Jason S. Lees

Abdominal wall injuries occurring after blunt trauma: incidence and grading system

BACKGROUND Traumatic abdominal wall injuries (AWIs) are being increasingly recognized after blunt force injury. METHODS All available abdominal/pelvic computed axial tomography (CAT) scans of blunt trauma patients evaluated at our level I trauma center from January 2005 to August 2006 were reviewed for the presence of AWI. AWI was graded using a severity-based numeric system. AWI grade was then compared with variables from a prospectively maintained trauma registry. RESULTS Of 1,549 reviewed CAT scans, 9% showed AWI (grade I = 53%, grade II = 28%, grade III = 9%, grade IV = 8%, and grade V = 2%). There was no association between AWI and seatbelt use, Injury Severity Score, weight, or need for abdominal surgery. CONCLUSIONS AWI occurs in 9% of blunt trauma patients undergoing abdominal/pelvic CAT scans. The incidence of herniation on CAT at presentation after blunt trauma is .2%, and the incidence of patients at risk of future hernia formation is 1.5%. AWI can be effectively cataloged using a straightforward numeric grading system.

Early Results from the Flexibility in Surgical Training Research Consortium: Resident and Program Director Attitudes Toward Flexible Rotations in Senior Residency

OBJECTIVE To assess the attitudes of residents and program directors (PDs) involved in flexible training to gauge satisfaction with this training paradigm and elicit limitations. DESIGN Anonymous surveys were sent to residents and PDs in participant programs. Respondents were asked to rate responses on a 5-point Likert scale (1 = strongly disagree and 5 = strongly agree). SETTING A total of 9 residency programs that are collaborating to prospectively study the effect of flexible tracks on resident performance and outcome. PARTICIPANTS A total of 138 residents who were in clinical years 4 and 5 and 10 PDs. RESULTS Of the 138 possible residents, 100 responded to the resident survey (72.5% response rate). Among resident respondents, 33% were participating in a flexible track option. The most frequently listed specialties of focus were cardiothoracic surgery (19%), vascular surgery (13%), acute care surgery (11%), colorectal surgery (8%), surgical oncology (7%), and pediatric surgery (7%). Participants in flexible tracks tended to strongly agree that their career would be enhanced by flexible rotations; interestingly, of those not in flexible tracks, most tended to also agree that flexible rotations would enhance their future careers. Flexible track participants report receiving greater autonomy on flexible rotations and believe they would be better prepared for fellowship and career. They express overall very high satisfaction with the flexible experience. Limitations expressed by residents (in flexible tracks or not) include uncertainty for how this paradigm serves those interested in comprehensive general surgery, concern about scheduling difficulties, and some displeasure in missing high-volume general surgery rotations in lieu of specialty-focused rotations. The PD survey was completed by 8 of 9 PDs for a response rate of 89%. All the respondents agreed or strongly agreed that careers of residents are enhanced by flexible rotations and that important operative and clinical experiences are gained. Overall, 87.5% of PD respondents agreed or strongly agreed that those in flexible tracks have greater opportunities for mentorship in their chosen field. PDs also expressed high levels of satisfaction with flexible rotations. Limitations include concerns that the flexibility option presents scheduling difficulties and does not go far enough in reforming postgraduate education. CONCLUSIONS This survey of 9 residency programs participating in flexible tracks indicates satisfaction with this training option. The role of comprehensive general surgery as a training end point and scheduling difficulties remain as major challenges. Outcomes of graduates in these tracks and control peers are being prospectively evaluated.

Initial inferior vena cava diameter on computed tomographic scan independently predicts mortality in severely injured trauma patients.

BACKGROUND In the trauma population, patients with physiologic compromise may present with “normal” vital signs. We hypothesized that the inferior vena cava (IVC) diameter could be used as a surrogate marker for hypovolemic shock and predict mortality in severely injured trauma patients. METHODS A retrospective cohort study was performed at a Level I trauma center on 161 severely injured adult (aged ≥16 years) trauma patients who were transported from the scene and underwent abdominal computed tomography within 1 hour. Exposure of interest was dichotomously defined as having an infrarenal transverse to anteroposterior IVC ratio of ≥1.9 (flat IVC) or <1.9 (not exposed) based on the area under the curve analysis. The primary outcome was in-hospital mortality. Covariates included initial heart rate, systolic blood pressure, bicarbonate, base excess, creatinine, hemoglobin, and Injury Severity Score (ISS). Correlation analysis between IVC ratio and other known markers of hypoperfusion was performed. Logistic regression was used to determine the independent effect of the IVC ratio on mortality. RESULTS Of the 161 patients, 30 had a flat IVC. The IVC ratio had a significant (p < 0.05) inverse correlation with initial bicarbonate, hemoglobin, and base excess and a direct correlation with Cr and ISS. After controlling for age, ISS, and presence of severe head injury, patients who had a flat IVC were 8.1 times (95% confidence interval, 1.5–42.9) more likely to die compared with the nonexposed cohort. Importantly, heart rate and systolic blood pressure had no predictive value in this patient population. CONCLUSION A flat IVC on initial abdominal computed tomographic scan has a significant correlation with other known markers of shock and is an independent predictor of mortality in severely injured trauma patients. This finding should heighten the awareness of the need for aggressive intervention and potential for physiological decompensation in patients with otherwise “normal” vital signs. LEVEL OF EVIDENCE Prognostic study, level III.

Field amputation: response planning and legal considerations inspired by three separate amputations.

BACKGROUND Surgical procedures in the field are occasionally required as life-saving measures. Few centers have a planned infrastructure for field physician support. Focused efforts are needed to create teams that can meet such needs. Additionally, certain legal issues surrounding these efforts should be considered. Three cases of field dismemberment inspired this call for preparation. METHODS In one case, an earthquake caused the collapse of a bridge, entrapping a child within a car. A through-knee amputation was required to free the patient with local anesthetic only. The second case was the result of a truck bomb causing the collapse of a building whereby a victim was trapped by a pillar. After retrieval of supplies from a local hospital, a through-knee amputation was performed. The third case involved a young man whose arm became entangled in an oil derrick. This patient was sedated and intubated in an erect position and the arm was amputated. RESULTS Fortunately, each of these victims survived. However, the care these patients received was unplanned and had the potential for failure. The authors feel that disaster teams, including a surgeon, should be identified in advance as responders to a disaster on short notice. Legal issues including statespecific Good Samaritan laws and financial support systems must also be considered. CONCLUSION As hospitals and trauma systems prepare for disaster situations, they should consider the eventuality of field dismemberment. This involves identifying a team, including a surgeon, and devising an infrastructure allowing rapid response capabilities, including surgical procedures in the field.

Decreased use of cervical spine clearance in blunt trauma: the implication of the injury mechanism and distracting injury

BACKGROUND Cervical spine injury (CSI) can be ruled out based on clinical examination and no X-ray is required if patient is awake, alert, and examinable. This is known as a clinical clearance (CC). Clinicians have decreased the use and reliance of CC and relied more upon X-ray, especially now that computerized tomography (CT) is fast and readily available. The objective of this study was to identify clinical factors, in particular, the injury mechanism and the distracting injuries, which may be associated with CSI. The knowledge may help to improve the use of CC. METHODS We retrospectively reviewed the records of all blunt trauma patients who were awake, alert, and examinable, with a Glasgow Coma Scale of 14-15, and who were admitted to our Level 1 Trauma Center during January 1 to December 31, 2005. We excluded patients who presented with gross neurological deficit or who died within 72 h. From the chart review, we collected the demographics; the injury severity score (ISS); the injury mechanism; the presence of distracting injuries (DI) which were defined as bony fractures (divided into upper body, lower body, or both); and the radiographs obtained. Patients who did not receive CC underwent a 3-view plain film X-ray, with or without CT scan. We then divided the group into those with CSI (Case) and those without (Control). We compared the two group variables and performed a multiple logistic regression analysis to identify clinical factors associated with CSI. Statistical significance was accepted with p-value <0.05. RESULTS Of the 985 patients evaluated, only 179 (18%) received CC. The remaining did not receive CC and went on to have radiographs. Of these, 76 were diagnosed CSI (Case). On a univariate analysis, the ISS, a motor vehicle collision (MVC) with rollover; MVC with rollover and ejection, the absence of DI, and a lower-body DI were significantly associated with CSI. However, on a multivariate analysis, only an MVC with rollover (odds ratio [OR], 2.326; 95% confidence interval [CI], 1.36-3.97) and a lower-body distracting injury (OR, 0.20; 95% CI, 0.07-0.55) were significantly associated with CSI. CONCLUSION The injury mechanism of MVC with rollover may prevent clinicians from utilizing CC, while the presence of a lower-body DI should not. A future and prospective study is needed to better understand the role of the injury mechanism and the distracting injury in relation to CSI.

Keeping Residents in the Dark: Do Night-Float Rotations Provide a Valuable Educational Experience?

OBJECTIVE To qualify and characterize resident overnight activity. DESIGN A prospective 3-phase study was conducted of surgical residents with attention to activities performed on the overnight rotation: needs assessment, direct observation of activities, and feedback. SETTING This study was conducted at the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. This is both a tertiary referral center and the only American College of Surgeons (ACS) verified level 1 trauma center in the state. PARTICIPANTS This study included current surgical residents within the residency program. RESULTS During the study period, 270 pages were individually recorded, with 60% of these pages defined as time-sensitive activities. In addition, most of the pages involved pressing patient-care issues irrespective of postgraduate year level. Analyses revealed that residents spend most of their time performing educational activities (62%). On feedback, residents reported overall satisfaction with the learning opportunities during night-shift (6.4/7.0) and indicated their perceptions of an adequate balance of service and education on night float (6.6/7.0). This correlates with our annual rotation assessment where residents identify night-float as an overall positive experience which provides educational benefit. CONCLUSIONS Work-hour restrictions induce residency programs to adapt to new training models. Our results report a breakdown of resident activities while on night-float and demonstrate that overnight shifts continue to provide important educational opportunities during training.