Michael R. Oreskovich

Geriatric trauma: injury patterns and outcome

Over a 2-year period, 100 consecutive patients more than 70 years of age with multiple injuries were evaluated at a metropolitan trauma center for injury patterns and factors that affected survival. The analysis incorporated mechanism of injury, body region affected, Injury Severity Score, shock, change from level of prehospital function, and mortality. The mortality for the group was 15%. It was found that the Injury Severity Score was not predictive of survival in the elderly injured. However, central nervous system injury (p less than 0.01) and hypovolemic shock (p less than 0.001) were predictive of survival. While 85% of the injured patients survived, 88% of these did not return to their previous level of independence.

Special Report: Suicidal Ideation Among American Surgeons

BACKGROUND Suicide is a disproportionate cause of death for US physicians. The prevalence of suicidal ideation (SI) among surgeons and their use of mental health resources are unknown. STUDY DESIGN Members of the American College of Surgeons were sent an anonymous cross-sectional survey in June 2008. The survey included questions regarding SI and use of mental health resources, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS Of 7905 participating surgeons (response rate, 31.7%), 501 (6.3%) reported SI during the previous 12 months. Among individuals 45 years and older, SI was 1.5 to 3.0 times more common among surgeons than the general population (P < .02). Only 130 surgeons (26.0%) with recent SI had sought psychiatric or psychologic help, while 301 (60.1%) were reluctant to seek help due to concern that it could affect their medical license. Recent SI had a large, statistically significant adverse relationship with all 3 domains of burnout (emotional exhaustion, depersonalization, and low personal accomplishment) and symptoms of depression. Burnout (odds ratio, 1.910; P < .001) and depression (odds ratio, 7.012; P < .001) were independently associated with SI after controlling for personal and professional characteristics. Other personal and professional characteristics also related to the prevalence of SI. CONCLUSIONS Although 1 of 16 surgeons reported SI in the previous year, few sought psychiatric or psychologic help. Recent SI among surgeons was strongly related to symptoms of depression and a surgeons degree of burnout. Studies are needed to determine how to reduce SI among surgeons and how to eliminate barriers to their use of mental health resources.

Prehospital cardiopulmonary resuscitation of the critically injured patient

Prehospital cardiopulmonary resuscitation combined with endotracheal intubation, vigorous fluid resuscitation, and rapid transport can be effective in resuscitating trauma patients in cardiopulmonary arrest. Survival does not correlate with the injury severity score or transport time once the patient has arrested but does correlate with the mechanism of injury, endotracheal intubation, and placement of intravenous lines.

Prevalence of Alcohol Use Disorders Among American Surgeons

OBJECTIVES To determine the point prevalence of alcohol abuse and dependence among practicing surgeons. DESIGN Cross-sectional study with data gathered through a 2010 survey. SETTING The United States of America. PARTICIPANTS Members of the American College of Surgeons. MAIN OUTCOME MEASURES Alcohol abuse and dependence. RESULTS Of 25,073 surgeons sampled, 7197 (28.7%) completed the survey. Of these, 1112 (15.4%) had a score on the Alcohol Use Disorders Identification Test, version C, consistent with alcohol abuse or dependence. The point prevalence for alcohol abuse or dependence for male surgeons was 13.9% and for female surgeons was 25.6%. Surgeons reporting a major medical error in the previous 3 months were more likely to have alcohol abuse or dependence (odds ratio, 1.45; P < .001). Surgeons who were burned out (odds ratio, 1.25; P = .01) and depressed (odds ratio, 1.48; P < .001) were more likely to have alcohol abuse or dependence. The emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse or dependence. Male sex, having children, and working for the Department of Veterans Affairs were associated with a lower likelihood of alcohol abuse or dependence. CONCLUSIONS Alcohol abuse and dependence is a significant problem in US surgeons. Organizational approaches for the early identification of problematic alcohol consumption followed by intervention and treatment where indicated should be strongly supported.

THE INFLUENCE OF ETHANOL INTOXICATION ON OUTCOME OF INJURED MOTORCYCLISTS

Previous reports have failed to demonstrate a statistically significant adverse effect of acute ethanol intoxication in the well-resuscitated trauma patient. In the present study the prevalence of acute alcohol intoxication and its effect on outcome was analyzed in a homogenous population of young, previously healthy motorcycle accident victims (N = 134). The incidence of intoxication was 25%. The intoxicated cyclists were at fault for the accident 50% more often than the nonintoxicated cyclists and were found to wear helmets one third as frequently. Furthermore, the protective effect of helmet use as seen in the nonintoxicated group was lost in the intoxicated group, who sustained head injuries twice as frequently. Only patients with critical head injuries died and, although the ISS levels of those dying were similar in the two groups, the mortality following the critical head injury was twice as high among intoxicated patients (80 vs. 43%). Overall, the intoxicated group had a fourfold increased mortality rate. Thus, although intoxicated motorcyclists comprised 25% of the total population, they represent a mere 9% of the helmet-wearing population, and, in contrast, 39% of the severely head-injured victims and a majority (57%) of the mortality rate.

Personal Consequences of Malpractice Lawsuits on American Surgeons

BACKGROUND Our objective was to identify the prevalence of recent malpractice litigation against American surgeons and evaluate associations with personal well-being. Although malpractice lawsuits are often filed against American surgeons, the personal consequences with respect to burnout, depression, and career satisfaction are poorly understood. STUDY DESIGN Members of the American College of Surgeons were sent an anonymous, cross-sectional survey in October 2010. Surgeons were asked if they had been involved in a malpractice suit during 2 previous years. The survey also evaluated demographic variables, practice characteristics, career satisfaction, burnout, and quality of life. RESULTS Of the approximately 25,073 surgeons sampled, 7,164 (29%) returned surveys. Involvement in a recent malpractice suit was reported by 1,764 of 7,164 (24.6%) responding surgeons. Surgeons involved in a recent malpractice suit were younger, worked longer hours, had more night call, and were more likely to be in private practice (all p <0.0001). Recent malpractice suits were strongly related to burnout (p < 0.0001), depression (p < 0.0001), and recent thoughts of suicide (p < 0.0001) among surgeons. In multivariable modeling, both depression (odds ratio = 1.273; p = 0.0003) and burnout (odds ratio = 1.168; p = 0.0306) were independently associated with a recent malpractice suit after controlling for all other personal and professional characteristics. Hours worked, nights on call, subspecialty, and practice setting were also independently associated with recent malpractice suits. Surgeons who had experienced a recent malpractice suit reported less career satisfaction and were less likely to recommend a surgical or medical career to their children (p < 0.0001). CONCLUSIONS Malpractice lawsuits are common and have potentially profound personal consequences for US surgeons. Additional research is needed to identify individual, organizational, and societal interventions to support surgeons subjected to malpractice litigation.

Role of intraoperative pancreatography in patients with injury to the pancreas

Over a 10 year period, 54 patients presented with pancreatic trauma. During the first 5 years of the study, when pancreatography was not utilized for the assessment of pancreatic duct injury, 55 percent of the patients had major pancreatic complications. During the subsequent 5 years, suspected proximal duct injury was evaluated by intraoperative pancreatography. This resulted in a decrease of postoperative morbidity to 15 percent. In addition, there were not postoperative deaths during this period. The reduction in adverse sequelae after pancreatic trauma leads us to support the following principles of treatment: early recognition of pancreatic injury with immediate surgical intervention, complete exploration of the pancreas with the liberal use of intraoperative pancreatography to determine the presence of major duct injury, and the use of techniques which ensure control of duct disruption.

Long-term disability associated with flail chest injury

Twenty-two trauma victims who had sustained flail chest as their only significant injury were evaluated to determine the final outcome. Fourteen patients (63.9 percent) were found to have long-term sequelae. The most common long-term problems after flail chest injury were persistent chest wall pain, chest wall deformity, and dyspnea on exertion. Five patients (22 percent) remained disabled in varying degrees.

Work-Home Conflicts Have a Substantial Impact on Career Decisions That Affect the Adequacy of the Surgical Workforce

OBJECTIVE To evaluate factors associated with work-home conflicts (W-HCs) of US surgeons and their potential personal and professional consequences. DESIGN Cross-sectional study. PARTICIPANTS Members of the American College of Surgeons. MAIN OUTCOME MEASURES Burnout, depression, quality of life, alcohol use, career satisfaction, and career decisions (ie, reduce work hours or leave current practice). RESULTS Of 7197 participating surgeons, 3754 (52.5%) had experienced a W-HC in the previous 3 weeks. On multivariate analysis, hours worked per week, having children, sex, and work location (Veterans Administration or academic center) were independently associated with an increased risk for W-HC (all P < .01), while some factors (increased age and subspecialty field) reduced the risk. Surgeons with a recent W-HC were more likely to have symptoms of burnout (36.9% vs 17.1%; P < .001), depression (50.9% vs 28.1%; P < .001), alcohol abuse/dependency (17.2% vs 14.4%; P = .003), and were less likely to recommend surgery as a career option to their children (46.0% vs 54.4%; P < .001). Work-home conflicts were also independently associated with surgeons reporting a moderate or higher likelihood of planning to reduce clinical work hours (odds ratio, 1.769) and leave their current practice in the next 24 months for a reason other than retirement (odds ratio, 1.706) after controlling for other personal and professional factors. CONCLUSIONS Integrating personal and professional lives is a substantial challenge for US surgeons. Conflict in this balance appears to be a major factor in their decision to reduce work hours and/or move to a new practice, with potential substantive manpower implications for the surgical workforce.

The prevalence of substance use disorders in American physicians.

BACKGROUND There have been few studies on the prevalence of substance use disorders (SUDS) in the physician population at large nor have any studies compared the prevalence of SUDS in American physicians by specialty. METHODS We conducted a national study of SUDS in a large sample of U.S. physicians from all specialty disciplines using the AMA Physician Masterfile. Substance Use Disorders (SUDS) were measured using validated instruments. RESULTS Of the 27,276 physicians who received an invitation to participate, 7,288 (26.7%) completed surveys. 12.9% of male physicians and 21.4% of female physicians met diagnostic criteria for alcohol abuse or dependence. Abuse of prescription drugs and use of illicit drugs was rare. Factors independently associated with alcohol abuse or dependence were age (OR = .985; p < .0001), hours worked (OR = .994; p = .0094), male gender (OR = .597; p < .0001), being married (OR 1.296; p = .0424) or partnered (OR 1.989; p = .0003), having children (OR .745; p = .0049), and being in any specialty other than internal medicine (OR 1.757; p = .0060). Specialty choice was strongly associated with alcohol abuse or dependence (p = .0011). Alcohol abuse or dependence was associated with burnout (p < .0001), depression (p < .0001), suicidal ideation (p = .0004), lower quality of life (p < .0001), lower career satisfaction (p = .0036), and recent medical errors (p = .0011). CONCLUSION Alcohol abuse or dependence is a significant problem among American physicians. Since prognosis for recovery of physicians from chemical dependency is exceptionally high, organizational approaches for the early identification of problematic alcohol consumption in physicians followed by intervention and treatment where indicated should be strongly supported.