Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training

Importance

Prior studies demonstrate a high prevalence of burnout and depression among surgeons. Limited data exist regarding how these conditions are perceived by the surgical community.

Objectives

To measure prevalence of burnout and depression among general surgery trainees and to characterize how residents and attendings perceive these conditions.

Design, Setting, and Participants

This cross-sectional study used unique, anonymous surveys for residents and attendings that were administered via a web-based platform from November 1, 2016, through March 31, 2017. All residents and attendings in the 6 general surgery training programs in North Carolina were invited to participate.

Main Outcomes and Measures

The prevalence of burnout and depression among residents was assessed using validated tools. Burnout was defined by high emotional exhaustion or depersonalization on the Maslach Burnout Inventory. Depression was defined by a score of 10 or greater on the Patient Health Questionnaire-9. Linear and logistic regression models were used to assess predictive factors for burnout and depression. Residents' and attendings' perceptions of these conditions were analyzed for significant similarities and differences.

Results

In this study, a total of 92 residents and 55 attendings responded. Fifty-eight of 77 residents with complete responses (75%) met criteria for burnout, and 30 of 76 (39%) met criteria for depression. Of those with burnout, 28 of 58 (48%) were at elevated risk of depression (P = .03). Nine of 77 residents (12%) had suicidal ideation in the past 2 weeks. Most residents (40 of 76 [53%]) correctly estimated that more than 50% of residents had burnout, whereas only 13 of 56 attendings (23%) correctly estimated this prevalence (P < .001). Forty-two of 83 residents (51%) and 42 of 56 attendings (75%) underestimated the true prevalence of depression (P = .002). Sixty-six of 73 residents (90%) and 40 of 51 attendings (78%) identified the same top 3 barriers to seeking care for burnout: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care.

Conclusions and Relevance

The prevalence of burnout and depression was high among general surgery residents in this study. Attendings and residents underestimated the prevalence of these conditions but acknowledged common barriers to seeking care. Discrepancies in actual and perceived levels of burnout and depression may hinder wellness interventions. Increasing understanding of these perceptions offers an opportunity to develop practical solutions.

Ventilator-Associated Pneumonia in Trauma Patients: Different Criteria, Different Rates

BACKGROUND

No consensus exists regarding the definition of ventilator-associated pneumonia (VAP). Even within a single institution, inconsistent diagnostic criteria result in conflicting rates of VAP. As a Level 1 trauma center participating in the Trauma Quality Improvement Project (TQIP) and the National Healthcare Safety Network (NHSN), our institution showed inconsistencies in VAP rates depending on which criteria was applied. The purpose of this study was to compare VAP definitions, defined by culture-based criteria, National Trauma Data Bank (NTDB) and NHSN, using incidence in trauma patients.

METHODS

A retrospective chart review of consecutive trauma patients who were diagnosed with VAP and met pre-determined inclusion and exclusion criteria admitted to our rural, 861-bed, Level 1 trauma and tertiary care center between January 2008 and December 2011 was performed. These patients were identified from the National Trauma Registry of the American College of Surgeons (NTRACS) database and an in-house infection control database. Ventilator-associated pneumonia diagnosis criteria defined by the U.S. Center for Disease Control and Prevention (used by the NHSN), the NTDB, and our institutional, culture-based criteria gold standard were compared among patients.

RESULTS

Two hundred seventy-nine patients were diagnosed with VAP (25.4% met NHSN criteria, 88.2% met NTDB, and 76.3% met culture-based criteria). Only 58 (20.1%) patients met all three criteria. When NHSN criteria were compared with culture-based criteria, NHSN showed a high specificity (92.5%) and low sensitivity (28.2%). The positive predictive value (PPV) was 84.5%, but the negative predictive value (NPV) was 47.1%. The agreement between the NHSN and the culture-based criteria was poor (κ = 0.18). Conversely, the NTDB showed a lower specificity (57.8%), but greater sensitivity (86.4%) compared with culture-based criteria. The PPV and NPV were both 74% and the two criteria showed fair agreement (κ = 0.41).

CONCLUSIONS

The lack of standard diagnostic criteria for VAP resulted in variable reporting to different agencies. Emphasis on establishing a consensus VAP definition should be undertaken.

Milestones: The Road to Faculty Development

PURPOSE

Milestones for the assessment of residents in graduate medical education mark a change in our evaluation paradigms. The Accreditation Council for Graduate Medical Education has created milestones and defined them as significant points in development of a resident based on the 6 competencies. We propose that a similar approach be taken for resident assessment of teaching faculty. We believe this will establish parity and objectivity for faculty evaluation, provide improved data about attending surgeons' teaching, and standardize faculty evaluations by residents.

METHODS

A small group of advanced surgery educators determined appropriate educational characteristics, resulting in creation of 11 milestones (Fig. 2) that were reviewed by faculty and residents. The residents have historically answered 16 questions, developed by our surgical education committee (Fig. 3), on a 5-point Likert score (never to very often). Three weeks after completing this Likert-type evaluation, the residents were asked to again evaluate attending faculty using the Faculty Milestones evaluation. The residents then completed a survey of 7 questions (scale of 1-9-disagree to strongly agree, neutral = 5), assessing the new milestones and compared with the previous Likert evaluation system.

RESULTS

Of 32 surgery residents, 13 completed the Likert evaluations (3760 data points) and 13 completed the milestones evaluations (1800 data points). The number completing both or neither is not known, as the responses are anonymous when used for faculty feedback. The Faculty Milestones attending physicians' scores have far fewer top of range scores (21% vs 42%) and have a wider spread of data giving better indication of areas for improvement in teaching skills. The residents completed 17 surveys (116 responses) to evaluate the new milestones system. Surveys indicated that milestones were easier to use (average rating 6.13 ± 0.42 Standard Error (SE)), effective (6.82 ± 0.39) and efficient (6.11 ± 0.53), and more objective (6.69 ± 0.39/6.75 ± 0.38) than the Likert evaluations are. Average response was 6.47 ± 0.46 for overall satisfaction with the Faculty Milestones evaluation. More surveys were completed than evaluations, as all residents had an opportunity to review both evaluation systems.

CONCLUSIONS

Faculty Milestones are more objective in evaluating surgical faculty and mirror the new paradigm in resident evaluations. Residents found this was an easier, more effective, efficient, and objective evaluation of our faculty. Although our Faculty Milestones are designed for surgical educators, they are likely to be applicable with appropriate modifications to other medical educators as well.

Maggot Therapy for Elephantiasis Nostras Verrucosa Reveals New Applications and New Complications: A Case Report

Elephantiasis nostras verrucosa (ENV) is a rare dermatologic condition caused by chronic nonfilarial lymphedema. The treatment for ENV is challenging and based solely on case reports. We report novel therapy for ENV with maggot debridement therapy (MDT), an effective wound therapy that has gained popularity with the rise of antimicrobial resistance. MDT, in combination with tangential surgical debridement, was effective in the treatment of ENV. In nature, sheep infested with more than 16 000 blow fly larvae exhibit ammonia toxicity. Although hyperammonemia as a side effect of maggot therapy has been theorized, its existence has not been described in human studies until this case. This patient exhibited hyperammonemia during maggot therapy; with alterations in serum ammonia reflecting changes in larval population. Maggot therapy should be considered for the treatment of ENV. Hyperammonemia with maggot therapy exists, and clinicians who employ this treatment should be aware of this potential adverse effect.

An Objective Study of the Impact of the Electronic Medical Record on Outcomes in Trauma Patients

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

An objective study of the impact of the electronic medical record on outcomes in trauma patients

It is commonly believed that the electronic medical record (EMR) will improve patient outcomes. However, there is scant published literature to support this claim and no studies in any surgical population. Our hypothesis was that the EMR would not improve objective outcome measures in patients with traumatic injury. Prospectively collected data from our university-based Level I trauma center was retrospectively reviewed. Demographic, injury severity as well as outcomes and complications data were compared for all patients admitted over a 20-month period before introduction of the EMR and a 20-month period after full, hospital-wide use of the EMR. Implementation of the EMR was associated with a decreased hospital length of stay, P = 0.02; intensive care unit length of stay, P = 0.001; ventilator days, P = 0.002; acute respiratory distress syndrome, P = 0.006, pneumonia, P = 0.008; myocardial infarction, P = 0.001; line infection, P = 0.03; septicemia, P = 0.000; renal failure, P = 0.000; drug complication, P = 0.001; and delay in diagnosis, P = 0.04. There was no difference in mortality, unexpected cardiac arrest, missed injury, pulmonary embolism/deep vein thrombosis, or late urinary tract infection. This is the first study to investigate the impact of the EMR in surgical patients. Although there was an improvement in some complications, the overall impact was inconsistent.

Physician behavior: not ready for 'Never'land

Disruptive physician behavior, particularly by surgeons, is a common perception. Increasing awareness and regulatory oversight is being felt in medical practice; however, little data exist regarding the frequency of these behaviors. This study was undertaken to determine the prevalence and type of reported behavioral issues. Blinded data for 2 years of physician behavior reports were reviewed for department, gender, event summary, and peer review conclusions. Chi-square analysis was used with statistical significance at P < 0.05. One hundred ninety-one behavior issues were reported in our 751-bed hospital, which employs 640 active physicians. One hundred fourteen (18%) physicians were reported. Forty-four (7%) physicians had multiple reports, accounting for 121 (63%) reports. Twenty-seven physicians were reported twice, eight 3 times, four 4 times, three 5 times, and one 6 times. Multiple-report physicians compared with single-report physicians showed no difference in distribution of outcomes, but more communication issues and fewer unacceptable behaviors. Specialty groups with a higher incidence of reported behaviors included anesthesia, cardiology, hospitalists, orthopedics, trauma, and obstetrics/gynecology. Female physicians were less likely to be reported. Staff reports were mainly against physicians within their hospital practice area (75 of 94 [80%]), whereas physician reports were mainly against physicians outside their practice area (18 of 25 [72%]). Disruptive physician behavior is variable and culturally defined. Although all reports should be taken seriously, fewer than 1 per cent of reported incidents were found to be definably disruptive and valid. As quality and oversight groups consider making disruptive physician behavior a "never" event, firm definitions and full peer review are mandatory.

Physician Behavior: Not Ready for ‘Never'land

Disruptive physician behavior, particularly by surgeons, is a common perception. Increasing awareness and regulatory oversight is being felt in medical practice; however, little data exist regarding the frequency of these behaviors. This study was undertaken to determine the prevalence and type of reported behavioral issues. Blinded data for 2 years of physician behavior reports were reviewed for department, gender, event summary, and peer review conclusions. Chi-square analysis was used with statistical significance at P < 0.05. One hundred ninety-one behavior issues were reported in our 751-bed hospital, which employs 640 active physicians. One hundred fourteen (18%) physicians were reported. Forty-four (7%) physicians had multiple reports, accounting for 121 (63%) reports. Twenty-seven physicians were reported twice, eight 3 times, four 4 times, three 5 times, and one 6 times. Multiple-report physicians compared with single-report physicians showed no difference in distribution of outcomes, but more communication issues and fewer unacceptable behaviors. Specialty groups with a higher incidence of reported behaviors included anesthesia, cardiology, hospitalists, orthopedics, trauma, and obstetrics/gynecology. Female physicians were less likely to be reported. Staff reports were mainly against physicians within their hospital practice area (75 of 94 [80%]), whereas physician reports were mainly against physicians outside their practice area (18 of 25 [72%]). Disruptive physician behavior is variable and culturally defined. Although all reports should be taken seriously, fewer than 1 per cent of reported incidents were found to be definably disruptive and valid. As quality and oversight groups consider making disruptive physician behavior a “never” event, firm definitions and full peer review are mandatory.

Open fractures: it doesn't come out in the wash

BACKGROUND

Six hours from injury to washout is considered the gold standard in the treatment of open traumatic fractures. Despite this being our hospital policy, the rural nature of our Level I trauma center causes delays in discovery and transport, creating a unique randomization of time to washout. We hypothesized that orthopedic complications after open fractures are related to the severity of the fractures, not the timing of the washout.

METHODS

Patients and fractures were reviewed retrospectively over 6.3 years, evaluating for demographics, injury severity, location of fracture, mechanism of injury, Gustilo fracture grade, and time from injury to initial washout. Orthopedic wound complication rates were compared using logistic regression.

RESULTS

A total of 1,487 open fractures in 1,278 patients were reviewed. Time from injury to washout was 26 to 4,749 min (mean, 510 min), with 48 patients having no washout. Overall, 8.2% of fractures (n=122) had an orthopedic complication, rates of which increased with severity (Injury Severity Score, Abbreviated Injury Score [AIS], and Gustilo class) and blunt injuries but were not related to time to washout. Penetrating injuries showed no difference in complication rates according to time to washout. Lower extremity fractures had a higher rate of complications than those of the upper extremity (odds ratio 2.2), likely because of differences in fracture grade. By multivariable logistic regression, only fracture grade, Revised Trauma Score (RTS), and male gender were independent predictors of wound complications; penetrating trauma was predictive of low risk. Time to washout was not an independent predictor of wound complications.

CONCLUSIONS

Although grossly contaminated fractures should not be left unattended, the degree of initial injury, as judged by fracture grade and physiology (RTS), was predictive of orthopedic wound complications, whereas time to washout was not. Hence, there is little benefit of washout in Gustilo grade 1/AIS 1 fractures or penetrating injuries, regardless of grade, and adherence to a specific time to washout is not beneficial.

Running out of gas but not trauma patients: the effect of the price of gas on trauma admissions

As fuel costs steadily rise and motor vehicle collisions continue to be a leading cause of morbidity and mortality, we examined the relationship between the price of gasoline and the rate of trauma admissions related to gasoline consumption (GRT). The National Trauma Registry of the American College of Surgeons data of a rural Level I trauma center were queried over 27 consecutive months to identify the rate of trauma admissions/month related to gas utilization compared with the number of nongasoline related trauma admissions, based on season and day of the week. The average price/gallon of regular gas in our region was obtained from the NorthCarolinaGasPrices. com database. A log linear model with a Poisson distribution was created. No significant association exists between the average price/gallon of gasoline and the GRT rate across the months, seasons, and weekday and weekend periods. As the price of gas continues to rise, the rate of rural GRT does not decrease. Over a longer period of time and with skyrocketing prices, this relationship may not hold true. These findings may also be explained by the rural area where limited alternative transportation opportunities exist and a trauma patient population participating in high risk behavior regardless of cost.

Running Out of Gas but not Trauma Patients: The Effect of the Price of Gas on Trauma Admissions

As fuel costs steadily rise and motor vehicle collisions continue to be a leading cause of morbidity and mortality, we examined the relationship between the price of gasoline and the rate of trauma admissions related to gasoline consumption (GRT). The National Trauma Registry of the American College of Surgeons data of a rural Level I trauma center were queried over 27 consecutive months to identify the rate of trauma admissions/month related to gas utilization compared with the number of nongasoline related trauma admissions, based on season and day of the week. The average price/gallon of regular gas in our region was obtained from the NorthCarolinaGasPrices. com database. A log linear model with a Poisson distribution was created. No significant association exists between the average price/gallon of gasoline and the GRT rate across the months, seasons, and weekday and weekend periods. As the price of gas continues to rise, the rate of rural GRT does not decrease. Over a longer period of time and with skyrocketing prices, this relationship may not hold true. These findings may also be explained by the rural area where limited alternative transportation opportunities exist and a trauma patient population participating in high risk behavior regardless of cost.

High-frequency oscillatory ventilation as a rescue therapy for adult trauma patients

BACKGROUND

High-frequency oscillatory ventilation is an alternative ventilation mode that improves oxygenation in trauma patients in whom conventional ventilation strategies have been unsuccessful.

OBJECTIVE

To evaluate the effect of high-frequency oscillatory ventilation on oxygenation, survival, and parameters predictive of survival in trauma patients.

METHODS

A retrospective case series of 24 adult patients admitted to the trauma intensive care unit at a level I trauma center between November 2001 and July 2005 and treated with high-frequency oscillatory ventilation. Survivors and nonsurvivors were compared for mechanism and severity of injury, oxygenation parameters related to high-frequency oscillatory ventilation, and hospital course.

RESULTS

Of the 8577 patients admitted during the study period, acute respiratory distress syndrome developed in 103 (1%). Of those 103 patients, 24 (23%) were treated with high-frequency oscillatory ventilation. Most of the patients treated with high-frequency oscillatory ventilation had sustained blunt trauma (79%). Oxygenation parameters improved significantly with high-frequency oscillatory ventilation in all patients, regardless of survival. Of the 24 patients treated with this ventilation mode, 15 (62%) survived. Survival did not correlate with improved oxygenation parameters but with the number of failed organ systems and injury severity.

CONCLUSION

Although high-frequency oscillatory ventilation improves oxygenation, severity of traumatic injury and organ failure, not respiratory parameters, are predictors of survival. High-frequency oscillatory ventilation should be considered for pulmonary rescue of severely injured patients with acute respiratory distress syndrome.

Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf?

INTRODUCTION

Trauma patients with hypotension in the field who arrive at a hospital with a normal blood pressure (BP) may not be recognized as significantly injured.

METHODS

Over a 5-year period, demographic, injury severity, and disposition data were retrospectively analyzed for patients > or =16 years of age with documented hypotension in the field (systolic BP < or =90 mm Hg) and normal BP (systolic BP >90 mmHg) on hospital arrival (hypotensive group). This group was compared to patients with normal BP in the field and on hospital arrival (normotensive group).

RESULTS

During the study, 2207 patients with documented BP were transported directly from the scene. Of this number 44 (2%) were assigned to the hypotensive group, 2086 (94%) were assigned to the normotensive group, and 77 (4%) patients were hypotensive on hospital arrival. The hypotensive group had a systolic BP in the field of 70 +/- 26 mmHg compared to 140 +/- 26 mmHg in the normotensive group (p < 0.0001). Arrival BP at the hospital was normal in both groups. Compared to the normotensive group, the hypotensive group had higher Injury Severity Scores (22.0 vs. 11.1, p < 0.0001), lower Glasgow Coma Scores (10.8 vs. 14.0, p < 0.0001), lower Revised Trauma Scores (65 vs. 7.4, p < 0.0O01), more emergency department deaths (7% vs. 0%, p < 0.001), longer lengths of stay in the intensive care unit (8.6 vs. 7.0 days, p < 0.0001) and hospital (14.0 vs. 7.0 days, p < 0.0001), and increased hospital mortality (18% vs. 4%, p < 0.001).

LIMITATIONS

The retrospective design and exclusion of patients without documentation of BP in the field may have resulted in selection bias.

CONCLUSION

Despite these limitations, field hypotension is a marker of significant injury in patients arriving at the hospital normotensive.

Impact of Acute Care General Surgery Coverage by Trauma Surgeons on the Trauma Patient

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days ( P < 0.0001), intensive care unit length of stay ( P < 0.0001), and hospital length of stay ( P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.

Impact of acute care general surgery coverage by trauma surgeons on the trauma patient

Although acute care general surgery (ACS) coverage by trauma surgeons may help re-invigorate the field of trauma surgery, introducing additional responsibilities to an already overburdened system may negatively impact the trauma patient. Our purpose was to determine the impact on the trauma patient of a progressive integration of ACS coverage into a trauma service. Data from a university, Level I trauma registry was retrospectively reviewed to compare demographics, injury severity, complications, and outcomes over a 6-year period. During this study period, the trauma service treated only trauma patients for 32 months, then added ACS coverage 2 days per week for 32 months, and then expanded to 4 days per week coverage for 9 months. Trauma patients admitted during periods of ACS coverage were not different with respect to gender, mechanism of injury, Revised Trauma Score, or Glasgow Coma Score; however, they were slightly older and had slightly higher injury severity scores. As ACS coverage progressively increased, trauma patients had an increase in ventilator days (P < 0.0001), intensive care unit length of stay (P < 0.0001), and hospital length of stay (P < 0.0001). Occurrences of neurologic, pulmonary, gastrointestinal, and infectious complications were similar during all three time periods, whereas cardiac and renal complications progressively increased after ACS coverage was added. Mortality remained unchanged after ACS integration.

Morbidity Reduction in Critically Ill Trauma Patients Through use of a Computerized Insulin Infusion Protocol: A Preliminary Study

BACKGROUND

Recent data have demonstrated that intensive glycemic control during critical illness improves outcome. The purpose of our study was to evaluate the effect of a computerized hospital insulin protocol (CHIP) on glycemic control and outcome in critically ill trauma patients.

METHODS

Two, 6-month cohorts were compared, one 6 months prior to chip implementation (pre-CHIP) and one from the 6-month period after implementation (post-CHIP), using finger stick blood glucose values and demographic, injury severity, and outcome variables for adult patients with intensive care unit length of stay (LOS) > or =72 hours. Infectious morbidity was based upon the National Trauma Registry of the American College of Surgeons definitions. Differences between cohorts were assessed using Student's t test and Fisher's exact test for continuous and categorical variables.

RESULTS

The 129 pre- and 128 post-CHIP patients were well matched for demographics and injury severity. Significant reductions in mean finger stick blood glucose, rates of ventilator- associated pneumonia, central venous line infection, total infections, and all LOS categories were demonstrated in the post-CHIP cohort. However, mortality was significantly higher in the post-CHIP cohort.

CONCLUSION

This preliminary study demonstrates significant morbidity and LOS reductions with the use of a CHIP, but significantly increased mortality. Further prospective studies are necessary to assess the effects of intensive glycemic control on outcome after injury, particularly in sub populations who might be adversely affected.

Body Mass Index and Outcomes in Critically Injured Blunt Trauma Patients: Weighing the Impact

BACKGROUND

The influence of increased body mass index (BMI) on morbidity and mortality in critically injured trauma patients has been studied, with conflicting results. The objective of this study was to investigate the relationship between stratified BMI and outcomes in blunt injured patients.

STUDY DESIGN

Consecutive adult trauma patients from July 2001 to November 2005 with Injury Severity Score (ISS) > or = 16 and blunt mechanism were evaluated using the National Trauma Registry of the American College of Surgeons. Demographics, injury severity, hospital course, complications, and mortality were compared among standard BMI strata. Logistic regression was used to determine odds ratios (OR) with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity and mortality. Statistical significance was set at p < 0.05.

RESULTS

The study group consisted of 1,543 patients. Controlling for age, gender, Injury Severity Score, and Revised Trauma Score, and using BMI 18.5 to 24.9 kg/m(2) as the reference category, morbid obesity (BMI> or =40 kg/m(2)) was associated with acute respiratory distress syndrome (OR 3.675, 95% CI, 1.237 to 10.916), acute respiratory failure (OR 2.793, 95% CI, 1.633 to 4.778), acute renal failure (OR 13.506, 2.388 to 76.385), multisystem organ failure (OR 2.639, 95% CI, 1.085 to 6.421), pneumonia (OR 2.487, 95% CI, 1.483 to 4.302), urinary tract infection (OR 2.332, 95% CI, 1.229 to 4.427), deep venous thrombosis (OR 4.112, 95% CI, 1.253 to 13.496), and decubitus ulcer (OR 2.841, 95% CI, 1.382 to 5.841). Morbid obesity was not associated with increased mortality (OR 0.810, 95% CI, 0.353 to 1.856).

CONCLUSIONS

This is the largest study to date evaluating the relationship between BMI and outcomes in critically injured trauma patients. Increasing BMI increases morbidity while having no proved influence on mortality.

Alcohol withdrawal syndrome: Turning minor injuries into a major problem

BACKGROUND

Abrupt cessation of chronic drinking patterns places hospitalized patients at risk for alcohol withdrawal syndrome (AWS). The purpose of this study was to investigate the effect of AWS on length of stay, morbidity, mortality, and cost in low injury acuity trauma patients.

METHODS

A retrospective review of the National Trauma Registry of the American College of Surgeons database from July 1999 to February 2004 was performed. All patients 15 years or older admitted to our Level I trauma center with an Injury Severity Score (ISS) <16 were included. AWS patients were compared with those without AWS. Demographics, mechanism of injury (MOI), ISS, revised trauma score, Glasgow Coma score, hospital course, morbidity, requirement of additional procedures, mortality, and cost were compared. Analysis was done with chi2 test and Student's t test. A p value of < or =0.05 determined significance.

RESULTS

Of 6,431 patients, 55 (0.9%) developed AWS. AWS patients were likely men (p < 0.001); had a higher ISS (p = 0.001) and lower Glasgow Coma score (p = 0.01); had more ventilator days (p = 0.008), intensive care unit days (p < 0.0001), and hospital days (p < 0.0001); suffered more complications, including respiratory failure (p < 0.0001), pneumonia (p < 0.0001), urinary tract infection (p = 0.0005), sepsis (p < 0.0001), tracheostomy (p < 0.0001), and percutaneous endoscopic gastrostomy (p < 0.0001); and had higher cost (p < 0.0001). Mortality was similar (p = 0.38) among groups.

CONCLUSIONS

Low injury acuity patients with AWS have increased morbidity, leading to increased hospital stay and cost. To allow minor injuries to remain minor problems, the best modality to identify patients at risk and to achieve AWS prophylaxis require further investigation.

A Collaborative Systems Approach to Rural Burn Care

A collaborative systems approach was created between the regional verified burn center (BC) and the rural verified Level 1 trauma center (TC) to treat minor burns. This study assesses the feasibility of providing outpatient burn care at the TC. A retrospective review was performed from January 2000 to June 2005 of burn patients seen at the TC. Seven trauma/critical care surgeons and a dedicated burn nurse staffed the clinic twice a week. Burn surgeons from the BC provided consultation via email and telephone links and served as the regional resource. In the TC clinic, 314 injuries occurred in 311 patients. 196 patients were male with an average age of 34.5 +/- 1.1 years. The mean burn TBSA was 2.9 +/- 0.2%. Fourteen patients (4%) required skin grafts. Patients averaged 3.5 +/- 0.1 clinic visits over a mean follow-up period of 42.9 +/- 7.4 days from initial injury. There were 1252 scheduled appointments during the study period. Silver sulfadiazine or triple antibiotic ointment was applied in the majority of the cases. Thirty-one patients (9.9%) were documented to have complications, most of which were local wound infections. Long-term sequelae (scarring, chronic pain, and contractures) occurred in 13.4% of patients. Clinical success in outpatient burn care can be achieved at a non burn center with dedicated personnel. The successful collaboration between the BC and TC can unload some minor burn care from the burn center, while providing good clinical care to the local rural population.

Low-dose dopamine: a physiologically based review

BACKGROUND

In an attempt to prevent or alter the course of acute renal failure, many surgeons continue to use low-dose dopamine. This article critically reviews the physiologic reasons why low-dose dopamine is not clinically efficacious.

METHODS

A critical review of English language literature.

RESULTS

The effect of dopamine on renal blood flow remains controversial. If dopamine does increase renal blood flow, the vascular anatomy of the kidney would limit its effectiveness. Rather than improving renal function, dopamine has been shown to impair renal oxygen kinetics, inhibit feedback systems that protect the kidney from ischemia, and may worsen tubular injury. Dopamine has not been proven useful in the prevention or alteration of the course of acute renal failure as a result of heart failure, cardiac surgery, abdominal aortic surgery, sepsis, and transplantation. Dopamine has been associated with multiple complications involving the cardiovascular, pulmonary, gastrointestinal, endocrine, and immune systems.

CONCLUSIONS

Based on the anatomy and physiology of the kidney, low-dose dopamine would not be expected to improve renal failure and this has been demonstrated by the lack of efficacy in clinical trials.

Predicting the Need for Early Tracheostomy: A Multifactorial Analysis of 992 Intubated Trauma Patients

BACKGROUND

Tracheostomy has few, severe risks, while prolonged endotracheal intubation causes morbidity. The need for tracheostomy was assessed, based on early clinical parameters.

METHODS

Adult trauma patients (January 1994-August 2004), intubated for resuscitation, ventilated >24 hours, were retrospectively evaluated for demographics, physiology, brain, and pulmonary injury. Tracheostomy patients were compared with those without. Chi-square, Mann-Whitney, and multivariate logistic regression were used with statistical significance at p < 0.05.*

RESULTS

Of 992 patients, 430 (43%) underwent tracheostomy at 9.22 +/- 5.7 days. Risk factors were age (45.6* +/- 18.8 vs. 36.7 +/- 15.9, OR: 2.1 (18 years increments), ISS (30.3* +/- 12.5 vs. 22.0 +/- 10.3, OR: 2.1 (12u increments), damage control (DC) [68%*(n = 51) vs. 32%*(n = 51), OR: 3.8], craniotomy [70%*(n = 21) versus 30%(n = 9), OR: 2.6], and intracranial pressure monitor (ICP) [65.4%*(n = 87) vs. 34.6%(n = 46), OR: 2.1]. A 100% tracheostomy rate (n = 30, 3.0%) occurred with ISS (injury severity score) = 75, ISS >or=50, and age >or=55, admit/24 hour GCS (Glasgow Coma Scale) = 3 and age >or=70, AIS abdomen, chest or extremities >or=5 and age >or=60, bilateral pulmonary contusions (BPC) and >or=8 rib fractures, craniotomy and age >or=50, craniotomy with intracranial pressure (ICP) and age >or=40, or craniotomy and GCS <or=4 at 24 hour.A tracheostomy rate of >or=90% (n = 105, 10.6%) was found with ISS >or=54, ISS >or=40, and age >or=40, admit/24 hour GCS = 3 and age >or=55, paralysis and age >or=40, BPC and age >or=55.A tracheostomy rate >or=80% (n = 248, 25.0%) occurred with ISS >or=38, age >or=80, admit/24 hour GCS = 3 and age >or=45, DC and age >or=50, BPC and age >or=50, aspiration and age >or=55, craniotomy with ICP, craniotomy with GCS <or=9 at 24 hour.

CONCLUSION

Discrete risk factors predict the need for tracheostomy for trauma patients. We recommend that patients with >or=90% risk undergo early tracheostomy and that it is considered in the >or=80% risk group to potentially decreased morbidity, increased patient comfort, and optimize resource utilization.

Language barrier leads to the unnecessary intubation of trauma patients

Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. A 9-year retrospective review was performed using the National Trauma Registry for The American College of Surgeons (NTRACS) database. We evaluated patients intubated on arrival to the trauma center and remaining intubated for less than 48 hours. Deaths were excluded. Patients who typically speak English were compared with patients who typically speak Spanish. Mechanism of injury (MOI), hypotension during resuscitation (HDR), illicit substance use, alcohol use, mean Glasgow Coma Score (GCS), mean Injury Severity Score (ISS), payer source, and hospital cost were compared. Forty-nine per cent and 38 per cent of Spanish and English speaking individuals, respectively, were intubated for less than 48 hours (P = 0.072). MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.

Language Barrier Leads to the Unnecessary Intubation of Trauma Patients

Airway evaluation in trauma patients is performed immediately upon patient contact, with communication being a vital component to this exam. Language and communication barriers may lead to the unnecessary placement of an artificial airway with resultant patient risk and elevation of health care costs. The objective of our study was to evaluate potentially preventable intubations in Spanish-speaking patients. A 9-year retrospective review was performed using the National Trauma Registry for The American College of Surgeons (NTRACS) database. We evaluated patients intubated on arrival to the trauma center and remaining intubated for less than 48 hours. Deaths were excluded. Patients who typically speak English were compared with patients who typically speak Spanish. Mechanism of injury (MOD, hypotension during resuscitation (HDR), illicit substance use, alcohol use, mean Glasgow Coma Score (GCS), mean Injury Severity Score (ISS), payer source, and hospital cost were compared. Forty-nine per cent and 38 per cent of Spanish and English speaking individuals, respectively, were intubated for less than 48 hours ( P = 0.072). MOI, HDR, ISS, illicit substance use, alcohol use, and payer source were similar. GCS was statistically higher in the Spanish-speaking group (14 vs 12; P = 0.004). Language and communication barriers lead to potentially preventable intubations in trauma patients.

Clinical predictors of subtherapeutic aminoglycoside levels in trauma patients undergoing once-daily dosing

BACKGROUND

After publication of the Hartford nomogram in 1995, conflicting data have emerged regarding the use of once-daily aminoglycoside (ODA) regimens in critically ill patients. The purpose of this study was to characterize a trauma patient population with low 10-hour aminoglycoside levels (THL) within the Hartford ODA protocol.

METHODS

Patients admitted to a Level I trauma center who received aminoglycosides were eligible for study. Clinical and demographic data were prospectively collected. Patients were dosed according to the Hartford protocol and a THL was obtained. Patients with THL < 2.0 microg/mL (OFF cohort) were compared with those falling within the nomogram (ON cohort).

RESULTS

Of 79 patients receiving ODA therapy, 46 (58.2%) patients fell off the nomogram. The OFF cohort was associated with younger age and higher creatinine clearance, and related inversely to net resuscitative volume.

CONCLUSION

Trauma patients undergoing ODA therapy with low THL are younger and exhibit less net preaminoglycoside resuscitative volume and higher creatinine clearance. These findings may have important clinical implications regarding antibiotic efficacy in these select patients.

The relationship of Injury Severity Score and Glasgow Coma Score to rehabilitative potential in patients suffering traumatic brain injury

The predictive utility of the Injury Severity Score (ISS) and Glasgow Coma Score (GCS) in relation to rehabilitative potential and functional outcome in traumatic brain injury (TBI) is untested. The purpose of this study was to define the relationship of ISS and GCS to rehabilitative potential using the functional independence measure (FIM) score. Trauma and inpatient rehabilitation (IR) registries were queried for demographic, disposition, and injury scoring data. FIM scores at admission (A) and discharge (D) were assessed including IR FIM gain (G). Analysis of variance was used to examine the relationship of ISS and GCS to FIM with predictive utility investigated through bivariate analysis. Of 5488 patients admitted to a Level I trauma center (1999-2000) 1437 suffered TBI with 285 (20%) entering IR. Compared with low-ISS patients the high-ISS patients had significantly lower FIM-A and FIM-D, but FIM-G was static. GCS results were similar, excluding FIM-G which was significantly higher for GCS < or = 8 compared with GCS > 8. Bivariate analysis revealed no ISS correlation with FIM-G (r = 0.16) and a weak GCS correlation (FIM-G r = -0.15). As prospective predictive measures ISS and GCS correlate weakly with rehabilitative potential in TBI patients. Severely injured patients including those with severe TBI have a rehabilitative gain toward functional independence that is similar to that of when compared with those less severely injured.

Initial presentation of Crohn's disease in pregnancy: report of a case

PURPOSE

This study evaluates the current morbidity and mortality of Crohn's disease presenting for the first time in pregnancy.

METHODS

A review of the English-language literature was performed to collect all reported cases of Crohn's disease presenting in pregnancy.

RESULTS

This review demonstrates a maternal mortality of 4 percent and morbidity of 40 percent and a fetal mortality of 38 percent, with 24 percent normal outcome of pregnancy.

CONCLUSIONS

This study shows improved maternal and fetal outcome compared with earlier data.

Utility of flexion and extension radiographs of the cervical spine in the acute evaluation of blunt trauma

BACKGROUND

The purpose of this study is to investigate the usefulness of flexion and extension radiographs of the cervical spine for the acute evaluation of ligamentous injury in cases of awake blunt trauma.

METHODS

A review of 106 consecutive cases of blunt trauma evaluated with flexion and extension radiographs of the cervical spine obtained in the acute setting at a Level I trauma center was performed. The data compiled included the age, sex, mechanism of injury, type of radiographic evaluations, interpretation of all radiographic studies, and clinical outcome on follow-up.

RESULTS

Sixty-six of the patients (62%) were involved in motor vehicle crashes. Other injuries included 15 falls (14%), 9 blunt assaults (8.5%), and 16 other types of blunt trauma (15%). Thirteen cervical spine injuries were diagnosed in 9 of 106 patients (8.5%). Injuries included two fractures, eight acute disc herniations, two ligamentous injuries, and one cord contusion diagnosed on the basis of all radiologic evaluation and clinical follow-up. Seventy-four patients (70%) had a range of flexion and extension motion interpreted as adequate for diagnostic purposes. Five of the 74 patients (6.75%) with an adequate range of motion had cervical spine injuries. No ligamentous injuries were misdiagnosed in this group. Thirty-two of the flexion and extension examinations (30%) were interpreted as inadequate because of limited motion. Four of the 32 patients (12.5%) with inadequate flexion and extension examinations had injuries subsequently detected on cross-sectional imaging (computed tomographic scanning or magnetic resonance imaging) including severe ligamentous injury.

CONCLUSION

When adequate motion was present on flexion and extension radiographs, the false-negative rate was zero in this study. However, in the acute setting, 30% of the examinations were limited by inadequate motion. A higher percentage of injury (12.5%) was detected by subsequent cross-sectional imaging in these patients. Limited flexion and extension motion on physical examination should preclude the use of flexion and extension radiographs, as they are of limited diagnostic utility. Cross-sectional imaging may be warranted in this high-risk group of patients.

Brachial plexopathy after prone positioning

Two cases of brachial plexus injury after prone position in the intensive care unit are described. Mechanisms of brachial plexus injury are described, as are methods for prevention of this unusual complication.

Prone positioning does not affect cannula function during extracorporeal membrane oxygenation or continuous renal replacement therapy

INTRODUCTION

Prone positioning in respiratory failure has been shown to be a useful adjunct in the treatment of severe hypoxia. However, the prone position can result in dislodgment or malfunction of tubes and cannulae. Certain patients receiving extracorporeal membrane oxygenation (ECMO) or continuous renal replacement therapy (CRRT) may also benefit from positional therapy. The impact of cannula-related complications in these patients is potentially disastrous. The safety and efficacy of prone positioning of these patients has not been previously reported.

MATERIALS AND METHODS

A retrospective chart review evaluated ECMO or CRRT cannula location, and displacement or malfunction during positional change or while prone. The study was set in a General Surgery and Trauma Intensive Care Unit. The subjects were all patients at our institution who simultaneously underwent ECMO or CRRT and prone positioning from July 1996 to July 2001. There were no interventions.

RESULTS

Ten patients underwent ECMO and 42 patients underwent CRRT during the study period. Seven patients underwent simultaneous prone positioning and either ECMO (4/10) or CRRT (4/42). A total of 68 turning events (prone to supine or supine to prone) were recorded, with each patient averaging 9.7 (range, 4-16) turning episodes. Turning was performed with sheets and extra nursing personnel; no special mechanical assist devices were used. No patients experienced inadvertent cannula removal during turning. Two patients had poor flow through their cannulae. In one patient, this occurred in the supine position and required repositioning of the cannula. In the second patient, cannulae were changed twice and flow was poor in both the supine and the prone positions. All ECMO and CRRT patients received venous cannulae. Cannula location (seven internal jugular and 11 femoral) did not the affect risk of malfunction.

DISCUSSION AND CONCLUSIONS

Patients with venous cannulae for ECMO or CRRT can be safely placed in the prone position. Flow rates are maintained in this position. Potential cannula complications of ECMO and CRRT are not a contraindication to prone positioning in severely ill patients.

An unusual late complication of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) now is managed frequently successfully without surgical intervention. NEC may result in strictures, which present after the acute inflammatory process has resolved. Strictures usually present as obstruction in the first year or two of life. A case report is presented of an 11-year-old child who had symptoms from a previously undiagnosed NEC stricture as a result of pica when coins obstructed the stricture. As treatment of NEC continues to improve, more and later complications of this disease can be expected. J Pediatr Surg 36:1853-1854.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.

Cholescintigraphy in the diagnosis of bile leak after laparoscopic cholecystectomy

Bile leaks are a recognized complication of laparoscopic cholecystectomy (LC). Different diagnostic approaches have been employed when this condition is suspected. We present our experience with cholescintigraphy as a primary imaging technique for the detection of bile leaks. The medical records of all patients who had cholescintigraphy after LC during a 58-month period were reviewed. Patients were selected for cholescintigraphy if fever unusual abdominal pain, nausea, vomiting, or jaundice were present beyond 36 hours after LC. Bile leaks were suspected in 25 out of 744 patients (3.36%). The nuclear imaging study was true positive in 7 cases and true negative in 18 cases, for a 100 per cent sensitivity, specificity, and accuracy in the detection of bile leaks. Five patients were treated by endoscopic retrograde cholangiopancreatography with stent and/or sphincterotomy, and two patients underwent exploratory laparotomy. None of the patients who underwent endoscopic retrograde cholangiopancreatography required peritoneal drainage. We conclude that cholescintigraphy is sensitive and accurate in the diagnosis of bile leaks. Its use along with a high index of suspicion of a bile leak may prevent the development of bile peritonitis.