Choosing wisely: A prospective study of direct to operating room trauma resuscitation including real-time trauma surgeon after-action review

INTRODUCTION

Although several centers have direct to operating room (DOR) resuscitation programs, there are no published prospective studies on optimal patient selection, interventions, outcomes, or real-time surgeon assessments.

METHODS

Direct to operating room cases for 1 year were prospectively enrolled. Demographics, injury types/severity, triage criteria, interventions, and outcomes including Glasgow Outcome Scale score were collected. Detailed time-to-event and sequence data on initial lifesaving interventions (LSIs) or emergent surgeries were analyzed. A structured real-time attending surgeon assessment tool for each case was collected. Direct to operating room activation criteria were grouped into categories: mechanism, physiology, injury pattern, or emergency medical services (EMS) suspicion.

RESULTS

There were 104 DOR cases: male, 84%; penetrating, 80%; and severely injured (Injury Severity Score, >15), 39%. The majority (65%) required at least one LSI (median of 7 minutes from arrival), and 41% underwent immediate emergent surgery (median, 26 minutes). Blunt patients were more severely injured and more likely to undergo LSI (86% vs. 59%) but less likely to require emergent surgery (19% vs. 47%, all p < 0.05). Analysis of DOR criteria categories showed unique patterns in each group for interventions and outcomes, with EMS suspicion associated with the lowest need for DOR. Surgeon assessment tool results found that DOR was indicated in 84% and improved care in 63%, with a small subset identified (9%) where DOR had a negative impact.

CONCLUSION

Direct to operating room resuscitation facilitated timely emergent interventions in penetrating truncal trauma and a select subset of critically ill blunt patients. Unique intervention/outcome profiles were identified by activation criteria groups, with little utility among activations for EMS suspicion. Real-time surgeon assessment tool identified high- and low-yield DOR groups.

LEVEL OF EVIDENCE

Prospective observational study, level III.

Traumatic thoracic rib cage and chest wall hernias: A review and discussion of management principles

Traumatic thoracic or chest wall hernias are relatively uncommon but highly challenging injuries that can be seen after a variety of injury mechanisms. Despite their description throughout history there remains scant literature on this topic that is primarily limited to case reports or series. Until recently, there also has been no effort to create a reliable grading system that can assess severity, predict outcomes, and guide the choice of surgical repair. The purpose of this article is to review the reported literature on this topic and to analyze the history, common injury mechanisms, likely presentations, and optimal management strategies to guide clinicians who are faced with these challenging cases. We also report a modified and updated version of our previously developed grading system for traumatic chest wall hernias that can be utilized to guide surgical management techniques and approaches.

Model for Team Training Using the Advanced Trauma Operative Management Course: Pilot Study Analysis

BACKGROUND

Education and training of surgeons has traditionally focused on the development of individual knowledge, technical skills, and decision making. Team training with the surgeon's operating room staff has not been prioritized in existing educational paradigms, particularly in trauma surgery. We aimed to determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' Advanced Trauma Operative Management (ATOM) course, would improve staff knowledge if conducted in a team-training environment.

METHODS

Between December 2012 and December 2014, 22 surgical technicians and nurses participated in a curriculum complementary to the ATOM course, consisting of 8 individual 8-hour training sessions designed by and conducted at our institution. Didactic and practical sessions included educational content, hands-on instruction, and alternating role play during 5 system-specific injury scenarios in a simulated operating room environment. A pre- and postcourse examination was administered to participants to assess for improvements in team members' didactic knowledge.

RESULTS

Course participants displayed a significant improvement in didactic knowledge after working in a team setting with trauma surgeons during the ATOM course, with a 9-point improvement on the postcourse examination (83%-92%, p = 0.0008). Most participants (90.5%) completing postcourse surveys reported being "highly satisfied" with course content and quality after working in our simulated team-training setting.

CONCLUSIONS

Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting. Improved communication, efficiency, appropriate equipment use, and staff awareness are the desired outcomes when shifting the paradigm from individual to surgical team training so that improved patient outcomes, decreased risk, and cost savings can be achieved.

OBJECTIVE

Determine whether a pilot curriculum for surgical technicians and nurses, based on the American College of Surgeons' ATOM course, improves staff knowledge if conducted in a team-training environment.

DESIGN

Surgical technicians and nurses participated in a curriculum complementary to the ATOM course. In all, 8 individual 8-hour training sessions were conducted at our institution and contained both didactic and practical content, as well as alternating role play during 5 system-specific injury scenarios. A pre- and postcourse examination was administered to assess for improvements in didactic knowledge.

SETTING

The course was conducted in a simulated team-training setting at the Legacy Institute for Surgical Education and Innovation (Portland, OR), an American College of Surgeons Accredited Educational Institute.

PARTICIPANTS

In all, 22 surgical technicians and operating room nurses participated in 8 separate ATOM(s) courses and had at least 1 year of surgical scrubbing experience in general surgery with little or no exposure to Level I trauma surgical care. Of these participants, 16 completed the postcourse examination.

RESULTS

Participants displayed a significant improvement in didactic knowledge (83%-92%, p = 0.0008) after the ATOM(s) course. Of the 14 participants who completed postcourse surveys, 90.5% were "highly satisfied" with the course content and quality.

CONCLUSIONS

Team training is critical to improving the knowledge base of surgical technicians and nurses in the trauma operative setting and may contribute to improved patient outcomes, decreased risk, and hospital cost savings.

Low-Velocity Nail-Gun Injuries to the Interventricular Septum: Report of Two Cases, One in a Child

Nail-gun injury to the heart is rare. Nail-gun injury to the interventricular septum is rarer: we could find only 5 reported cases, and none involving a child. We report 2 additional cases, in which nails penetrated the interventricular septum without causing acute pericardial tamponade, heart block, or shunt across the septum. Transesophageal echocardiography provides a dynamic way to evaluate the patient preoperatively, intraoperatively, and postoperatively. In the cases reported here, both the adult with multiple interventricular nails and the child with a single nail underwent foreign-object removal via median sternotomy. The child needed cardiopulmonary bypass for removal of the nail. There were no short-term or long-term sequelae from these interventricular septal injuries.

Extracorporeal membrane oxygenation can provide cardiopulmonary support during bronchoscopic clearance of airways after sand aspiration

BACKGROUND

Sand aspiration occurs in situations of cave-in burial and near-drowning. Sand in the tracheobronchial airways adheres to the mucosa and can cause tracheal and bronchial obstruction, which can be life-threatening even with intensive management. In previous case reports of airway obstruction caused by sand aspiration, fiber optic or rigid bronchoscopy has been effective in removing loose sand, but removal of sand particles lodged in smaller airways has proven challenging and time-consuming.

CASE REPORT

In this case report of sand aspiration with acute pulmonary failure, the use of extracorporeal membrane oxygenation for respiratory support allowed more effective removal of sand particles by rigid bronchoscopy and lavage with less patient compromise.

CONCLUSION

Our case of sand aspiration is unique in that the patient presents with complex medical problems (mixed respiratory and metabolic acidosis), hypothermia, hypoxemia, and neoplastic conditions. The fact that she survived the sand aspiration and a long inter-hospital transport time (90 min) with inadequate ventilation and oxygenation without apparent ill effects suggests that the measures we took to resuscitate her and extract the sand from her airways were reasonable and appropriate.

Surgical stabilization of flail chest injuries with MatrixRIB implants: a prospective observational study

BACKGROUND

Surgical stabilization of flail chest injury with generic osteosynthesis implants remains challenging. A novel implant system comprising anatomic rib plates and intramedullary splints may improve surgical stabilization of flail chest injuries. This observational study evaluated our early clinical experience with this novel implant system to document if it can simplify the surgical procedure while providing reliable stabilization.

METHODS

Twenty consecutive patients that underwent stabilization of flail chest injury with anatomic plates and intramedullary splints were prospectively enrolled at two Level I trauma centres. Data collection included patient demographics, injury characterization, surgical procedure details and post-operative recovery. Follow-up was performed at three and six months to assess pulmonary function, durability of implants and fixation and patient health.

RESULTS

Patients had an Injury Severity Score of 28±10, a chest Abbreviated Injury Score of 4.2±0.4 and 8.5±2.9 fractured ribs. Surgical stabilization was achieved on average with five plates and one splint. Intra-operative contouring was required in 14% of plates. Post-operative duration of ventilation was 6.4±8.6 days. Total hospitalization was 15±10 days. At three months, patients had regained 84% of their expected forced vital capacity (%FVC). At six months, 7 of 15 patients that completed follow-up had returned to work. There was no mortality. Among the 91 rib plates, 15 splints and 605 screws in this study there was no hardware failure and no loss of initial fixation. There was one incidence of wound infection. Implants were removed in one patient after fractures had healed.

CONCLUSIONS

Anatomic plates eliminated the need for extensive intraoperative plate contouring. Intramedullary rib splints provided a less-invasive fixation alternative for single, non-comminuted fractures. These early clinical results indicate that the novel implant system provides reliable fixation and accommodates the wide range of fractures encountered in flail chest injury.

Poor discriminatory function for endoscopic skills on a computer-based simulator

BACKGROUND

Computer-based endoscopy simulators may enable trainees to learn and develop technical skills before performing on patients. Simulators require validation as adequate models of live endoscopy before being used for training or assessment purposes.

OBJECTIVE

To evaluate content and criterion validity of the CAE EndoscopyVR Simulator colonoscopy and EGD modules as predictors of clinical endoscopic skills.

DESIGN

Prospective, observational, non-randomized, parallel cohort study.

SETTING

Single academic center with accredited gastroenterology training program.

PARTICIPANTS

Five novice first-year gastroenterology fellows and 6 expert gastroenterology attending physicians.

INTERVENTION

Participants performed 18 simulated colonoscopies and 6 simulated EGDs. The simulator recorded objective performance parameters. Participants then completed feedback surveys.

MAIN OUTCOME MEASUREMENTS

The 57 objective performance parameters measured by the endoscopy simulator were compared between the two study groups. Novice and expert survey responses were analyzed.

RESULTS

Significant differences between novice and expert performance were detected in only 19 of 57 (33%) performance metrics. Eight of these 19 (42%) were time-related metrics, such as total procedure time, time to anatomic landmarks, and time spent in contact with GI mucosa. Of 49 non-time related measures, the few additional statistically significant differences between novices and experts involved air insufflation, sedation management, endoscope force, and patient comfort. These findings are of uncertain clinical significance. Survey data found multiple aspects of the simulation to be unrealistic compared with human endoscopy.

LIMITATIONS

Small sample size.

CONCLUSION

The CAE EndoscopyVR Simulator displays poor content and criterion validity and is thereby incapable of predicting skill during in vivo endoscopy.

Successful resuscitation after multiple injuries in the wilderness

BACKGROUND

Survival of blunt trauma associated with hypothermic and hemorrhagic cardiac arrest in wilderness areas is extremely rare.

CASE REPORT

We describe a case of a 19-year-old female college sophomore who, while glissading down Mt. Adams, had a 400-pound boulder strike her back and left pelvis, propelling her 40 feet down the mountain to land face down in the snow at 7000 feet. It took 4 h from the time of injury until the arrival of the helicopter at our Emergency Department and Trauma Center. The patient lost vital signs en route and had no CO(2) production. A cardiothoracic surgeon was the trauma surgeon on call. The patient was taken directly from the helipad to the operating room, where cutdowns enabled initial intravenous access, median sternotomy and pericardiotomy open heart massage, massive transfusion, chest and abdominal cavity irrigations with warm saline, correction of acid base imbalances and coagulopathies, and epicardial pacing that led to a successful reanimation of the patient. The patient was rewarmed without extracorporeal membrane oxygenation or heat exchangers. The ensuing multiple organ failures (heart, lungs, kidneys, intestines, brain, and immune system) and rhabdomyolysis led to a 2-month intensive care unit stay. She received over 120 units of blood and blood products. The patient regained cognitive function, mobility, and overcame multiple organ failure.

CONCLUSION

This report is presented to increase awareness of the potential survivability in hypothermia, and to recognize the heroic efforts of the emergency services personnel whose efforts saved the patient's life.

Residual urinary volume and urinary tract infection, a life threatening illness: a case report

Multiple Sclerosis (MS) is an inflammatory disease that demyelinates the central nervous system causing progressive disability. The urodynamics of MS patients is an important consideration because these patients are susceptible to acute urinary bladder retention associated with a high fever. Treatment should include irrigation using a Foley catheter and an irrigation syringe to remove residual urine and sediment from the neurogenic bladder, intravenous fluid resuscitation, bacteriological analysis of the residual urine, and admission to an Intensive Care Unit for further evaluation by a urologist. After discharge, suprapubic cystostomy should be a consideration for patients who have chronic urinary tract infections associated with acute urinary bladder retention, as well as limited mobility to perform self catheterization, or limited personal care assistants trained to perform a urethral clean intermittent catheterization.

Scientific basis for the selection of skin closure techniques

This scientific article was designed to teach the individual reader the scientific basis for suture and needle selection as well as to illustrate the appropriate surgical techniques involved in wound repair of skin incisions. Because the US Food and Drug Administration permits 1.5% of the sterile surgical gloves to have holes, the operating room personnel should wear sterile surgical double-glove hole indication systems that detect holes in the outer glove. From the surgeon's point of view, the rate of gain of strength of the skin wound is a key determinant of many decisions including when the suture can be removed, the level of patient activity, and the selection of the incision. Important considerations in wound closure are type of suture and mechanical performance, in vivo and in vitro. Measurements of the in vivo degradation of sutures separate them into two general classes, absorbable and nonabsorbable. Sutures that undergo rapid degradation in tissues, losing their tensile strength within 60 days, are considered absorbable. Those that maintain their tensile strength for longer than 60 days are considered nonabsorbable. For skin closure with nonabsorbable suture, we favor the use of the polybutester suture that is coated with an absorbable polymer, VASCUFIL™. When absorbable sutures are used for a dermal skin closure, the synthetic monofilament MAXON™ is recommended. Absorption of the suture is complete between 90 and 110 days. In either case, we would recommend that the suture be attached by a sewage attachment to a SURGALLOY™ reverse cutting stainless steel suture. Continuous percutaneous suture closure has definite, distinct advantages over interrupted suture closure. Although continuous dermal wound closure is technically more challenging for the surgeon than interrupted dermal suture closure, it has become an important wound closure technique. A monofilament absorbable synthetic MAXON™ attached to a reverse cutting edge SURGALLOY™ stainless steel needle is ideally suited for continuous dermal skin suture closure.

Reducing accidental injuries during surgery

All surgical healthcare professionals and their patients should be aware of exposure to blood from individuals infected with potentially transmissible disease. The site that was most susceptible to sharp injuries was the index finger of the surgeon's hand. It is also important to note that needles cause the vast majority of sharp injuries. During the last two decades, there have been two revolutionary advances in preventing accidental needlestick injuries during surgery that include the development of blunt tapering point needles as well as the double-glove hole indication systems. During the innovative development of blunt taper point needles, a glove manufacturer, Molnlycke, Inc., devised non-latex and latex double-glove hole puncture indication systems that are being used throughout the world. The reliability of these double-glove hole indication systems in detecting holes in the outer glove has been reliably documented by scientific studies that are published in peer-reviewed journals. On the basis of these extensive quantitative studies, the authors recommended that the double-glove hole indication system be used in all operative procedures to prevent the transmission of deadly bloodborne viral infections.

Scientific basis for the selection of surgical staples and tissue adhesives for closure of skin wounds

During the last four decades, there have been revolutionary advances in the development of skin staples as well as tissue adhesives. One of the purposes of this collective review is to provide an overview of recent advances in the development of metal and absorbable skin staples and tissue adhesives. In addition, we will provide technical considerations in the use of metal and absorbable skin staples and tissue adhesives during surgery. On the basis of extensive experimental studies, we would recommend the Autosuture™ Multifire Premium™ metal skin stapler. During a surgical operation, the rotating head of this skin stapler can have its skin stapling cartridge removed once for additional stapling. The revolutionary Insorb™ subcuticular skin stapler is designed to combine the cosmetic result of absorbable sutures with the rapid closure times associated with metal skin staplers, while eliminating the need for metal staple removal postoperatively. The Insorb™ absorbable staple is composed of a copolymer that is predominantly polylactide, which is absorbed over a period of a few months. The superior performance of the Insorb™ absorbable staple has been confirmed by experimental and clinical studies. In the last 20 years, surgeons have become increasingly interested in replacing sutures by means of adhesive bonds in the closure of surgical wounds. A recent collective review of clinical studies done with tissue adhesive has recommended that there is a need for well-designed randomized, controlled trials comparing tissue adhesives and alternate methods of closure, especially in patients whose health may interfere with wound healing.

Wound closure sutures and needles: a new perspective

Ideally, the choice of the suture material should be based on the biological interaction of the materials employed, the tissue configuration, and the biomechanical properties of the wound. Measurements of the in vivo degradation of sutures separate them into two general classes: absorbable and nonabsorbable sutures. The nonabsorbable sutures and absorbable sutures are classified according to their origin. When considering an absorbable suture's tensile strength in vivo, we recommend that the manufacturer provides specific recommendations of its holding strength, rather than the percentage retained of its initial tensile strength. The newest advance in nonabsorbable sutures is polybutester suture, which is a block copolymer that contains butylene terephthalate (84%) and polytetramethylene ether glycol terephthalate (16%). The expanded polytetrafluoroethylene (ePTFE) suture has been expanded to produce a porous microstructure that is approximately 50% air by volume. The clinical performance of polybutester suture has been enhanced by coating its surface with a unique absorbable polymer. A search for a synthetic substitute for absorbable collagen sutures led to the development of the POLYSORB™ sutures that can reliably approximate tissues with a low risk for infection. The latest innovation in the development of monofilament absorbable sutures has been in the rapidly absorbing CAPROSYN™ suture. A new high-nickel stainless steel, SURGALLOY™, has been used recently to manufacture surgical needles. Biomechanical performance studies of cutting edge needles made of S45500 stainless steel alloy and SURGALLOY™ stainless steel demonstrated that needles made of SURGALLOY™ had superior performance characteristics over those made of S45500.

An injury prevention program to prevent gymnastic injuries in children and teenagers

There are more than 5 million participants in 1 of 6 gymnastic disciplines that are prone to spinal cord injuries. Working with the gifted scholar and attorney, Jeffrey Beaton, the authors have participated in developing an injury prevention program for children and teenagers who participate in gymnastics. This program includes the following components: (1) a gymnastics center that complies with the e-Book design of gymnasticszone.com; (2) all teachers and students in gymnastics should be members of USA Gymnastics (USAG) and purchase a copy of the USA Gymnastics Safety Manual, the official manual of the United States Gymnastics Safety Association; (3) trampolines should be sunk in the ground with the bed level with the floor; and finally, (4) immediate emergency access of the injured gymnast to either a skilled orthopedic or neurosurgeon.

A case report: femoral fracture in a multiple sclerosis patient with vitamin d deficiency--a preventable injury

In this report, we describe the management of a multiple sclerosis patient with a femoral fracture who had severe vitamin D deficiency. After the patient's preoperative laboratory studies revealed a normal platelet count, the orthopedic surgeon performed an intramedullary rod fixation on the patient's left femoral fracture. After the surgery, the diagnosis of vitamin D deficiency was made by measuring the circulating serum concentration of 25-dihydroxyvita-min D (25(OH)D) via Disorin's Vitamin D immunochemiluminometric assay LIASION by LabCorp (Laboratory Corporation of America). The patient's postoperative management included the oral administration of 4000 IU of vitamin D3 in a gel-cap suspension that resulted in an elevation of the blood serum concentration of 25(OH)D to an optimal concentration of >80 nmol/L (32 ng/ml).

Nursing home fractures: a challenge and a solution

Hip fracture occurrences in nursing homes are associated with high morbidity, mortality, and high health care costs in elderly people. In the United States, approximately 340,000 hip fractures occur each year, while more then 90% are associated with falls. Osteoporosis is a skeletal disorder causing impaired bone strength that increases the risk of fracture. In the United States alone, osteoporosis affects < 10 million individuals aged > or =50. The American Association of Clinical Endocrinologists (AACE), North American Menopause Society (NAMS), and National Osteoporosis Foundation (NOF) have developed recommendations for the identification of patients with osteoporosis who need therapy. Good nutrition with adequate supplements of calcium and vitamin D3 is considered one of the most important lifestyle factors for maintaining adequate bone mineral density. Only a combination of calcium and vitamin D therapy has been shown to increase the bone mineral density as well as a reduction in the nonvertebral fractures.

Reducing workers' compensation costs for latex allergy and litigation against glove manufacturing companies

It has been well documented in the medical literature that powdered medical gloves can have serious consequences to patients and health-care workers. Adverse reactions to natural latex gloves, such as contact dermatitis and urticaria, occupational asthma, and anaphylaxis, have been documented as a significant cause of Workers' Compensation claims among health-care workers. While the cost of examination and surgical gloves is significant, this factor must be considered with the total cost of Workers' Compensation claims and possible litigation bestowed upon hospitals and glove manufacturing companies. In the United States, Canada, Belgium, and Germany, medical leaders have documented the dangers of powdered latex gloves and have implemented transition programs that are reducing Workers' Compensation claims filed by health-care workers. While attorneys view litigation against powdered glove manufacturers as the "next big tort", the authors of this article were not able to document all compensation costs to disabled workers because many settlements do not allow the claimant to disclose this information.

Pandemic preparedness for swine flu influenza in the United States

In March and early April 2009, Mexico experienced outbreaks of influenza caused by the H1N1 virus, which has spread throughout the world. With the pandemic of H1N1 infections, we have discussed in this scientific article strategies that should limit the spread of the influenza A (H1N1) virus in our country. Specific vaccines against the influenza H1N1 virus are being manufactured, and a licensed vaccine is expected to be available in the United States by mid-October 2009. However, some health-care workers may be hesitant to take a vaccine because it contains a mercury preservative-thimerosal-which can be harmful to their health. When caring for patients with respiratory infections, the health-care worker should be wearing a facial respirator. In a report from the Centers for Disease Control and Prevention (CDC), it was indicated that each health-care professional should be required to do a respiratory fit testing to identify the ideal model. Because it has been well documented that a vitamin D deficiency can precipitate the influenza virus, we strongly recommend that all health-care workers and patients be tested and treated for vitamin D deficiency to prevent exacerbation of a respiratory infection.