And Miles to Go Before We Sleep: EAST Diversity and Inclusivity Progress and Remaining Challenges.

OBJECTIVE: The aim of this study was to examine the diversity, equity, and inclusion landscape in academic trauma surgery and the EAST organization. SUMMARY BACKGROUND DATA: In 2019, the Eastern Association for the Surgery of Trauma (EAST) surveyed its members on equity and inclusion in the #EAST4ALL survey and assessed leadership representation. We hypothesized that women and surgeons of color (SOC) are underrepresented as EAST members and leaders. METHODS: Survey responses were analyzed post-hoc for representation of females and SOC in academic appointments and leadership, EAST committees, and the EAST board, and compared to the overall respondent cohort. EAST membership and board demographics were compared to demographic data from the Association of American Medical Colleges. RESULTS: Of 306 respondents, 37.4% identified as female and 23.5% as SOC. There were no significant differences in female and SOC representation in academic appointments and EAST committees compared to their male and white counterparts. In academic leadership, females were underrepresented ( P < 0.0001), whereas SOC were not ( P = 0.08). Both females and SOC were underrepresented in EAST board membership ( P = 0.002 and P = 0.043, respectively). Of EAST's 33 presidents, 3 have been white women (9%), 2 have been Black, non-African American men (6%), and 28 (85%) have been white men. When compared to 2017 AAMC data, women are well-represented in EAST's 2020 membership ( P < 0.0001) and proportionally represented on EAST's 2019-2020 board ( P > 0.05). CONCLUSIONS: The #EAST4ALL survey suggests that women and SOC may be underrepresented as leaders in academic trauma surgery. However, lack of high-quality demographic data makes evaluating representation of structurally marginalized groups challenging. National trauma organizations should elicit data from their members to re-assess and promote the diversity landscape in trauma surgery.

Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury.

BACKGROUND: Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older. METHODS: We conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications. RESULTS: Of 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women. CONCLUSIONS: Older men were more likely to have any in-hospital complications than women.

Anesthetic Management of Patients After Traumatic Injury With Resuscitative Endovascular Balloon Occlusion of the Aorta.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver for noncompressible torso hemorrhage. To our knowledge, this single-center brief report provides the most extensive anesthetic data published to date on patients who received REBOA. As anticipated, patients were critically ill, exhibiting lactic acidosis, hypotension, hyperglycemia, hypothermia, and coagulopathy. All patients received blood products during their index operations and received less inhaled anesthetic gas than normally required for healthy patients of the same age. This study serves as an important starting point for clinician education and research into anesthetic management of patients undergoing REBOA.

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults.

OBJECTIVE: To determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center. DESIGN: Retrospective cohort study. SETTING: R Adams Cowley Shock Trauma Center. PARTICIPANTS: Black and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902). MAIN OUTCOME MEASURES: We assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities. RESULTS: There were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70). CONCLUSIONS: In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.

Use of Survey and Delphi Process to Understand Trauma Anesthesia Care Practices.

BACKGROUND: Few trauma guidelines evaluate and recommend anesthesiology practices and there are no trauma anesthesia-specific guidelines. There is no information on how anesthesiologists perceive clinical practice patterns. Our objective was to understand the perceptions of anesthesiologists regarding trauma anesthesia practices. METHODS: A survey assessing anesthesia management of trauma patients was distributed to 21,491 anesthesiologists. A subset of 10 of these questions was subsequently reviewed by a trauma anesthesiology focus group through a 3-round web-based Delphi process. A question was deemed to have respondent consensus if the response with the highest percentage of agreement was unchanged between rounds 1 and 2. RESULTS: A total of 2360 anesthesiologists (11% response rate) responded to the survey. Results demonstrated that the practitioners' answers conflicted with existing surgical trauma society recommendations (ie, when to transfuse component therapy), and several areas that lacked any guidelines, resulted in response variability among anesthesiologists where not 1 answer achieved >75% agreement (ie, intubation technique of choice for patients with uncleared cervical spine). Thirteen trauma anesthesiologists participated in round 1 (response rate 100%), and 12 responded in rounds 2 and 3 (response rate 92%) of the Delphi process. None of the questions received 100% agreement. Consensus was achieved on 9 of 10 statements pertaining to trauma anesthesia care. Consensus was not reached on the intubating technique in a hemodynamically unstable patient with an uncleared cervical spine with deficits. Delphi participant opinion conflicted with existing guidelines on 2 statements: the use of cricoid pressure, and when to begin blood component therapy. CONCLUSIONS: There are several important areas of trauma anesthesia practice where guidelines do not exist and several where existing guidelines are not endorsed by the majority of practitioners who completed our survey. The lack of consensus on trauma anesthesia management and the variation in survey responses demonstrate a need to develop evidence-based trauma anesthesia guidelines.

Management of the Traumatized Airway.

There is a lack of evidence-based approach regarding the best practice for airway management in patients with a traumatized airway. General recommendations for the management of the traumatized airway are summarized in table 5. Airway trauma may not be readily apparent, and its evaluation requires a high level of suspicion for airway disruption and compression. For patients with facial trauma, control of the airway may be significantly impacted by edema, bleeding, inability to clear secretions, loss of bony support, and difficulty with face mask ventilation. With the airway compression from neck swelling or hematoma, intubation attempts can further compromise the airway due to expanding hematoma. For patients with airway disruption, the goal is to pass the tube across the injured area without disrupting it or to insert the airway distal to the injury using a surgical approach. If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach. Alternatively, if orotracheal intubation is chosen, spontaneous ventilation may be maintained or RSI may be performed. RSI is a common approach. Thus, some of the patients intubated may subsequently require tracheostomy. A stable patient with limited injuries may not require intubation but should be watched carefully for at least several hours. Because of a paucity of evidence-based data, the choice between these approaches and the techniques utilized is a clinical decision depending on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment. Inability to obtain a definitive airway is always an absolute indication for an emergency cricothyroidotomy or surgical tracheostomy.

Anesthesia Care Capacity at Health Facilities in 22 Low- and Middle-Income Countries.

BACKGROUND: Globally, an estimated 2 billion people lack access to surgical and anesthesia care. We sought to pool results of anesthesia care capacity assessments in low- and middle-income countries (LMICs) to identify patterns of deficits and provide useful targets for advocacy and intervention. METHODS: A systematic review of PubMed, Cochrane Database of Systematic Reviews, and Google Scholar identified reports that documented anesthesia care capacity from LMICs. When multiple assessments from one country were identified, only the study with the most facilities assessed was included. Patterns of availability or deficit were described. RESULTS: We identified 22 LMICs (15 low- and 8 middle-income countries) with anesthesia care capacity assessments (614 facilities assessed). Anesthesia care resources were often unavailable, including relatively low-cost ones (e.g., oxygen and airway supplies). Capacity varied markedly between and within countries, regardless of the national income. The availability of fundamental resources for safe anesthesia, such as airway supplies and functional pulse oximeters, was often not reported (72 and 36 % of hospitals assessed, respectively). Anesthesia machines and the capability to perform general anesthesia were unavailable in 43 % (132/307 hospitals) and 56 % (202/361) of hospitals, respectively. CONCLUSION: We identified a pattern of critical deficiencies in anesthesia care capacity in LMICs, including some low-cost, high-value added resources. The global health community should advocate for improvements in anesthesia care capacity and the potential benefits of doing so to health system planners. In addition, better quality data on anesthesia care capacity can improve advocacy, as well as the monitoring and evaluation of changes over time and the impact of capacity improvement interventions.

Increased Rates of Mild Traumatic Brain Injury Among Older Adults in US Emergency Departments, 2009-2010.

OBJECTIVE: To estimate rates of emergency department (ED) visits for mild traumatic brain injury (TBI) among older adults. We defined possible mild TBI cases to assess underdiagnoses. DESIGN: Cross-sectional. SETTING: National sample of ED visits in 2009-2010 captured by the National Hospital Ambulatory Medical Care Survey. PARTICIPANTS: Aged 65 years and older. MEASUREMENTS: Mild TBI defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes (800.0x-801.9x, 803.xx, 804.xx, 850.xx-854.1x, 950.1x-950.3x, 959.01) and a Glasgow Coma Scale score of 14 or more or missing, excluding those admitted to the hospital. Possible mild TBI was defined similarly among those without mild TBI and with a fall or motor vehicle collision as cause of injury. We calculated rates of mild TBI and examined factors associated with a diagnosis of mild TBI. RESULTS: Rates of ED visits for mild TBI were 386 per 100 000 among those aged 65 to 74 years, 777 per 100 000 among those aged 75 to 84 years, and 1205 per 100 000 among those older than 84 years. Rates for women (706/100 000) were higher than for men (516/100 000). Compared with a possible mild TBI, a diagnosis of mild TBI was more likely in the West (odds ratio = 2.31; 95% confidence interval, 1.02-5.24) and less likely in the South/Midwest (odds ratio = 0.52; 95% confidence interval, 0.29-0.96) than in the Northeast. CONCLUSIONS: This study highlights an upward trend in rates of ED visits for mild TBI among older adults.

International disparities in trauma care.

PURPOSE OF REVIEW: Trauma care has been a low priority topic in the global health agenda until recently, despite its social and economic impact. Although prevention is the key, provision and quality of trauma care has been the weakest link in the survival chain. We aim to summarize the differences in global trauma care to propose solutions in this article. RECENT FINDINGS: Patients with life-threatening injuries are six times more likely to die following a trauma in a low-income country than in a high-income country. Unintentional injuries currently rank fourth in the global causes of death, resulting in 5.8 million premature deaths and millions more with disability. The WHO member countries started the first global Decade of Action for Road Safety 2011-2020 initiative in May 2011. Governments across the world agreed to take steps to improve the safety of roads and vehicles, enhance the behavior of all road users and strengthen post-trauma care. SUMMARY: Several core strategies have been identified: human resource planning; physical resources (equipment and supplies); and administration (quality improvement and data collection) need to be developed for effective and adaptable prehospital care, patient transfer, in-hospital care and rehabilitation systems for injured persons worldwide. Clear definition of the problem to propose solutions is critical.

Analysis of field reports from anaesthesia volunteers in low- to middle-income countries.

OBJECTIVES: The objective of this study was to identify key experiences and common motifs of volunteer doctors who have participated in anaesthesia-related volunteer experiences abroad through the Health Volunteers Overseas (HVO) programme. An additional goal was to understand the effects of medical volunteerism in developing countries on the volunteers themselves. METHODS: After a medical mission with HVO, anaesthesia volunteers submit a post-experience report. Twenty-five reports were randomly selected from the 58 available trip reports, including five from each of the five countries collaborating with HVO. Data in the reports were analysed using a modified grounded theory and constant comparative technique until thematic saturation was achieved. RESULTS: Three major discoveries emerged from the analysis of post-experience reports: (i) anaesthesia residents and attending physicians find their volunteer experiences in the developing world to be personally rewarding and positive; (ii) most participants feel their educational interventions have a positive impact on local students and anaesthesia providers, and (iii) global volunteerism poses challenges, primarily caused by lack of resource availability and communication issues. CONCLUSIONS: Our results give new insight into the experiences of and challenges faced by a cohort of HVO-sponsored anaesthesia volunteers while abroad and validates the positive effects these global health experiences have on the volunteers themselves. This group of anaesthesia volunteers was able to further their personal and professional growth, sharpen their physical diagnosis and clinical reasoning skills in resource-poor environments and, most importantly, provide education and promote an exchange of ideas and information.

Team composition and perceived roles of team members in the trauma bay.

Perceptions of trauma team members and their roles may impact team performance, requiring intervention. Participant observation and semistructured interviews were performed with trauma team members: attendings, nurses, fellows, residents, and medical students. Some team members do not include nurses as members of the team. A greater proportion of male than female team leaders perceived their role as teacher or educator. Nurses, attendings, and fellows, provided parallel descriptions of good leaders, whereas medical students and residents stressed other qualities. Inconsistencies in trauma team role definition and membership should be addressed, toward the goal of improving team communication and patient outcomes.

A review of the fundamental principles and evidence base in the use of extracorporeal membrane oxygenation (ECMO) in critically ill adult patients.

Extracorporeal membrane oxygenation (ECMO) comprises a commonly used method of extracorporeal life support. It has proven efficacy and is an accepted modality of care for isolated respiratory or cardiopulmonary failure in neonatal and pediatric populations. In adults, there are conflicting studies regarding its benefit, but it is possible that ECMO may be beneficial in certain adult populations beyond postcardiotomy heart failure. As such, all intensivists should be familiar with the evidence-base and principles of ECMO in adult population. The purpose of this article is to review the evidence and to describe the fundamental steps in initiating, adjusting, troubleshooting, and terminating ECMO so as to familiarize the intensivist with this modality.

Collaboration and Decision-Making on Trauma Teams: A Survey Assessment.

INTRODUCTION: Leadership, communication, and collaboration are important in well-managed trauma resuscitations. We surveyed resuscitation team members (attendings, fellows, residents, and nurses) in a large urban trauma center regarding their impressions of collaboration among team members and their satisfaction with patient care decisions. METHODS: The Collaboration and Satisfaction About Care Decisions in Trauma (CSACD.T) survey was administered to members of ad hoc trauma teams immediately after resuscitations. Survey respondents self-reported their demographic characteristics; the CSACD.T scores were then compared by gender, occupation, self-identified leader role, and level of training. RESULTS: The study population consisted of 281 respondents from 52 teams; 111 (39.5%) were female, 207 (73.7%) were self-reported White, 78 (27.8%) were nurses, and 140 (49.8%) were physicians. Of the 140 physician respondents, 38 (27.1%) were female, representing 13.5% of the total surveyed population. Nine of the 52 teams had a female leader. Men, physicians (vs nurses), fellows (vs attendings), and self-identified leaders trended toward higher satisfaction across all questions of the CSACD.T. In addition to the comparison groups mentioned, women and general team members (vs non-leaders) gave lower scores. CONCLUSION: Female residents, nurses, general team members, and attendings gave lower CSACD.T scores in this study. Identification of nuances and underlying causes of lower scores from female members of trauma teams is an important next step. Gender-specific training may be necessary to change negative team dynamics in ad hoc trauma teams.

An organized, comprehensive, and security-enabled strategic response to the Haiti earthquake: a description of pre-deployment readiness preparation and preliminary experience from an academic anesthesiology department with no preexisting international disaster response program.

BACKGROUND: On Tuesday, January 12, 2010 at 16:53 local time, a magnitude 7.0 M(w) earthquake struck Haiti. The global humanitarian attempt to respond was swift, but poor infrastructure and emergency preparedness limited many efforts. Rapid, successful deployment of emergency medical care teams was accomplished by organizations with experience in mass disaster casualty response. Well-intentioned, but unprepared, medical teams also responded. In this report, we describe the preparation and planning process used at an academic university department of anesthesiology with no preexisting international disaster response program, after a call from an American-based nongovernmental organization operating in Haiti requested medical support. The focus of this article is the pre-deployment readiness process, and is not a post-deployment report describing the medical care provided in Haiti. METHODS: A real-time qualitative assessment and systematic review of the Hospital of the University of Pennsylvania's communications and actions relevant to the Haiti earthquake were performed. Team meetings, conference calls, and electronic mail communication pertaining to planning, decision support, equipment procurement, and actions and steps up to the day of deployment were reviewed and abstracted. Timing of key events was compiled and a response timeline for this process was developed. Interviews with returning anesthesiology members were conducted. RESULTS: Four days after the Haiti earthquake, Partners in Health, a nonprofit, nongovernmental organization based in Boston, Massachusetts, with >20 years of experience providing medical care in Haiti contacted the University of Pennsylvania Health System to request medical team support. The departments of anesthesiology, surgery, orthopedics, and nursing responded to this request with a volunteer selection process, vaccination program, and systematic development of equipment lists. World Health Organization and Centers for Disease Control guidelines, the American Society of Anesthesiology Committee on Trauma and Emergency Preparedness, published articles, and in-country contacts were used to guide the preparatory process. CONCLUSION: An organized strategic response to medical needs after an international natural disaster emergency can be accomplished safely and effectively within 6 to 12 days by an academic anesthesiology department, with medical system support, in a center with no previously established response system. The value and timeliness of this response will be determined with further study. Institutions with limited experience in putting an emergency medical team into the field may be able to quickly do so when such efforts are executed in a systematic manner in coordination with a health care organization that already has support infrastructure at the site of the disaster.