Deborah A. Kuhls

Impact of Increased Use of Laparoscopy on Negative Laparotomy Rates after Penetrating Trauma

BACKGROUND Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. METHODS Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. RESULTS There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. CONCLUSION An aggressive laparoscopic program can improve patient management after PAT.

Advanced surgical skills for exposure in trauma: a new surgical skills cadaver course for surgery residents and fellows.

BACKGROUND Surgical education is changing owing to workforce and economic demands. Simulation and other technical teaching methods are used to acquire skills transferable to the operating room. Operative management of traumatic injuries has declined, making it difficult to acquire and maintain competence. The ASSET course was developed by the Committee on Trauma’s Surgical Skills Committee to fill a surgical skills need in resident and fellow education. Using a human cadaver, standardized rapid exposure of vital structures in the extremities, neck, thorax, abdomen, retroperitoneum, and pelvis is taught. METHODS A retrospective analysis of 79 participants in four ASSET courses was performed. Operative experience data were collected, and self-efficacy questionnaires (SEQs) were administered before and after the course. Course evaluations and instructor evaluation data were analyzed. Student’s and paired samples t tests as well as analysis of variance and Spearman &rgr; correlation coefficient analysis were performed using &agr; at p < 0.05. We hypothesized that the ASSET course would teach new surgical techniques and that learner self-assessed ability would improve. RESULTS Participants included 27 PGY-4, 20 PGY-5, 24 PGY-6 or PGY-7 and PGY-8 at other levels of training. Self-assessed confidence improved in all body regions (p < 0.001), with the greatest increase in upper extremity and chest. Pre- and post-SEQ scores correlated with trauma operative experience. Precourse SEQ scores differed by level of training. Instructor evaluations correlated with previous experience on a trauma service. Program evaluations averaged 4.73 on a 5-point scale, with gaining new knowledge rated at 4.8 and learning new techniques at 4.72. CONCLUSION A standardized cadaver-based surgical exposures course offered to senior surgical residents adds new surgical skills and improves participant self-assessed ability to perform emergent surgical exposure of vital structures.

Multidisciplinary trauma intensive care unit checklist: impact on infection rates.

The purpose of this study was to implement a multidisciplinary daily quality checklist in a trauma intensive care setting to determine adherence to infection prevention protocols as well as the impact on infection and complications. Methods: A multidisciplinary team developed a checklist incorporating evidence-based practice guidelines for the prevention of hospital-acquired infections. Infection rates were monitored and correlated with checklist completion. Results: Central line, urinary tract infections, and ventilator-associated pneumonia decreased during the study period by 100%, 26%, and 82%, respectively. Conclusion: Initiation of a multidisciplinary daily quality checklist is correlated with decreased infection rates in a trauma intensive care setting.

Older Adult Falls Seen by Emergency Medical Service Providers: A Prevention Opportunity.

INTRODUCTION Among people aged ≥65 years, falling is the leading cause of emergency department visits. Emergency medical services (EMS) are often called to help older adults who have fallen, with some requiring hospital transport. Chief aims were to determine where falls occurred and the circumstances under which patients were transported by EMS, and to identify future fall prevention opportunities. METHODS In 2012, a total of 42 states contributed ambulatory data to the National EMS Information System, which were analyzed in 2014 and 2015. Using EMS records from 911 call events, logistic regression examined patient and environmental factors associated with older adult transport. RESULTS Among people aged ≥65 years, falls accounted for 17% of all EMS calls. More than one in five (21%) of these emergency 911 calls did not result in a transport. Most falls occurred at home (60.2%) and residential institutions such as nursing homes (21.7%). Logistic regression showed AORs for transport were greatest among people aged ≥85 years (AOR=1.14, 95% CI=1.13, 1.16) and women (AOR=1.30, 95% CI=1.29, 1.32); for falls at residential institutions or nursing homes (AOR=3.52, 95% CI=3.46, 3.58) and in rural environments (AOR=1.15, 95% CI=1.13, 1.17); and where the EMS impression was a stroke (AOR=2.96, 95% CI=2.11, 4.10), followed by hypothermia (AOR=2.36, 95% CI=1.33, 4.43). CONCLUSIONS This study provides unique insight into fall circumstances and EMS transport activity. EMS personnel are in a prime position to provide interventions that can prevent future falls, or referrals to community-based fall prevention programs and services.

Survey of American College of Surgeons Committee on trauma members on firearm injury: Consensus and opportunities

BACKGROUND In the United States, there is a perceived divide regarding the benefits and risks of firearm ownership. The American College of Surgeons Committee on Trauma Injury Prevention and Control Committee designed a survey to evaluate Committee on Trauma (COT) member attitudes about firearm ownership, freedom, responsibility, physician-patient freedom and policy, with the objective of using survey results to inform firearm injury prevention policy development. METHODS A 32-question survey was sent to 254 current U.S. COT members by email using Qualtrics. SPSS was used for &khgr;2 exact tests and nonparametric tests, with statistical significance being less than 0.05. RESULTS Our response rate was 93%, 43% of COT members have firearm(s) in their home, 88% believe that the American College of Surgeons should give the highest or a high priority to reducing firearm-related injuries, 86% believe health care professionals should be allowed to counsel patients on firearms safety, 94% support federal funding for firearms injury prevention research. The COT participants were asked to provide their opinion on the American College of Surgeons initiating advocacy efforts and there was 90% or greater agreement on 7 of 15 and 80% or greater on 10 of 15 initiatives. CONCLUSION The COT surgeons agree on: (1) the importance of formally addressing firearm injury prevention, (2) allowing federal funds to support research on firearms injury prevention, (3) retaining the ability of health care professionals to counsel patients on firearms-related injury prevention, and (4) the majority of policy initiatives targeted to reduce interpersonal violence and firearm injury. It is incumbent on trauma and injury prevention organizations to leverage these consensus-based results to initiate prevention, advocacy, and other efforts to decrease firearms injury and death. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level I; therapeutic care, level II.

Firearm injury prevention: a consensus approach to reducing preventable deaths

What Is the Magnitude of the Problem? The past five decades have witnessed dramatic improvements in trauma care, trauma centers, and trauma systems. Our communities and our patients have all dramatically benefitted from these improvements. In most US trauma centers, firearm injuries account for a relatively small fraction of injured patients. We recently queried all levels of trauma centers who submit data to the National Trauma Data Bank and found that firearm injuries account for fewer than 5% of trauma patients in these trauma centers. From 1979 to 2014, adult firearm homicide rates have decreased by approximately 50% (from 8.22 to 4.16 deaths per 100,000). Therefore, it is probably not surprising that many trauma surgeons and nurses may underestimate the substantial impact firearm injury contributes to the burden of death in the United States. Owing to the lethality of firearm injury, many of these deaths are never cared for in the trauma and emergency medical service system. There are three dominant mechanisms that account for the majority of trauma injuries and deaths in the United States, namely, motor vehicle crashes, firearm injuries, and falls. Amazingly, each of these three mechanisms accounts for almost identical rates of death: motor vehicle, 10.6 deaths per 100,000 per year; firearm, 10.5 deaths per 100,000 per year; and falls, 10.4 deaths per 100,000 per year (Fig. 1). So, even though firearm injuries account for less than 5% of the patients cared for in trauma centers, firearm injuries account for roughly the same number of deaths as those for motor vehicle crashes. This is attributable to a high firearm case-fatality rate, thus emphasizing the crucial need for firearm injury prevention.

Selective use of pericardial window and drainage as sole treatment for hemopericardium from penetrating chest trauma

Background Penetrating cardiac injuries (PCIs) are highly lethal, and a sternotomy is considered mandatory for suspected PCI. Recent literature suggests pericardial window (PCW) may be sufficient for superficial cardiac injuries to drain hemopericardium and assess for continued bleeding and instability. This study objective is to review patients with PCI managed with sternotomy and PCW and compare outcomes. Methods All patients with penetrating chest trauma from 2000 to 2016 requiring PCW or sternotomy were reviewed. Data were collected for patients who had PCW for hemopericardium managed with only pericardial drain, or underwent sternotomy for cardiac injuries grade 1–3 according to the American Association for the Surgery of Trauma (AAST) Cardiac Organ Injury Scale (OIS). The PCW+drain group was compared with the Sternotomy group using Fisher’s exact and Wilcoxon rank-sum test with P<0.05 considered statistically significant. Results Sternotomy was performed in 57 patients for suspected PCI, including 7 with AAST OIS grade 1–3 injuries (Sternotomy group). Four patients had pericardial injuries, three had partial thickness cardiac injuries, two of which were suture-repaired. Average blood drained was 285 mL (100–500 mL). PCW was performed in 37 patients, and 21 had hemopericardium; 16 patients proceeded to sternotomy and 5 were treated with pericardial drainage (PCW+drain group). All PCW+drain patients had suction evacuation of hemopericardium, pericardial lavage, and verified bleeding cessation, followed by pericardial drain placement and admission to intensive care unit (ICU). Average blood drained was 240 mL (40–600 mL), and pericardial drains were removed on postoperative day 3.6 (2–5). There was no significant difference in demographics, injury mechanism, Revised Trauma Score exploratory laparotomies, hospital or ICU length of stay, or ventilator days. No in-hospital mortality occurred in either group. Conclusions Hemodynamically stable patients with penetrating chest trauma and hemopericardium may be safely managed with PCW, lavage and drainage with documented cessation of bleeding, and postoperative ICU monitoring. Level of evidence Therapeutic study, level IV.

Evaluating the traditional day and night shift in an acute care surgery fellowship: Is the swing shift a better choice?

BACKGROUND Fellowship trainees in acute care surgery require experience in the management of complex and operative trauma cases. Trauma center staffing usually follows standard 12-hour or 24-hour shifts, with resident and fellow trainees following a similar schedule. Although trauma admissions can be generally unpredictable, we analyzed temporal trends of trauma patient arrival times to determine the best time frame to maximize trainee experience during each day. METHODS We reviewed 10 years (2007–2016) of trauma registry data for blunt and penetrating trauma activations. Hourly volumetric trends were observed, and three specific events were chosen for detailed analysis: (1) trauma activation with Injury Severity Score (ISS) greater than 15, (2) laparotomy for trauma, and (3) thoracotomy for trauma. A retrospective shift log was created, which included day (7:00 AM to 7:00 PM), night (7:00 PM to 7:00 AM), and swing (noon to midnight) shifts. A swing shift was chosen because it captures the peak volume for all three events. Means and 95% confidence intervals were calculated, and comparisons were made between shifts using the Wilcoxon matched-pairs signed rank test with Bonferroni correction, and p less than 0.05 considered significant. RESULTS During the 10-year study period, 28,287 patients were treated at our trauma center. This included the evaluation and management of 7,874 patients with ISS greater than 15, performance of 1,766 laparotomies, and 392 thoracotomies for trauma. Swing shift was superior to both day and night shifts for ISS greater than 15 (p < 0.001). Both swing and night shifts were superior to day shift for laparotomies (p < 0.001). Swing shift was superior to both day shift (p < 0.001) and night shift (p = 0.031). Shifts with the highest yield of ISS greater than 15, laparotomies, and thoracotomies include night and swing shifts on Fridays and Saturdays. CONCLUSION Projected experience of acute care surgery fellows in managing complex trauma patients increases with the integration of swing shifts into the schedule. Daily trauma volume follows a temporal pattern which, when used correctly, can increase trainee exposure to complex and operative trauma cases. We encourage other centers to analyze their volume and adjust trainee schedules accordingly to maximize their educational experience. Level of Evidence Therapeutic study, level IV.

Freedom with Responsibility: A Consensus Strategy for Preventing Injury, Death, and Disability from Firearm Violence

Reducing violence-related, intentional injury (including intentional firearm-related injury) requires a multifaceted, integrated public health approach. This requires engagement, responsibility and partnership across disciplines, geographic regions, and philosophic differences. A commitment to the values of civility, professionalism, humility and mutual respect are required.

Basic Disaster Life Support (BDLS) Training Improves First Responder Confidence to Face Mass-Casualty Incidents in Thailand

BACKGROUND Medical response to mass-casualty incidents (MCIs) requires specialized training and preparation. Basic Disaster Life Support (BDLS) is a course designed to prepare health care workers for a MCI. The purpose of this study was to evaluate the confidence of health care professionals in Thailand to face a MCI after participating in a BDLS course. METHODS Basic Disaster Life Support was taught to health care professionals in Thailand in July 2008. Demographics and medical experience were recorded, and participants rated their confidence before and after the course using a five-point Likert scale in 11 pertinent MCI categories. Survey results were compiled and compared with P<.05 statistically significant. RESULTS A total of 162 health care professionals completed the BDLS course and surveys, including 78 physicians, 70 nurses, and 14 other health care professionals. Combined confidence increased among all participants (2.1 to 3.8; +1.7; P<.001). Each occupation scored confidence increases in each measured area (P<.001). Nurses had significantly lower pre-course confidence but greater confidence increase, while physicians had higher pre-course confidence but lower confidence increase. Active duty military also had lower pre-course confidence with significantly greater confidence increases, while previous disaster courses or experience increased pre-course confidence but lower increase in confidence. Age and work experience did not influence confidence. CONCLUSION Basic Disaster Life Support significantly improves confidence to respond to MCI situations, but nurses and active duty military benefit the most from the course. Future courses should focus on these groups to prepare for MCIs. Kuhls DA , Chestovich PJ , Coule P , Carrison DM , Chua CM , Wora-Urai N , Kanchanarin T . Basic Disaster Life Support (BDLS) training improves first responder confidence to face mass-casualty incidents in Thailand. Prehosp Disaster Med. 2017;32(5):492-500 .