Dan L. Deckelbaum

Severely injured geriatric population: morbidity, mortality, and risk factors.

BACKGROUND With an increasing life expectancy and more active elderly population, management of geriatric trauma patients continues to evolve. The aim was to describe the mechanism and injuries of severely injured geriatric patients and to identify risk factors associated with mortality. METHODS The Trauma Registry at a Canadian Level I trauma center was queried for all trauma patients older than 65 years and injury severity score >15 from 2004 to 2006, resulting in a retrospective chart review of 276 patients. The data were subsequently analyzed using univariate and multivariate analysis. RESULTS Average age was 81.5 years (mean injury severity score of 25). Most common comorbid illness was hypertension (57.3%) and most frequent mechanism of injury was falls (72.3%). The overall mortality was comparable with the US National Trauma Data Bank (26.8% vs. 32.0%, confidence interval, 0.00-0.10). Geriatric patients requiring intubation, blood transfusions, or suffering from head, C-spine, or chest trauma had an increased likelihood of death. In-hospital respiratory, gastrointestinal, or infectious complications also had higher likelihood of death. CONCLUSIONS Falls continue to be the most frequent mechanism of injury in severely injured geriatric patients. Risk factors associated with a higher likelihood of death are identified. More research is needed to better understand this important and increasing group of trauma patients.

Assessing the impact of the trauma team training program in Tanzania.

BACKGROUND In sub-Saharan Africa, injury is responsible for more deaths and disability-adjusted life years than AIDS and malaria combined. The trauma team training (TTT) program is a low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation. The purpose of this study was to assess the impact of TTT on trauma knowledge and performance of Tanzanian physicians and nurses; and to demonstrate the validity of a questionnaire assessing trauma knowledge. METHODS This is a prospective study of physicians and nurses from Dar es Salaam undergoing TTT (n = 20). Subjects received a precourse test and, after the course, an alternate postcourse test. The equivalence and construct validity of these 15-item multiple-choice questionnaires was previously demonstrated. After the course, subjects were divided into four teams and underwent a multiple injuries simulation, which was scored with a trauma resuscitation simulation assessment checklist. A satisfaction questionnaire was then administered. Test data are expressed as median score (interquartile ratio) and were analyzed with the Wilcoxons signed rank test. RESULTS After the TTT course, subjects improved their scores from 9 (5-12) to 13 (9-13), p = 0.0004. Team performance scores for the simulation were all >80%. Seventy-five percent of subjects were very satisfied with TTT and 90% would strongly recommend it to others and would agree to teach future courses. CONCLUSIONS After completion of TTT, there was a significant improvement in trauma resuscitation knowledge, based on results from a validated questionnaire. Trauma team performance was excellent when assessed with a novel trauma simulation assessment tool. Participants were very supportive of the course.

Strategies to improve clinical research in surgery through international collaboration

More than 235 million patients undergo surgery every year worldwide, but less than 1% are enrolled in surgical clinical trials--few of which are international collaborations. Several levels of action are needed to improve this situation. International research collaborations in surgery between developed and developing countries could encourage capacity building and quality improvement, and mutually enhance care for patients with surgical disorders. Low-income and middle-income countries increasingly report much the same range of surgical diseases as do high-income countries (eg, cancer, cardiovascular disease, and the surgical sequelae of metabolic syndrome); collaboration is therefore of mutual interest. Large multinational trials that cross cultures and levels of socioeconomic development might have faster results and wider applicability than do single-country trials. Surgeons educated in research methods, and aided by research networks and trial centres, are needed to foster these international collaborations. Barriers to collaboration could be overcome by adoption of global strategies for regulation, health insurance, ethical approval, and indemnity coverage for doctors.

Prioritizing injury care: a review of trauma capacity in low and middle-income countries

BACKGROUND Trauma is a large contributor to the global burden of disease, particularly in low and middle-income countries (LMICs). This study aimed to summarize the literature assessing surgical capacity in LMICs to provide a current assessment of trauma capacity, which will help guide future efforts. MATERIALS AND METHODS The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy, cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank. RESULTS Seventeen studies were reviewed, documenting data from 531 hospitals in seventeen countries. None of the countries had access to all twelve trauma criteria in all their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). CONCLUSIONS Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs.

Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery.

BACKGROUND We evaluated the role of the Charlson age-comorbidity index (CACI), a weighted comorbidity index that reflects cumulative increased likelihood of 1-year mortality, in predicting perioperative outcomes in an emergency general surgery population at a large Canadian teaching hospital. METHODS A retrospective chart review of emergency general surgery admissions in 2010 was conducted. Patients who had surgery were identified. Mode of surgery and CACI were recorded, as well as measures of outcome, including 30-day mortality and intensive care unit (ICU) admission. A multivariate stepwise logistic regression model was created to assess the effect of age-adjusted Charlson comorbidity index on postoperative outcomes while controlling for the effect of possible confounders. The prediction ability of CACI for mortality was assessed using receiver operating characteristic analyses considering the area under the curve and its 95% confidence intervals (CIs). RESULTS Of the 529 admissions to general surgery from the emergency department, 257 patients underwent a surgical intervention. The CACI scores ranged from 0 to 16. We described a total of 11 deaths (4.3%) and 30 ICU admissions (11.7%). CACI was associated with an increased risk of 30-day mortality (adjusted odds ratio,1.39; 95% CI, 1.11–1.73; p = 0.0034). Receiver operating characteristic analysis was consistent with high accuracy of CACI for mortality prediction alone, resulting in area under the curve or c statistic of 0.90 (95% CI, 0.84–0.95). CACI was similar in predicting mortality to a multivariate model. CACI was also found to be associated with ICU admission (adjusted odds ratio, 1.17; 95% CI, 1.01–1.37; p < 0.0382). CACI is not as good a predictor for ICU admission when compared with the multivariate model. CONCLUSION We have shown that the CACI is a valid tool for 30-day mortality prediction in the context of emergency general surgery. LEVEL OF EVIDENCE Prognostic study, level III.

Augmenting surgical capacity in resource-limited settings

www.thelancet.com Vol 380 August 25, 2012 713 Defi ciencies in access to surgical care in low-income and middle-income countries are well recognised. Despite the awareness and benchmarks generated by the Millennium Development Goals, most sub-Saharan African nations have a negative annual growth rate in the number of physicians compared with their population growth rate. In several sub-Saharan African nations, there are only 0·9 physicians per 1000 population, compared with 21 physicians per 1000 population in the UK and 28 per 1000 population in the USA. These trends raise concerns about the morbidity, mortality, and disability-adjusted life-years lost due to injury and diseases requiring surgical treatment (including obstetrics) in sub-Saharan Africa. Policy makers and health-care leaders in Rwanda, a nation with only 0·1 general surgeons per 100 000 population (compared with 6·4 per 100 000 in the USA), have recognised the substantial negative socioeconomic eff ect caused by such defi ciencies and have committed themselves to tackling these challenges. 5–7 A partnership has been created between the Faculty of Medicine at the National University of Rwanda and McGill University Health Centre, Canada, to build on the academic elements of the only surgical residency in Rwanda. A needs assessment was done revealing a substantial requirement to augment surgical capacity through growth of the existing programme. Historically, the residency training has been service based, with relatively few academic activities; a refl ection of an overwhelming clinical workload and substantial staff shortages. These factors have resulted in a low intake of residents into the programme. Through the partnership, a system-based curriculum was developed, which is divided into 2-week modules covering locally relevant topics of general surgery. Each module contains lectures, resident case presentations, a journal club, morbidity and mortality rounds, and module evaluation by the residents. A Canadian surgeon, whose subspecialty is matched to the module topic, participates on a rotating basis in daily academic and clinical activities. This surgeon is not meant to replace local faculty in their responsibilities, but rather functions as an educator, moderator, and facilitator for the programme. Most activities are implemented by local faculty and residents. All activities are supervised by local faculty. These principles promote local programme accountability and, in keeping with the concept of “train the trainer”, form the necessary foundation for programme sustainability and success. This paradigm improves on previous models addressing the high morbidity and mortality from injury and surgical disease. Such models range from short-term, service-provision programmes, which, although they provide an exceptional service to indiv idual patients, are heavily dependent on the donor organisation, to slightly longer programmes that focus on surgical education, such as essential surgical skills, and trauma. We now recognise that the highest impact programmes for increasing surgical capacity will be based on long-term partnerships focused on training of local physicians, thereby increasing information retention and sustain ability. For the implementation of productive programmes, there are several important principles: local motivation and accountability, establishment of strong partnerships, understanding the local environment, curricu lum development based on local needs and not on western models, early programme assessment, and substantial involvement of local partners for pro gramme development. Additionally, the focus should be on Augmenting surgical capacity in resource-limited settings 7 Jylha M. What is self-rated health and why does it predict mortality? Towards a unifi ed conceptual model. Soc Sci Med 2009; 69: 307–16. 8 Mackenbach JP, Simon JG, Looman CW, Joung IM. Self-assessed health and mortality: could psychosocial factors explain the association? Int J Epidemiol 2002; 31: 1162–68. 9 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38: 21–37. 10 Zavalaa DE, Bokongo S, John IA, et al. Implementing a hospital based injury surveillance system in Africa: lessons learned. Med Confl Surviv 2008; 24: 260–72. 11 Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011; 11: 109. 12 Rani M, Bonu S. Attitudes toward wife beating: a cross-country study in Asia. J Interpers Violence 2009; 24: 1371–97. 13 Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. 14 Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specifi c socioeconomic and behavioral correlates. PLoS One 2010; 5: e14252. 15 Lee J. Pathways from education to depression. J Cross Cult Gerontol 2011; 26: 121–35. 16 WHO. Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946. http://www.who.int/ governance/eb/who_constitution_en.pdf (accessed May 26, 2011).

A Descriptive Study of Bicycle Helmet Use in Montreal, 2011

ObjectiveThe purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.MethodsUsing a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1–3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.ResultsA total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47–52 vs. 44%, 95% CI 42–45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52).ConclusionsAlthough above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.RésuméObjectifDécrire le port du casque de cycliste chez les cyclistes montréalais en vue d’instaurer des programmes de prévention des blessures.MéthodeÀ la faveur d’une étude transversale, nous avons observé les cyclistes sur des périodes de 60 minutes à 22 endroits sur l’île de Montréal. Il y a eu de 1 à 3 périodes d’observation à chaque endroit. Les observations ont eu lieu entre le 16 août et le 31 octobre 2011. Nous avons utilisé des méthodes statistiques types et calculé les rapports de cotes ajustés et non ajustés et les intervalles de confiance de 95 %.RésultatsNous avons observé 4 789 cyclistes en tout. La proportion observée de cyclistes portant le casque était de 46 % globalement (IC de 95 %: 44-47). Cette proportion était plus élevée chez les femmes (50 %, IC de 95 %: 47–52) que chez les hommes (44 %, IC de 95 %: 42–45). Les jeunes étaient proportionnellement les plus nombreux à porter un casque (73 %, IC de 95 %: 64-81), tandis que les jeunes adultes étaient proportionnellement les moins nombreux à le faire (34 %, IC de 95 %: 30-37). Le port du casque observé chez les cyclistes membres de minorités visibles était de 29 % (IC de 95 %: 25-34), contre 47 % chez les cyclistes blancs (IC de 95 %: 46-49). Les utilisateurs du BIXI (vélo en libre-service) ont été observés en train de porter un casque 12 % du temps (IC de 95 %: 10-15), contre 51 % du temps chez les cyclistes ayant leur propre vélo (IC de 95 %: 49-52).ConclusionsBien qu’il soit supérieur à la moyenne nationale, le port du casque de cycliste à Montréal est encore très faible, car la majorité des cyclistes n’en porte pas. Les programmes de prévention des blessures pourraient cibler tous les cyclistes, mais il serait justifié d’accorder une attention particulière à certains groupes: les jeunes hommes, les minorités visibles, les utilisateurs du BIXI et les cyclistes dans les zones touristiques. Par ailleurs, une collaboration avec le système de vélos en libre-service BIXI Montréalmc en vue d’assurer la disponibilité de casques de cyclistes pour les usagers du BIXI pourrait être fructueuse.

Abolishment of 24-hour continuous medical call duty in Quebec: a quality of life survey of general surgical residents following implementation of the new work-hour restrictions

BACKGROUND The implementation of work hour restrictions across North America have resulted in decreased levels of self injury and medical errors for Residents. An arbitration ruling in Quebec has led to further curtailment of work hours beyond that proposed by the ACGME. This may threaten Resident quality of life and in turn decrease the educational quality of surgical residency training. METHODS We administered a quality of life questionnaire with an integrated education quality assessment tool to all General Surgery residents training at McGill 6 months after the work hour restrictions. RESULTS Across several strata respondents reveal a decreased sense of educational quality and quality of life. CONCLUSIONS The arbitration argued that work- hour restrictions would be necessary to improve quality of life for trainees and hence improve patient safety. Results from this study demonstrate the exact opposite in a large majority of respondents, who report a poorer quality of life and a self-reported inability on their part to provide continuous and safe patient care.

What Are the Principles That Guide Behaviors in the Operating Room?: Creating a Framework to Define and Measure Performance.

Objective: To identify the core principles that guide expert intraoperative behaviors and to use these principles to develop a universal framework that defines intraoperative performance. Background: Surgical outcomes are associated with intraoperative cognitive skills. Yet, our understanding of factors that control intraoperative judgment and decision-making are limited. As a result, current methods for training and measuring performance are somewhat subjective—more task rather than procedure-oriented—and usually not standardized. They thus provide minimal insight into complex cognitive processes that are fundamental to patient safety. Methods: Cognitive task analyses for 6 diverse surgical procedures were performed using semistructured interviews and field observations to describe the thoughts, behaviors, and actions that characterize and guide expert performance. Verbal data were transcribed, supplemented with content from published literature, coded, thematically analyzed using grounded-theory by 4 independent reviewers, and synthesized into a list of items. Results: A conceptual framework was developed based on 42 semistructured interviews lasting 45 to 120 minutes, 5 expert panels and 51 field observations involving 35 experts, and 135 sources from the literature. Five domains of intraoperative performance were identified: psychomotor skills, declarative knowledge, advanced cognitive skills, interpersonal skills, and personal resourcefulness. Within the advanced cognitive skills domain, 21 themes were perceived to guide the behaviors of surgeons: 18 for surgical planning and error prevention, and 3 for error/injury recognition, rescue, and recovery. The application of these thought patterns was highly case-specific and variable amongst subspecialties, environments, and individuals. Conclusions: This study provides a comprehensive definition of intraoperative expertise, with greater insight into the complex cognitive processes that seem to underlie optimal performance. This framework provides trainees and other nonexperts with the necessary information to use in deliberate practice and the creation of effective thought habits that characterize expert performance. It may help to identify gaps in performance, and to isolate root causes of surgical errors with the ultimate goal of improving patient safety.

Promoting quality of care in disaster response: A survey of core surgical competencies

BACKGROUND Recent humanitarian crises have led to a call for professionalization of the humanitarian field, but core competencies for the delivery of surgical care have yet to be established. The objective of this study was to survey surgeons with experience in disaster response to identify surgical competencies required to be effective in these settings. METHODS An online survey elucidating demographic information, scope of practice, and previous experience in global health and disaster response was transmitted to surgeons from a variety of surgical societies and nongovernmental organizations. Participants were provided with a list of 111 operative procedures and were asked to identify those deemed essential to the toolset of a frontline surgeon in disaster response via a Likert scale. Responses from personnel with experience in disaster response were contrasted with those from nonexperienced participants. RESULTS A total of 147 surgeons completed the survey. Participants held citizenship in 22 countries, were licensed in 30 countries, and practiced in >20 countries. Most respondents (56%) had previous experience in humanitarian response. The majority agreed or strongly agreed that formal training (54%), past humanitarian response (94%), and past global health experiences (80%) provided adequate preparation. The most commonly deemed important procedures included control of intraabdominal hemorrhage (99%), abdominal packing for trauma (99%), and wound debridement (99%). Procedures deemed important by experienced personnel spanned multiple specialties. CONCLUSION This study addressed specifically surgical competencies in disaster response. We provide a list of operative procedures that should set the stage for further structured education programs.