Dispelling Dogma: American Association for Surgery of Trauma Prospective, Multicenter Trial of Index vs Delayed Fasciotomy after Extremity Trauma.

BACKGROUND: Surgical dogma states that "if you think about doing a fasciotomy, you do it," yet the benefit of this approach remains unclear. We hypothesized that early fasciotomy during index operative procedures for extremity vascular trauma would be associated with improved patient outcomes. STUDY DESIGN: This prospective, observational multicenter (17 level 1, 1 level 2) analysis included patients ≥15 years old with extremity vascular injury requiring operative management. Clinical variables were analyzed with respect to fasciotomy timing for correlation with outcomes, including muscle necrosis and limb amputation. Associated variables (p < 0.05) were input into multivariable logistic regression models evaluating these endpoints. RESULTS: Of 436 study patients, most were male (87%) with penetrating (57%), lower extremity (77%), arterial (73%), vein (40%), and bony (53%) injury with prolonged hospital length of stay (11 days). Patients who had index fasciotomy (66%) were compared with those who did not (34%), and no differences were appreciated with respect to age, initial systolic blood pressure, tourniquet time, "hard" signs of vascular injury, massive transfusion protocol activation, or Injury Severity Score (all p < 0.05). Of the 289 patients who underwent index fasciotomy, 49% had prophylactic fasciotomy, 11% developed muscle necrosis, 4% required an additional fasciotomy, and 8% required amputation, although only 28 of 147 (19%) required delayed fasciotomy in those without index fasciotomy. Importantly, forgoing index fasciotomy did not correlate (p > 0.05) with additional muscle necrosis or amputation risk in the delayed fasciotomy group. After controlling for confounders, index surgery fasciotomy was not associated with either muscle necrosis or limb salvage in multivariable models. CONCLUSIONS: Routine, index operation fasciotomy failed to demonstrate an outcome benefit in this prospective, multicenter analysis. Our data suggest that a careful observation and fasciotomy-when-needed approach may limit unnecessary surgery and its resulting morbidity in extremity vascular trauma patients.

Rethinking protocolized completion angiography following extremity vascular trauma: A prospective observational multicenter trial.

BACKGROUND: Completion angiography (CA) is commonly used following repair of extremity vascular injury and is recommended by the Eastern Association for the Surgery of Trauma practice management guidelines for extremity trauma. However, it remains unclear which patients benefit from CA because only level 3 evidence exists. METHODS: This prospective observational multicenter (18LI, 2LII) analysis included patients 15 years or older with extremity vascular injuries requiring operative management. Clinical variables and outcomes were analyzed with respect to with our primary study endpoint, which is need for secondary vascular intervention. RESULTS: Of 438 patients, 296 patients required arterial repair, and 90 patients (30.4%) underwent CA following arterial repair. Institutional protocol (70.9%) was cited as the most common reason to perform CA compared with concern for inadequate repair (29.1%). No patients required a redo extremity vascular surgery if a CA was performed per institutional protocol; however, 26.7% required redo vascular surgery if the CA was performed because of a concern for inadequate repair. No differences were observed in hospital mortality, length of stay, extremity ischemia, or need for amputation between those who did and did not undergo CA. CONCLUSION: Completion angiogram following major extremity injury should be considered in a case-by-case basis. Limiting completion angiograms to those patients with concern for an inadequate vascular repair may limit unnecessary surgery and morbidity. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Blunt pancreatic trauma: A Western Trauma Association critical decisions algorithm.

BACKGROUND: The Western Trauma Association (WTA) has undertaken publication of best practice clinical practice guidelines on multiple trauma topics. These guidelines are based on scientific evidence, case reports, and best practices per expert opinion. Some of the topics covered by this consensus group do not have the ability to have randomized controlled studies completed because of complexity, ethical issues, financial considerations, or scarcity of experience and cases. Blunt pancreatic trauma falls under one of these clinically complex and rare scenarios. This algorithm is the result of an extensive literature review and input from the WTA membership and WTA Algorithm Committee members. METHODS: Multiple evidence-based guideline reviews, case reports, and expert opinion were compiled and reviewed. RESULTS: The algorithm is attached with detailed explanation of each step, supported by data if available. CONCLUSION: Blunt pancreatic trauma is rare and presents many treatment challenges.

Disparate resource allocation during the COVID-19 pandemic among trauma centers: A Western Trauma Association national survey.

BACKGROUND: During the pandemic, hospitals implemented disaster plans to conserve resources while maintaining patient care. It was unclear how these plans impacted injury care and trauma surgeons. STUDY DESIGN: A 16 question survey assessing COVID-related hospital policy and resource allocation pre-COVID-19 peak (March), and a 19 question post-peak (June) survey was distributed to Trauma/Critical Care attending's via social media and the Western Trauma Association member email list. RESULTS: There were 120 pre- and 134 post-peak respondents. Most (95%) altered trauma PPE components, a nd 67% noted changes in their admission population pre-peak while 80% did so post-peak. Penetrating injury increased 56% at Level 1 centers and 27% at Level 2 centers. Altered ICU and transfusion criteria were noted with 25% relocating TBI patients, 17% revised rib fracture admission criteria, and 23% adjusted transfusion practices. Importantly, 12% changed their massive transfusion protocol, with 11% reducing the symptomatic transfusion threshold from 7 g/dL to 6 g/dL. Half (50%) disclosed impediments to patient care including PPE shortages and COVID test-related procedural delay (Fig. 2). While only 14% felt their institution was overwhelmed by COVID, the vast majority (81%) shared durable concerns about personal health and safety. CONCLUSIONS: Disparate approaches to COVID-19 preparedness and response characterize survey respondent facility actions. These disparities, especially between Level 1 and Level 2 centers, represent opportunities for the trauma community to coordinate best-practice planning and implementation in light of future consequence infection or pandemic care.

Teaching communication and supporting autonomy with a team-based operative simulator.

BACKGROUND: Changing residency structure emphasizes the need for formal instruction on team leadership and intraoperative teaching skills. A high fidelity, multi-learner surgical simulation may offer opportunities for senior learners (SLs) to learn these skills while teaching technical skills to junior learners (JLs). METHODS: We designed and optimized a low-cost inguinal hernia model that paired JLs and SLs as an operative team. This was tested in 3 pilot simulations. Participants' feedback was analyzed using qualitative methods. RESULTS: JL feedback to SLs included the themes "guiding and instructing" and "allowing autonomy." Senior Learner feedback to JLs focused on "mechanics," "knowledge," and "perspective/flow." Both groups focused on "communication" and "professionalism." CONCLUSIONS: A multi-learner simulation can successfully meet the technical learning needs of JLs and the teaching and communication learning needs of SLs. This model of resident-driven simulation may illustrate future opportunities for operative simulation.

A night float week in a surgical clerkship improves student team cohesion.

BACKGROUND: We hypothesize that night float rotations in the third-year surgical clerkship improve student learning and perceptions of team cohesion. METHODS: A 1-week night float (NF) system was implemented during the 2013 to 2014 academic year for students. Each student completed 1 week of NF with the Trauma/Emergency General Surgery service. The Perceived Cohesion Scale survey was prospectively administered and National Board of Medical Examiners academic performance retrospectively reviewed. RESULTS: We surveyed 70 medical students, 37 traditional call and 33 NF students, with 91% response rate. Perception of team cohesion increased significantly, without perceived loss of educational benefit. Examination scores increased significantly comparing pre- and postintervention groups, with this trend continuing in the following academic year. CONCLUSIONS: A week-long student NF experience significantly improved perception of team cohesion and standardized examination results. A dedicated period of NF during the surgical clerkship may improve its overall educational value.

A Disease-Specific Hybrid Rotation Increases Opportunities for Deliberate Practice.

IMPORTANCE: Incorporating deliberate practice (DP) into residency curricula may optimize education. DP includes educationally protected time, continuous expert feedback, and a focus on a limited number of technical skills. It is strongly associated with mastery level learning. OBJECTIVE: Determine if a multidisciplinary breast rotation (MDB) increases DP opportunities. DESIGN: Beginning in 2010, interns completed the 4-week MDB. Three days a week were spent in surgery and surgical clinic. Half-days were in breast radiology, pathology, medical oncology, and didactics. The MDB was retrospectively compared with a traditional community rotation (TCR) and a university surgical oncology service (USOS) using rotation feedback and resident operative volume. Data are presented as mean ± standard deviation. SETTING: Oregon Health and Science University in Portland, Oregon; an academic tertiary care general surgery residency program. PARTICIPANTS: General surgery residents at Oregon Health and Science University participating in either the MDB, TCR or USOS. RESULTS: A total of 31 interns rated the opportunity to perform procedures significantly higher for MDB than TCR or USOS (4.6 ± 0.6 vs 4.2 ± 0.9 and 4.1 ± 1.0, p < 0.05). MDB was rated higher than TCR on quality of faculty teaching and educational materials (4.5 ± 0.7 vs 4.1 ± 0.9 and 4.0 ± 1.2 vs 3.5 ± 1.0, p < 0.05). Interns operated more on the MDB than on the USOS and were more focused on breast resections, lymph node dissections, and port placements than on the traditional surgical rotation or USOS. CONCLUSIONS: The MDB incorporates multidisciplinary care into a unique, disease-specific, and educationally focused rotation. It is highly rated and affords a greater opportunity for DP than either the USOS or TCR. DP is strongly associated with mastery learning and this novel rotation structure could maximize intern education in the era of limited work hours.

A Consortium Approach to Surgical Education in a Developing Country: Educational Needs Assessment.

IMPORTANCE: Surgical disease is a global health priority, and improving surgical care requires local capacity building. Single-institution partnerships and surgical missions are logistically limited. The Alliance for Global Clinical Training (hereafter the Alliance) is a consortium of US surgical departments that aims to provide continuous educational support at the Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania (MUHAS). To our knowledge, the Alliance is the first multi-institutional international surgical collaboration to be described in the literature. OBJECTIVE: To assess if the Alliance is effectively responding to the educational needs of MUHAS and Muhimbili National Hospital surgeons. DESIGN, SETTING, AND PARTICIPANTS: During an initial 13-month program (July 1, 2013, to August 31, 2014), faculty and resident teams from 3 US academic surgical programs rotated at MUHAS as physicians and teachers for 1 month each. To assess the value of the project, we administered anonymous surveys. MAIN OUTCOMES AND MEASURES: Anonymous surveys were analyzed on a 5-point Likert-type scale. Free-text answers were analyzed for common themes. RESULTS: During the study period, Alliance members were present at MUHAS for 8 months (1 month each). At the conclusion of the first year of collaboration, 15 MUHAS faculty and 22 MUHAS residents completed the survey. The following 6 areas of educational needs were identified: formal didactics, increased clinical mentorship, longer-term Alliance presence, equitable distribution of teaching time, improved coordination and language skills, and reciprocal exchange rotations at US hospitals. The MUHAS faculty and residents agreed that Alliance members contributed to improved patient care and resident education. CONCLUSIONS AND RELEVANCE: A multi-institutional international surgical partnership is possible and leads to perceived improvements in patient care and resident learning. Alliance surgeons must continue to focus on training Tanzanian surgeons. Improving the volunteer surgeons' Swahili-language skills would be an asset. Future efforts should provide more teaching coverage, equitably distribute educational support among all MUHAS surgeons, and collaboratively develop a formal surgical curriculum.

Effect of ascorbic acid concentrations on hemodynamics and inflammation following lyophilized plasma transfusion.

BACKGROUND: Compared with lyophilized plasma (LP) buffered with other acids, LP with ascorbic acid (AA) attenuates systemic inflammation and DNA damage in a combat relevant polytrauma swine model. We hypothesize that increasing concentrations of AA in transfused LP will be safe, will be hemodynamically well tolerated, and will attenuate systemic inflammation following polytraumatic injury and hemorrhage in swine. METHODS: This prospective, randomized, blinded study involved 52 female swine. Forty animals were subjected to our validated polytrauma model and resuscitated with LP. Baseline control sham (n = 6), operative control sham (n = 6), low-AA (n = 10), medium-AA (n = 10), high-AA (n = 10) groups, and a hydrochloric acid control (HCL, n = 10) were randomized. Hemodynamics, thrombelastography, and blood chemistries were assessed. Inflammatory cytokines (tumor necrosis factor α, interleukin 6 [IL-6], C-reactive protein, and IL-10) and DNA damage were measured at baseline, 2 hours, and 4 hours after liver injury. Significance was set at p < 0.05, with a Bonferroni correction for multiple comparisons. RESULTS: Hemodynamics, shock, and blood loss were similar between groups. All animals had robust procoagulant activity 2 hours following liver injury. Inflammation was similar between groups at baseline, and AA groups remained similar to HCL following liver injury. IL-6 and tumor necrosis factor α were increased at 2 hours and 4 hours compared with baseline within all groups (p < 0.008). DNA damage increased at 2 hours compared with baseline in all groups (p < 0.017) and further increased at 4 hours compared with baseline in HCL, low-, and high-AA groups (p < 0.005). C-reactive protein was similar between and within groups. IL-10 increased at 2 hours compared with baseline in low- and high-AA groups and remained elevated at 4 hours compared with baseline in the low-AA group (all, p < 0.017). CONCLUSION: Concentrations of AA were well tolerated and did not diminish the procoagulant activity of LP. Within our tested range of concentrations, AA can safely be used to buffer LP.