Hee Soo Jung

Number of rib fractures thresholds independently predict worse outcomes in older patients with blunt trauma.

Background. There have been conflicting reports regarding whether the number of rib fractures sustained in blunt trauma is associated independently with worse patient outcomes. We sought to investigate this risk‐adjusted relationship among the lesser‐studied population of older adults. Methods. A retrospective review of the National Trauma Data Bank was performed for patients with blunt trauma who were ≥65 years old and had rib fractures between 2009 and 2012 (N = 67,695). Control data were collected for age, sex, injury severity score, injury mechanism, 24 comorbidities, and number of rib fractures. Outcome data included hospital mortality, hospital and intensive care unit durations of stay, duration of mechanical ventilation, and the occurrence of pneumonia. Multiple logistic and linear regression analyses were performed. Results. Sustaining ≥5 rib fractures was associated with increased intensive care unit admission (odds ratio: 1.14, P < .001) and hospital duration of stay (relative duration: 105%, P < .001). Sustaining ≥7 rib fractures was associated with an increased incidence of pneumonia (odds ratio: 1.32, P < .001) and intensive care unit duration of stay (relative duration: 122%, P < .001). Sustaining ≥8 rib fractures was associated with increased mortality (odds ratio: 1.51, P < .001) and duration of mechanical ventilation (relative duration: 117%, P < .001). Conclusion. In older patients with trauma, sustaining at least 5 rib fractures is a significant predictor of worse outcomes independent of patient characteristics, comorbidities, and trauma burden.

Primary prevention of contact sports-related concussions in amateur athletes: a systematic review from the Eastern Association for the Surgery of Trauma

Background Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years. Our objective is to conduct a prospectively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions. Methods Using the Grading of Recommendations Assessment, Development, and Evaluation methodology, we performed a systematic review of the literature to answer seven population, intervention, comparator, and outcomes (PICO) questions regarding concussion education, head protective equipment, rules prohibiting high-risk activity and neck strengthening exercise for prevention of contact sports-related concussion in pediatric and adult amateur athletes. A query of MEDLINE, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Embase was performed. Letters to the editor, case reports, book chapters, and review articles were excluded, and all articles reviewed were written in English. Results Thirty-one studies met the inclusion criteria and were applicable to our PICO questions. Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes. Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes. Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported. Conclusion Despite increasing scientific attention to sports-related concussion, studies evaluating preventive interventions remain relatively sparse. This systematic review serves as a call to focus research on primary prevention strategies for sports-related concussion. Level of evidence IV. PROSPERO registration number #42016043019.

Using epistemic network analysis to identify targets for educational interventions in trauma team communication

Background. Epistemic Network Analysis (ENA) is a technique for modeling and comparing the structure of connections between elements in coded data. We hypothesized that connections among team discourse elements as modeled by ENA would predict the quality of team performance in trauma simulation. Methods. The Modified Non‐technical Skills Scale for Trauma (T‐NOTECHS) was used to score a simulation‐based trauma team resuscitation. Sixteen teams of 5 trainees participated. Dialogue was coded using Verbal Response Modes (VRM), a speech classification system. ENA was used to model the connections between VRM codes. ENA models of teams with lesser T‐NOTECHS scores (n = 9, mean = 16.98, standard deviation [SD] = 1.45) were compared with models of teams with greater T‐NOTECHS scores (n = 7, mean = 21.02, SD = 1.09). Results. Teams had different patterns of connections among VRM speech form codes with regard to connections among questions and edifications (meanHIGH = 0.115, meanLOW = −0.089; t = 2.21; P = .046, Cohen d = 1.021). Greater‐scoring groups had stronger connections between stating information and providing acknowledgments, confirmation, or advising. Lesser‐scoring groups had a stronger connection between asking questions and stating information. Discourse data suggest that this pattern reflected increased uncertainty. Lesser‐scoring groups also had stronger connections from edifications to disclosures (revealing thoughts, feelings, and intentions) and interpretations (explaining, judging, and evaluating the behavior of others). Conclusion. ENA is a novel and valid method to assess communication among trauma teams. Differences in communication among higher‐ and lower‐performing teams appear to result from the ways teams use questions. ENA allowed us to identify targets for improvement related to the use of questions and stating information by team members.

Identifying Nontechnical Skill Deficits in Trainees Through Interdisciplinary Trauma Simulation

OBJECTIVE The goal of this study was to investigate nontechnical skills in a simulated trauma setting both before and after a debriefing session in order to better understand areas to target for the development of educational interventions. DESIGN Wilcoxon signed rank tests were used to compare scores on the 5 domains of the T-NOTECHS pre- and postdebriefings. A qualitative analysis using the PEARLS debriefing framework was performed to provide a rich description of the strategies used by the debriefing facilitators. SETTING The Joint Trauma Simulation Program is an interdisciplinary project designed to improve the quality of trauma care through simulation exercises emphasizing nontechnical skills development. PARTICIPANTS Thirteen teams of 5 trauma trainees participated in trauma resuscitation simulations: a surgical chief resident, a surgical junior resident, an emergency medicine resident, and 2 emergency medicine nurses. RESULTS Teams significantly improved on communication and interaction skills in the simulation scenarios from pre- to postdebriefing. The debrief facilitators spent most of their time engaged in Directive Performance Feedback (56.13%). CONCLUSIONS Interprofessional team simulation in trauma resuscitation scenarios followed by debriefing differently affected individual nontechnical skills domains. Additional facilitation strategies, such as focused facilitation and encouraging learner self-assessment, may target other nontechnical skills in different ways.

Socioeconomic disparities in the thoracic trauma population

BACKGROUND Health-care disparities based on socioeconomic status have been well documented in the trauma literature; however, there is a paucity of data on how these factors affect outcomes in patients experiencing severe thoracic trauma. This study aims to identify the effect of insurance status and race on patient mortality and disposition after thoracic trauma. METHODS The National Trauma Data Bank was queried from 2007 to 2012 for patients with sternal fractures, rib fractures, and flailed chest. Demographics data were examined for the cohort based on insurance status. Univariate and multivariate logistic regression models were used, controlling for patient comorbidities, age, injury severity score, and associated injuries, to determine the impact of race and insurance status on length of stay, mortality, and discharge disposition. RESULTS A total of 152,655 thoracic traumas were included in our analysis. As compared to privately insured patients, uninsured patients with thoracic trauma were 1.9 times more likely to die (odds ratio [OR]: 1.91, confidence interval [CI]: 1.76-2.09) and 4.6 times more likely to leave against medical advice (OR: 4.61, CI: 3.14-6.79). When compared to Caucasians, Hispanics had slightly higher in-hospital mortality (OR: 1.14, CI: 1.02-1.27), but there was no survival difference seen in black patients (OR: 0.95, CI: 0.86-1.05). CONCLUSIONS Insurance status appears to have a more significant effect on thoracic trauma patient outcomes than race, but substantial socioeconomic disparities were seen in this patient population. Further studies are needed to show reproducibility of our findings and to investigate the impact of universal health care and expansion of insurance availability on thoracic trauma outcomes. LEVEL OF EVIDENCE Level 3, economic/decision.

Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care:

Introduction: End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients. Methods: Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice. Results: Chi-square analysis of 2 966 444 patient’s transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer (P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer (P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice (P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians (P < .0001). Conclusions: Race and ethnicity are independent predictors of a trauma patient’s transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.

What Does an Academic Career Look Like in Surgical Education

Surgical education is rapidly growing as a formal career option. Choosing a focus area is the key to success. Opportunities exist at the medical student, resident, fellow, and practicing physician level. There is also the option of focusing on teaching, curriculum development and evaluation, or traditional experimental or investigational research. This chapter will focus on the various career opportunities in surgical education and provide examples of real-life career paths demonstrating the many options for a successful, fulfilling academic career in surgical education.

Damage Control Resuscitation in Penetrating Trauma: Rules of the Game

Dr. William Halstead once wrote, “The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage.” In no other field of surgery is this more apparent than in trauma. Hemorrhage is a major factor for mortality in patients presenting after injury. Thus, it is imperative for the competent surgeon to treat hemorrhage expeditiously in order to restore physiologic homeostasis and prevent the dire consequences of ongoing bleeding.