Najma Ahmed

Video-assisted thoracic surgery: state of the art in trauma care

The majority of chest-injured patients are managed with resuscitation and placement of chest tubes. Further interventions are required for complications or missed injuries. Video-assisted thoracic surgery (VATS) has become standard in elective surgery. Our purpose was to review the use of VATS in trauma. The literature and our experience support the use of VATS for specific indications. These indications are: (1) management of retained haemothorax; (2) management of persistent pneumothorax; (3) evaluation of the diaphragm in penetrating thoraco-abdominal injuries and management; (4) management of infected pleural space collections; and (5) diagnosis and management of on-going bleeding in haemodynamically stable patients. VATS for specific indications in trauma is associated with improved outcomes and decreased length of stay. VATS provides diagnostic and therapeutic benefit and should be included in the trauma surgeons clinical armamentarium.

Venous Thromboembolism as a Marker of Quality of Care in Trauma

BACKGROUNDnVenous thromboembolism (VTE) is reported to occur among 7% to 58% of trauma patients. Variability in VTE rates might reflect differences in case mix and quality of care, but also screening practices or data capture. We explored the variation in VTE rates across trauma centers to determine its use as a measure of the quality of patient care.nnnSTUDY DESIGNnThe National Trauma Data Bank (version 7.1, admission year 2006) was used to capture a cohort at risk for VTE. Crude and adjusted rates of VTE were determined, and the observed and expected rates were compared across centers. Outlier hospitals were defined as those with considerably more (or fewer) patients than expected. We then assessed the level of concordance between outlier status for deep vein thrombosis (DVT) and pulmonary embolism (PE). Intraclass correlation coefficients (ICC) were calculated to evaluate for the presence of a center effect using multilevel modeling.nnnRESULTSnThe 22,421 patients met inclusion criteria from 30 trauma centers. There was marked variability in the rate of VTE across centers, ranging from 0.2% to 13.3%, which was more pronounced for DVT (0.2% to 13.1%) than for PE (0% to 1.7%). There was poor concordance for DVT and PE outlier status. Intraclass correlation coefficient was four times greater for DVT (0.23) than for PE (0.06).nnnCONCLUSIONSnThere was substantial variation in rates of VTE across trauma centers. There was no relationship between DVT and PE outlier status, which is counter to the understanding of the biologic relationship between the two. Lastly, the very low Intraclass correlation coefficient for PE compared with DVT suggests that to a large extent, practice variation has very little impact on PE rates. In light of these findings and concerns about patient ascertainment of DVT, VTE rates might not be a useful measure of quality of care.

Attitudes about Injury among High School Students

BACKGROUNDnDespite education and changes in public policy, trauma-related injuries continue to exact an unacceptably high morbidity and mortality, particularly among young people. Most injuries are preventable and can often be attributed to poor choices.nnnSTUDY DESIGNnA mixed methods study involving 262 high school students was conducted to study the effect on knowledge and risk assessment after a day-long injury prevention program, and to develop a theoretic framework to better understand attitudes and beliefs that underlie commonly seen behaviors among young people.nnnRESULTSnKnowledge about injury increased after participation in the program, but was not durable over time. Risk perception and capacity to discern safer options improved after the program and persisted for up to 30 days. A qualitative analysis revealed seven themes that reflect a sense of invincibility and a belief that fate is more important than choice in determining the outcomes of a situation.nnnCONCLUSIONSnEffective injury prevention programs should include risk perception training that is informed by the attitudes and beliefs of the recipients.

Controversies in the management of splenic trauma

BACKGROUNDnThe technologic innovations of the last three decades, coupled with a deeper understanding of the immunologic role of the spleen, have significantly shifted the management of splenic injuries towards non-operative approaches. However, there continuous to be a wide range of practice patterns related to the non-operative management of splenic injuries, from which the authors infer a gap between the best available evidence and its translation into practice. We sought to explore ongoing areas of controversy in the non-operative management of splenic trauma with the aim of further elucidating why these controversies continue to exist.nnnMETHODSnWe explored areas of ongoing controversy in the management of splenic injury though a series of iterative surveys. We invited 70 experts in trauma care from ten countries around the world to participate. Areas of controversy explored included: indications and frequency for in-hospital and follow-up imaging, definitions of failure of non-operative management, indications for angioembolisation and non-operative management in special populations (i.e. elderly, concomitant traumatic brain injury, penetrating trauma).nnnRESULTSnA 49% response rate was obtained. Even though a wide range of practice patterns were identified, no controversies were identified in areas that do not involve the adoption of new technologies. In areas where practice pattern variation was observed, the strong influence of the local environment was constantly identified as an impediment to changes in practice.nnnCONCLUSIONSnWe have identified that barriers present within local practice environments are the major driving forces behind controversies in the non-operative management of splenic injuries.

Alcohol, drugs and trauma: consequences, screening and intervention in 2009

Alcohol use is a preventable cause of injury as it doubles the risk of re-injury and increases mortality. For this reason, the American College of Surgeons, Committee on Trauma had mandated a screening and subsequent intervention strategy for all Level I centres, and there is good evidence to support the efficacy of such programmes. Clinicians can play a key role in reducing injury related to alcohol use through their participation in these programmes. Although validated screening tools and evidence to support brief interventions for alcohol use exist, the benefit of these experiences for other recreational drugs awaits further research in this area. In the meantime, the implementation of alcohol screening and brief intervention programmes across all trauma programmes and emergency departments should become a global healthcare priority.

Career Plans and Perceptions in Readiness to Practice of Graduating General Surgery Residents in Canada

INTRODUCTIONnOverall, 25% of American general surgery residents identified as not feeling confident operating independently at graduation, which may contribute to 70% pursuing further training. This study was undertaken to identify intended career plans of general surgery graduates in Canada on a national level, and perceived strengths and weaknesses of training that would affect transition to early practice.nnnMETHODSnQuestionnaires were distributed to graduating general surgery residents at a Canadian national review course in 2012 and 2013. Data were analyzed for overall trends.nnnRESULTSnOverall, 75% (78/104) of graduating residents responded in 2012 and 53% (50/95) in 2013. Greater than 60% of respondents were entering a fellowship program upon graduation (49/78 in 2012 and 37/50 in 2013); the most common fellowship choices were minimally invasive surgery (24% in 2012 and 39% in 2013) or surgical oncology (16% in 2012). Most residents reported that they were completing subspecialty training to meet career goals (64/85 overall) rather than feeling unprepared for practice (0/85 overall). Most residents planned on practicing in urban centers (54%) and academic hospitals (73%). Residents perceived a need for assistance for laparoscopic adrenalectomy, neck dissection, laparoscopic splenectomy, laparoscopic low anterior resection, groin dissection, and thyroidectomy.nnnCONCLUSIONSnAn overwhelming majority of general surgery graduates plan to pursue fellowship training to meet career goals of working in urban, academic centers, rather than a perceived lack of competence. It is vital to describe operative competency expectations for residents and to promote a variety of practice opportunities following graduation.

Interprofessional communication between surgery trainees and nurses in the inpatient wards: Why time and space matter

ABSTRACT Optimal interprofessional communication (IPC) is broadly viewed as a prerequisite to providing quality patient care. In this study, we explored the enablers and barriers to IPC between surgical trainees and ward nurses with a view towards improving IPC and the quality of surgical patient care. We conducted an ethnography in two academic centres in Canada totalling 126 hours of observations and 32 semi-structured interviews with trainees and nurses. Our findings revealed constraints on IPC between trainees and nurses derived from contested meanings of space and time. Trainees experienced the contested spatial boundaries of the surgical ward when they perceived nurses to project a sense of territoriality. Nurses expressed difficulty getting trainees to respond and attend to pages from the ward, and to have a poor understanding of the nurses’ role. Contestations over time spent in training and patient care were found in trainee–nurse interactions, wherein trainees perceived seasoned nurses to devalue their clinical knowledge on the ward. Nurses viewed the limited time that trainees spent in clinical rotation in the ward as adversely affecting communication. This study underscores that challenges to enhancing IPC at academic health centres are rooted in team and professional cultures. Efforts to improve IPC should therefore: identify and target the social and cultural dimensions of healthcare team member relations; recognise how power is deployed and experienced in ways that negatively impact IPC; and enhance an understanding and appreciation in the temporal and spatial dimensions of IPC.

The case of a migrating bullet.

In February, 2006, a 22-year-old man was brought to our trauma resuscitation room. He reported having been shot twice in the back. On examination, his blood pressure and heart rate were 130/70 mm Hg and 80 bpm, respectively. He was awake, alert, and oriented. The gunshot wounds were in the right back, below the 12th rib, four fi ngerbreadths lateral to the midline. A thorough search revealed no other wounds. Both chest (fi gure A) and plain abdominal supine radiography showed a single foreign body. No free intra-peritoneal or intra-pericardial fl uid was detected by ultrasonography. The patient underwent an intravenous injected CT of the chest, abdomen, and pelvis. A single bullet was identifi ed lodged in the right paraspinal muscle. Otherwise, the images were interpreted as negative for intra-thoracic or intra-abdominal injuries. The second bullet wound was presumed to be a graze injury. Further imaging review showed a foreign body in the left thigh, asymmetry of the psoas muscles with fullness in the right compared with the left, and minimal fl uid around the vena cava. In the interim, the patient complained of diff use abdominal pain in the left upper quadrant and epigastrium. The pain migrated to the basal left chest. Vital signs were normal. Repeat chest radiography showed a new foreign body in the chest (fi gure B). The patient immediately underwent a repeat chest CT. This showed a bullet in the right ventricle. Plain radiography of the left leg showed that the foreign body had disappeared. An interventional team attempted, unsuccessfully, to remove the intra-cardiac bullet. A venogram showed no discernible injury in the vena cava. A repeat abdominal CT showed slightly increased haemoperitioneum with stranding around the right adrenal gland and posterior vena cava. Surgery was therefore delayed until the third post-injury day, when the patient underwent sternotomy and cardiotomy with cardiac bypass under full anticoagulation. Full heparinisation for cardiac bypass was considered safe after the venogram confi rmed integrity of the posterior wall of the vena cava. A 1 cm bullet was removed from behind a tricuspid valve leafl et. The patient was discharged on the 7th post-operative day. When seen for fi nal follow-up in, July, 2006, the patient had recovered fully without any complications. A review of the events leads us to assume that the second bullet traversed the psoas muscle and pierced the posterior aspect of the infra-hepatic vena cava, stopped, and fell into the left profunda femoris vein. The welldeveloped psoas muscle in this young man absorbed the majority of the potential energy, stopping the bullet in its tracts. Otherwise the bullet would have pierced the anterior wall of the vena cava, probably causing massive haemoperitoneum and haemodynamic instability. The migrating abdominal pain may have been related to the bullet obstructing mesenteric venous beds as it travelled via the inferior vena cava to the heart. This is an unusual and potentially serious complication of a bullet embolising through the venous system and to the heart. A fi rst review of the CT failed to identify the foreign body in the profunda femoris vein. The clinicians were focused on identifying retroperitoneal and intra-abdominal injuries, and none was immediately obvious. This case highlights the importance of a systematic review of all imaging by an experienced reader before clinical decisions are made. In addition, this case report emphasises the need to aggressively rule out anatomical traumatic lesions in patients with gunshot wound to the torso, until proven otherwise, by both clinical and advanced radiological examinations.

Why Do General Surgeons Decide to Retire?: A Population-level Survey

&NA; Limited recent data exist regarding intended retirement plans for general surgeons (GS). We sought to understand when and why surgeons decide to stop operating as primary surgeon and stop all clinical work. A paper-based survey of practicing GS in the province of Ontario, Canada, was conducted. A questionnaire was developed using a systematic approach of item generation and reduction. Face and content validity were tested. The survey was administered via mail, with a planned reminder. Overall response rate was 33.5% (242/723). The median age at which respondents planned to/did stop operating was 65 (interquartile range 60–67.5). The median age at which respondents planned to/did retire from all clinical work was 70 (interquartile range 65–72.5). Career satisfaction (97%), sense of identity (90%), and financial need (69%) were factors that influenced the decision to continue operating. Enjoyment of work (79%), camaraderie with surgical colleagues (66%), and financial need (45%) were reasons to continue working after ceasing to operate as the primary surgeon. On multivariate analysis, younger respondents (36–50 years old) perceived they were less likely to continue operating past age 65 (odds ratio 0.13), and academic surgeons were more likely to stop operating after age 65 (odds ratio 2.39). Call coverage by nonstaff surgeons was not associated with retirement age. Overall, GS plan to stop operating at age 65, and to cease all clinical activities at age 70. Younger, nonacademic surgeons plan to stop operating earlier. Career satisfaction, sense of identity, and financial need are the principal reported motivations to continue operating.