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Soliman SI, Panuganti BA, Francis DO, Pang J, Klebaner D, Asturias A, Alattar A, Wood S, Terry M, Bryson PC, Tipton CB, Zhao EE, O’Rourke A, Santa Maria C, Grimm DR, Sung CK, Lao WP, Thompson JM, Crawley BK, Rosen S, Berezovsky A, Kupfer R, Hennesy TB, Clary M, Joseph IT, Sarhadi K, Kuhn M, Abdel-Aty Y, Kennedy MM, Lott DG, Weissbrod PA. Factors Associated With Otolaryngologists Performing Tracheotomy. JAMA Otolaryngol Head Neck Surg 2023; 149:1066-1073. [PMID: 37796485 PMCID: PMC10557025 DOI: 10.1001/jamaoto.2023.2698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/27/2023] [Indexed: 10/06/2023]
Abstract
Importance Tracheotomies are frequently performed by nonotolaryngology services. The factors that determine which specialty performs the procedure are not defined in the literature but may be influenced by tracheotomy approach (open vs percutaneous) and other clinicodemographic factors. Objective To evaluate demographic and clinical characteristics associated with tracheotomies performed by otolaryngologists compared with other specialists and to differentiate those factors from factors associated with use of open vs percutaneous tracheotomy. Design, Setting, and Participants This multicenter, retrospective cohort study included patients aged 18 years or older who underwent a tracheotomy for cardiopulmonary failure at 1 of 8 US academic institutions between January 1, 2013, and December 31, 2016. Data were analyzed from September 2022 to July 2023. Exposure Tracheotomy. Main Outcomes and Measures The primary outcome was factors associated with an otolaryngologist performing tracheotomy. The secondary outcome was factors associated with use of the open tracheotomy technique. Results A total of 2929 patients (mean [SD] age, 57.2 [17.2] years; 1751 [59.8%] male) who received a tracheotomy for cardiopulmonary failure (652 [22.3%] performed by otolaryngologists and 2277 [77.7%] by another service) were analyzed. Although 1664 of all tracheotomies (56.8%) were performed by an open approach, only 602 open tracheotomies (36.2%) were performed by otolaryngologists. Most tracheotomies performed by otolaryngologists (602 of 652 [92.3%]) used the open technique. Multivariable regression analysis revealed that self-reported Black race (odds ratio [OR], 1.89; 95% CI, 1.52-2.35), history of neck surgery (OR, 2.71; 95% CI, 2.06-3.57), antiplatelet and/or anticoagulation therapy (OR, 1.74; 95% CI, 1.29-2.36), and morbid obesity (OR, 1.54; 95% CI, 1.24-1.92) were associated with greater odds of an otolaryngologist performing tracheotomy. In contrast, history of neck surgery (OR, 1.36; 95% CI, 0.96-1.92), antiplatelet and/or anticoagulation therapy (OR, 0.80; 95% CI, 0.56-1.14), and morbid obesity (OR, 0.94; 95% CI, 0.74-1.19) were not associated with undergoing open tracheotomy when performed by any service, and Black race (OR, 0.56; 95% CI, 0.44-0.71) was associated with lesser odds of an open approach being used. Age-adjusted Charlson Comorbidity Index score greater than 4 was associated with greater odds of both an otolaryngologist performing tracheotomy (OR, 1.26; 95% CI, 1.03-1.53) and use of the open tracheotomy technique (OR, 1.48, 95% CI, 1.21-1.82). Conclusions and Relevance In this study, otolaryngologists were significantly more likely than other specialists to perform a tracheotomy for patients with history of neck surgery, morbid obesity, and ongoing anticoagulation therapy. These findings suggest that patients undergoing tracheotomy performed by an otolaryngologist are more likely to present with complex and challenging clinical characteristics.
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Affiliation(s)
- Shady I. Soliman
- Department of Otolaryngology, University of California San Diego, La Jolla
| | | | - David O. Francis
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Wisconsin, Madison
| | - John Pang
- Department of Otolaryngology–Head & Neck Surgery, Louisiana State University, Shreveport
| | - Dasha Klebaner
- Department of Otolaryngology, University of California San Diego, La Jolla
| | - Alicia Asturias
- Department of Otolaryngology, University of California San Diego, La Jolla
| | - Ali Alattar
- Department of Otolaryngology, University of California San Diego, La Jolla
| | - Samuel Wood
- Department of Otolaryngology, University of California San Diego, La Jolla
| | - Morgan Terry
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio
| | - Paul C. Bryson
- Department of Otolaryngology, Cleveland Clinic, Cleveland, Ohio
| | - Courtney B. Tipton
- Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Elise E. Zhao
- Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli O’Rourke
- Department of Otolaryngology–Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Chloe Santa Maria
- Department of Otolaryngology–Head & Neck Surgery, Stanford University, Palo Alto, California
| | - David R. Grimm
- Department of Otolaryngology–Head & Neck Surgery, Stanford University, Palo Alto, California
| | - C. Kwang Sung
- Department of Otolaryngology–Head & Neck Surgery, Stanford University, Palo Alto, California
| | - Wilson P. Lao
- Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Jordan M. Thompson
- Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Brianna K. Crawley
- Department of Otolaryngology–Head & Neck Surgery, Loma Linda University Health, Loma Linda, California
| | - Sarah Rosen
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, University of Wisconsin, Madison
| | - Anna Berezovsky
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Robbi Kupfer
- Department of Otolaryngology–Head & Neck Surgery, University of Michigan, Ann Arbor
| | - Theresa B. Hennesy
- Department of Otolaryngology–Head & Neck Surgery, University of Colorado School of Medicine, Aurora
| | - Matthew Clary
- Department of Otolaryngology–Head & Neck Surgery, University of Colorado School of Medicine, Aurora
| | - Ian T. Joseph
- Department of Otolaryngology–Head and Neck Surgery, UC Davis Health, Sacramento
| | - Kamron Sarhadi
- Department of Otolaryngology–Head and Neck Surgery, UC Davis Health, Sacramento
| | - Maggie Kuhn
- Department of Otolaryngology–Head and Neck Surgery, UC Davis Health, Sacramento
| | - Yassmeen Abdel-Aty
- Department of Otolaryngology–Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona
| | - Maeve M. Kennedy
- Department of Otolaryngology–Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona
| | - David G. Lott
- Department of Otolaryngology–Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona
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Update on Tracheostomy and Upper Airway Considerations in the Head and Neck Cancer Patient. Surg Clin North Am 2022; 102:267-283. [DOI: 10.1016/j.suc.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Powers B, Smith CD, Arroyo N, Francis DO, Fernandes-Taylor S. How Do Academic Otolaryngologists Decide to Implement New Procedures Into Practice? Otolaryngol Head Neck Surg 2021; 167:253-261. [PMID: 34546818 DOI: 10.1177/01945998211047434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To identify barriers and facilitators to adoption of a new surgical procedure via an implementation science framework to characterize associated socioemotional, clinical, and decision-making processes. STUDY DESIGN Qualitative study with a semistructured interview approach. SETTING Large tertiary care referral center. METHODS Academic otolaryngologists with at least 2 years of practice were identified and interviewed. Transcripts were thematically coded and separated into steps in the clinical pathway. Synthesis of major themes characterized facilitators and barriers to uptake of a new surgical technique. RESULTS Of 22 otolaryngologists, 19 were interviewed (85% male). They had a median 18 years of practice (interquartile range, 7.8-26.3), and 65% were subspecialty trained. In the decision to implement a new procedure, improving patient outcomes and addressing unmet clinical needs facilitated adoption, whereas costs and adopting profit-driven technologies without improved outcomes were barriers. In patient consults, establishing trust facilitated implementation of new techniques; barriers included participants' hesitation to communicate about the unknowns of a new procedure. Intraoperatively, little change to existing workflow or improved efficiency facilitated adoption, while a substantial learning curve for the new procedure was a barrier. Achieving favorable outcomes and patient satisfaction sustained implementation of new procedures. Too few referrals or indications for the new procedure hindered implementation. CONCLUSION Our study demonstrates that innovation in otolaryngology is often an individual iterative process that providers pursue to improve patients' outcomes. Although models for the oversight of surgical innovation emphasize the need for evidence, obtaining sufficient numbers of providers and patients to generate evidence remains a challenge in specialty surgical practice.
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Affiliation(s)
- Bethany Powers
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Cara Damico Smith
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Natalia Arroyo
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - David O Francis
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Henry LE, Paul EA, Atkins JH, Martin ND, Chalian AA, Rassekh CH. Institutional analysis of intra- and post-operative tracheostomy management for risk reduction. World J Otorhinolaryngol Head Neck Surg 2021; 8:370-377. [DOI: 10.1016/j.wjorl.2021.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 02/18/2021] [Indexed: 11/29/2022] Open
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Deonarain AR, Harrison RV, Gordon KA, Looi T, Agur AMR, Estrada M, Wolter NE, Propst EJ. Synthetic Simulator for Surgical Training in Tracheostomy and Open Airway Surgery. Laryngoscope 2021; 131:E2378-E2386. [PMID: 33452681 DOI: 10.1002/lary.29359] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) To create and validate a synthetic simulator for teaching tracheostomy and laryngotracheal reconstruction (LTR) using anterior costal cartilage and thyroid ala cartilage grafts. METHODS A late adolescent/adult neck and airway simulator was constructed based on CT scans from a cadaver and a live patient. Images were segmented to create three-dimensional printed molds from which anatomical parts were casted. To evaluate the simulator, expert otolaryngologists - head and neck surgeons performed tracheostomy and LTR using anterior costal cartilage and thyroid ala cartilage grafts on a live anesthetized porcine model (gold standard) followed by the synthetic simulator. They evaluated each model for face validity (realism and anatomical accuracy) and content validity (perceived effectiveness as a training tool) using a five-point Likert scale. For each expert, differences for each item on each simulator were compared using Wilcoxon Signed-Rank tests with Sidak correction. RESULTS Nine expert faculty surgeons completed the study. Experts rated face and content validity of the synthetic simulator an overall median of 4 and 5, respectively. There was no difference in scores between the synthetic model and the live porcine model for any of the steps of any of the surgical procedures. CONCLUSION The synthetic simulator created for this study has high face and content validity for tracheostomy and LTR with anterior costal cartilage and thyroid ala cartilage grafts and was not found to be different than the live porcine model for these procedures. LEVEL OF EVIDENCE 5 Laryngoscope, 131:E2378-E2386, 2021.
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Affiliation(s)
- Ashley R Deonarain
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Image Guided Innovation and Therapeutic Intervention (CIGITI), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Robert V Harrison
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Karen A Gordon
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Thomas Looi
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Canada.,Centre for Image Guided Innovation and Therapeutic Intervention (CIGITI), The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Anne M R Agur
- Division of Anatomy, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Marvin Estrada
- Laboratory Animal Services, The Hospital for Sick Children, Toronto, Canada
| | - Nikolaus E Wolter
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Evan J Propst
- Department of Otolaryngology-Head & Neck Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Canada.,Centre for Image Guided Innovation and Therapeutic Intervention (CIGITI), The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Deonarain AR, Harrison RV, Gordon KA, Wolter NE, Looi T, Estrada M, Propst EJ. Live porcine model for surgical training in tracheostomy and open‐airway surgery. Laryngoscope 2019; 130:2063-2068. [DOI: 10.1002/lary.28309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/16/2019] [Accepted: 09/03/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Ashley R. Deonarain
- Department of Otolaryngology–Head and Neck Surgery The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
- Centre for Image Guided Innovation and Therapeutic Intervention The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
- Institute of Biomaterials and Biomedical Engineering University of Toronto Toronto Ontario Canada
| | - Robert V. Harrison
- Department of Otolaryngology–Head and Neck Surgery The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
| | - Karen A. Gordon
- Department of Otolaryngology–Head and Neck Surgery The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
| | - Nikolaus E. Wolter
- Department of Otolaryngology–Head and Neck Surgery The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
| | - Thomas Looi
- Centre for Image Guided Innovation and Therapeutic Intervention The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
| | - Marvin Estrada
- Laboratory Animal Services The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
| | - Evan J. Propst
- Department of Otolaryngology–Head and Neck Surgery The Hospital for Sick Children, University of Toronto Toronto Ontario Canada
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Bowen AJ, Nowacki AS, Benninger MS, Lamarre ED, Bryson PC. Is tracheotomy on the decline in otolaryngology? A single institutional analysis. Am J Otolaryngol 2018; 39:97-100. [PMID: 29287719 DOI: 10.1016/j.amjoto.2017.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 12/20/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE A recent study reported decreasing trends in tracheotomy procedures by its otolaryngology service. We set out to determine whether the previously reported decrease in otolaryngology performed tracheotomies by one institution is a local or generalizable phenomenon. DESIGN Retrospective cohort study from 2010 to 2015. SETTING Tertiary care hospital and affiliated regional hospitals. SUBJECT AND METHODS All patients who received tracheotomy during the period of analysis were included. Performing specialty, surgical technique, and procedure location were recorded. Procedures were stratified by year and specialty to generate incidence rate ratios for otolaryngologists and non-otolaryngologists. Incidence rate ratios were estimated with negative binomial regression across services. RESULTS The otolaryngology service demonstrated a yearly decrease of 3.4% in the total number of tracheotomies (95% CI -7.9% to +1.4, P=0.17). While the thoracic service remained constant (+0.3%, 95% CI -2.6% to +3.3%, p=0.83), general surgery demonstrated the greatest increase in procedures (+4.4%, 95% CI -6.0% to +15.8%, P=0.42). Thoracic and general surgery both dramatically increased the number of percutaneous tracheotomies performed, with general surgery also performing a greater number of bedside procedures. CONCLUSIONS AND RELEVANCE We observed a similar decline in the number of tracheotomies otolaryngology over six years. Our trend is likely due to changes in consultations patterns, increasing use of the percutaneous method, and an increase in adjunctive gastrostomy tube placements. Investigations on the impact of a greater number of non-otolaryngology performed tracheotomies on follow up care is warranted.
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Open tracheostomy training: a nationwide survey among Otolaryngology-Head and Neck Surgery residents. Eur Arch Otorhinolaryngol 2017; 274:4035-4042. [PMID: 28936545 DOI: 10.1007/s00405-017-4751-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022]
Abstract
The aim of this study was to examine the training methods and needs of Otolaryngology-Head and Neck Surgery (OTO-HNS) residents to independently perform open tracheostomy (OT). An anonymous 26-items questionnaire pertaining to OT teaching aspects was distributed to all 93 Israeli OTO-HNS residents during March-June 2016. Residents were categorized as 'juniors,' if they were in their post-graduate year (PGY)-1 and PGY-2; 'mid-residency' (PGY-3 and PGY-4); or 'seniors' (PGY-5 and PGY-6). Response rate was 74% (n = 69). There were 25 'juniors' (36%), 24 'mid-residency' (35%) and 20 'seniors' (29%). Overall, the responses of the 3 groups were similar. Forty-seven (68%) residents estimated that there are ≥ 50 tracheostomies/year in their hospital, which roughly corresponds to an exposure of ~ 8 tracheostomies/year/resident. There was an inconsistency between the number of teaching hours given and the number of hours requested for OT training (23% received ≥ 5 h, but 82% declared they needed ≥ 5 h). Eighty-two percentage reported that their main training was conducted during surgery with peer residents or senior physicians. Forty-five (65%) feel competent to perform OT, including juniors. Due to the need to perform OT in urgent scenarios, the competency of OTO-HNS resident is crucial. Training for OT in Israeli OTO-HNS residency programs is not well structured. Yet, residents reported they feel confident to perform OT, already in the beginning of their residency. Planned educational programs to improve OT training should be done in the beginning of the residency and may include designated 'hands-on' platforms; objective periodic surgical competence assessments; and specialist's feedback, using structured assessment forms.
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Lesko D, Showmaker J, Ukatu C, Wu Q, Chang CWD. Declining Otolaryngology Resident Training Experience in Tracheostomies: Case Log Trends from 2005 to 2015. Otolaryngol Head Neck Surg 2017; 156:1067-1071. [DOI: 10.1177/0194599817706327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To evaluate recent tracheostomy surgical experience among otolaryngology residents and general surgery residents. Study Design Retrospective database review. Setting Accreditation Council for Graduate Medical Education otolaryngology and general surgery programs. Subjects and Methods Accreditation Council for Graduate Medical Education case log data from 2005 to 2015 for resident graduates in otolaryngology and general surgery were used to obtain mean graduate tracheostomy numbers, mean graduate composite case numbers, and number of graduating residents. Market share for each specialty was estimated through the derived metric of nationwide total tracheostomy graduate experience, calculated by multiplying the number of graduating residents by the mean number of graduate tracheostomies. Linear regression analysis was used to calculate trends. Multiple linear regression analysis was used for pairwise comparison of trends. Results From 2005 to 2015, mean graduate tracheostomy numbers for otolaryngology residents declined 2.3% per year, while those for general surgery residents increased 1.8% per year. Accounting for changes in number of resident graduates, market share of tracheostomy decreased 1.0% per year for otolaryngology and increased 3.0% per year for general surgery. Mean graduate composite case numbers increased significantly by 1.8% and 1.0% per year for otolaryngology and general surgery residents, respectively. Conclusion Tracheostomy case volume in otolaryngology residency has decreased steadily in comparison with general surgery residency. However, current otolaryngology graduates have more experience in tracheostomy when compared with general surgery graduates. While otolaryngology residents have excellent exposure to tracheostomy, otolaryngology programs should be made aware of this declining trend as well as changing procedural trends, which may affect training needs.
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Affiliation(s)
- David Lesko
- University of Missouri, Columbia, Missouri, USA
| | - Jason Showmaker
- Capital Region Medical Center, Jefferson City, Missouri, USA
| | | | - Qiwei Wu
- University of Missouri, Columbia, Missouri, USA
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Pollock RA. Percutaneous Tracheostomy and Percutaneous Angiography: The Diuturnity of Sven-Ivar Seldinger of Mora, Pasquale Ciaglia of Utica. Craniomaxillofac Trauma Reconstr 2016; 9:323-334. [PMID: 27833711 PMCID: PMC5101119 DOI: 10.1055/s-0036-1584526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
In the latter part of the 20th century, three developments intersected: skin-to-artery catheterization, percutaneous tracheostomy, and market introduction of video-chip camera-tipped endoscopes. By the millennium, every vessel within the body could be visualized radiographically, and percutaneous tracheostomy (with tracheal-ring "dilation," flawless high-resolution intratracheal video-imagery, and tracheal intubation) could consistently be achieved at the patient's bedside. Initiated through the skin and abetted by guide-wire insertion, these procedures are the lasting gifts of Sven-Ivar Seldinger (1921-1998) of Mora, Sweden, and Pasquale Ciaglia (1912-2000) of Utica, New York. Physicians and surgeons managing intracranial, craniofacial, and maxillofacial injury are among those honoring the Seldinger-Ciaglia "collaboration."
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Affiliation(s)
- Richard A. Pollock
- Lancaster Regional Medical Center, Lancaster, Pennsylvania
- Heart of Lancaster Regional Medical Center, Lititz, Pennsylvania
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Krouse JH. Highlights from the Current Issue: March 2015. Otolaryngol Head Neck Surg 2015; 152:379-380. [PMID: 29130852 DOI: 10.1177/0194599815568963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John H Krouse
- 1 Temple University, Philadelphia, Pennsylvania, USA
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