140 US medical schools accredited by the Association of American Medical Colleges. PARTICIPANTS: 30 651 graduating medical students in 2016 and 2017. MAIN OUTCOME MEASURES: Self-reported sex, race or ethnicity, and sexual orientation groups were considered, based on the unique combinations of historically marginalized identities held by students. Multivariable linear regression was used to determine the association between unique identity groups and burnout along two dimensions (exhaustion and disengagement) as measured by the Oldenburg Burnout Inventory for Medical Students while accounting for mistreatment and discrimination. RESULTS: Students with three marginalized identities (female; non-white; lesbian, gay, or bisexual (LGB)) had the largest proportion reporting recurrent experiences of multiple types of mistreatment (88/299, P<0.001) and discrimination (92/299, P<0.001). Students with a higher number of marginalized identities also had higher average scores for exhaustion. Female, non-white, and LGB students had the largest difference in average exhaustion score compared with male, white, and heterosexual students (adjusted mean difference 1.96, 95% confidence interval 1.47 to 2.44). Mistreatment and discrimination mediated exhaustion scores for all identity groups but did not fully explain the association between unique identity group and burnout. Non-white and LGB students had higher average disengagement scores than their white and heterosexual counterparts (0.28, 0.19 to 0.37; and 0.73, 0.52 to 0.94; respectively). Female students, in contrast, had lower average disengagement scores irrespective of the other identities they held. After adjusting for mistreatment and discrimination among female students, the effect among female students became larger, indicating a negative confounding association. CONCLUSION: In this study population of US medical students, those with multiple marginalized identities reported more mistreatment and discrimination during medical school, which appeared to be associated with burnout.

Association Between Sexual Orientation, Mistreatment, and Burnout Among US Medical Students.

Importance: Medical trainee burnout is associated with poor quality care and attrition. Medical students in sexual minority groups report fear of discrimination and increased mistreatment, but the association between sexual orientation, burnout, and mistreatment is unknown. Objective: To evaluate whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment. Design, Setting, and Participants: This cross-sectional study surveyed US medical students graduating from Association of American Medical Colleges (AAMC)-accredited US allopathic medical schools who responded to the AAMC graduation questionnaire in 2016 and 2017. Statistical analyses were performed from March 15, 2019, to July 2, 2020, and from November 20 to December 9, 2020. Main Outcomes and Measures: Burnout was measured using the Oldenburg Burnout Inventory for Medical Students, and sexual orientation was categorized as either heterosexual or lesbian, gay, or bisexual (LGB). Logistic regression models were constructed to evaluate the association between sexual orientation and experiencing burnout (defined as being in the top quartile of exhaustion and disengagement burnout dimensions) and to test the mediating association of mistreatment. Results: From 2016 to 2017, 30 651 students completed the AAMC Graduation Questionnaire, and 26 123 responses were analyzed. Most respondents were younger than 30 years (82.9%) and White (60.3%). A total of 13 470 respondents (51.6%) were male, and 5.4% identified as LGB. Compared with heterosexual students, a greater proportion of LGB students reported experiencing mistreatment in all categories, including humiliation (27.0% LGB students vs 20.7% heterosexual students; P < .001), mistreatment not specific to identity (17.0% vs 10.3%; P < .001), and mistreatment specific to gender (27.3% vs 17.9%; P < .001), race/ethnicity (11.9% vs 8.6%; P < .001), and sexual orientation (23.3% vs 1.0%; P < .001). Being LGB was associated with increased odds of burnout (adjusted odds ratio, 1.63 [95% CI, 1.41-1.89]); this association persisted but was attenuated after adjusting for mistreatment (odds ratio, 1.36 [95% CI, 1.16-1.60]). The odds of burnout increased in a dose-response manner with mistreatment intensity. Lesbian, gay, or bisexual students reporting higher mistreatment specific to sexual orientation had and 8-fold higher predicted probability of burnout compared with heterosexual students (19.8% [95% CI, 8.3%-31.4%] vs 2.3% [95% CI, 0.2%-4.5%]; P < .001). Mediation analysis showed that mistreatment accounts for 31% of the total association of LGB sexual orientation with overall burnout (P < .001). Conclusions and Relevance: This study suggests that LGB medical students are more likely than their heterosexual peers to experience burnout, an association that is partly mediated by mistreatment. Further work is needed to ensure that medical schools offer safe and inclusive learning environments for LGB medical students.

Validation of the Denver Emergency Department Trauma Organ Failure Score to Predict Post-Injury Multiple Organ Failure.

BACKGROUND: Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. STUDY DESIGN: We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. RESULTS: We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). CONCLUSIONS: The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.

Validation of rules to predict emergent surgical intervention in pediatric trauma patients.

BACKGROUND: Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it with the American College of Surgeons' Major Resuscitation Criteria (MRC). STUDY DESIGN: We used data from 1993 through 2010 from 2 level 1 trauma centers in Denver, CO. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within 1 hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED), was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals were calculated. RESULTS: There were 8,078 patients included, and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (interquartile range [IQR] 7 to 14 years), 70% were male, 30% had penetrating mechanisms, and the median Injury Severity Score (ISS) was 25 (IQR 9 to 41). At the 2 institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI 45% to 94%) and 76% (95% CI 69% to 83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI 70% to 92%) and 81% (95% CI 77% to 85%), respectively. CONCLUSIONS: Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

Phase II trial of induction chemotherapy followed by surgery for squamous cell carcinoma of the oral tongue in young adults.

BACKGROUND: We conducted a phase II clinical trial of induction chemotherapy followed by surgery ± radiotherapy for squamous cell carcinoma of the oral tongue (SCCOT) in young adults. METHODS: From September 2001 to October 2004, 23 patients aged 18 to 49 years with clinical T2-3 N0-2 M0 SCCOT and no prior radiotherapy, chemotherapy, or neck dissection underwent induction chemotherapy (paclitaxel, ifosfamide, and carboplatin) followed by glossectomy and neck dissection ± radiotherapy and chemotherapy. RESULTS: On final surgical pathology, 9 patients (39%) had a complete/major (2 complete) histologic response at the primary tumor site; 8 patients (35%) had no response or progression. Similarly, 9 patients (39%) had a complete response in the neck or remained node negative; 6 patients (26%) had an increase in nodal category. No treatment-associated deaths occurred, and toxicity was modest. At a median follow-up from the end of treatment of 52 months (minimum, 23 months), 10 patients (43%) developed recurrence, and all 10 died of cancer. Crude recurrence/cancer death rates were associated with ≤ a partial response at the tongue (p = .029), poor histologic differentiation (p = .012), and multiple adverse features on final surgical pathology (p = .040). CONCLUSION: Response rates and overall survival with this induction chemotherapy regimen were limited, but complete/major response at the tongue was associated with excellent prognosis. Additionally, improved patient selection and predictive tumor biomarkers will be needed for induction chemotherapy to be routinely incorporated into the treatment of oral tongue cancer in young adults.