Paul J. Schenarts

Prospective Comparison of Admission Computed Tomographic Scan and Plain Films of the Upper Cervical Spine in Trauma Patients with Altered Mental Status

OBJECTIVE The accurate evaluation of patients with multiple injuries is logistically complex and time sensitive, and must be cost-effective. We hypothesize that computed tomographic (CT) scan of the upper cervical spine (occiput to C3 [Co-C3]) would add little to the initial evaluation of patients with multiple injuries who have altered mental status. METHODS The study consisted of a prospective, unblinded, consecutive series. Patients met entry criteria if they had sustained a blunt mechanism of injury and had an altered mental status requiring CT scan of two or more body systems. All patients received CT scan of Co-C3 with 2-mm cuts and subsequent reconstructions as well as five-view cervical spine plain films. Cervical spine injury was defined as any radiographically identified fracture or subluxation that required treatment. Patients were excluded if they died or were cleared clinically before plain film series were obtained. CT scan of Co-C3 and cervical spine films were reviewed by two different attending radiologists. RESULTS Of the 2,690 consecutive admissions between December 1998 and November 1999, 1,356 patients met entry criteria. Seventy patients (5.2%) had a total of 95 injuries to the upper cervical spine. CT scan of Co-C3 identified 67 of 70 patients and plain films identified 38 of 70 patients with injuries to the upper cervical spine. Twelve patients (17%) had neurologic deficits attributable to Co-C3 injuries. Three patients had false-negative CT scans of Co-C3, and one patient was quadriplegic. There were 32 patients with false-negative plain films, including four patients with motor deficits (one with quadriplegia). Use of the guidelines developed by the Eastern Association for the Surgery of Trauma identified all patients with upper cervical spine injuries; to date, no patient in the study group was readmitted or has initiated a lawsuit for missed injury of the upper cervical spine. CONCLUSION CT scan of Co-C3 was superior to plain films in the early identification of upper cervical spine injury. Plain films failed to identify 45% of upper cervical spine injuries; four of these missed injuries resulted in motor deficits. Our study supports the practice guidelines developed by the Eastern Association for the Surgery of Trauma for clearance of the upper cervical spine in patients with altered mental status, as all patients with injuries were identified using these guidelines.

Is your residency program ready for Generation Y

Current residency applicants are members of Generation Y and are significantly different from previous generations of trainees as well as the faculty who attract, recruit, and manage them. Generation Y has been affected by globalization, diversification, terrorism, and international crisis. They are products of the self-esteem movement in child rearing, education, and extracurricular activities where they were all declared winners. Childrens activities no longer had winners and losers or first, second, and third place; every child received a participation trophy. Even though they were raised to be a team player, their parents always told them they are special. Technology is ingrained into their daily lives, and they expect its use to be effective and efficient. Generation Y-ers desire to impact the world and give back to their communities and demand immediate access to leadership. This generation poses a challenge to residency programs that will need to attract, recruit, and manage them effectively. This article will provide an overview of Generation Y, contrast Generation Y with Generation X, and discuss how to use generation-specific strategies to attract, recruit, and manage a Generation Y resident.

Perceptions of Graduating General Surgery Chief Residents: Are They Confident in Their Training?

BACKGROUND Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

Disparity Between Resident and Faculty Surgeons' Perceptions of Preoperative Preparation, Intraoperative Teaching, and Postoperative Feedback

PURPOSE The education occurring within the operating room is fundamental to the development of a surgical resident. The purpose of this study was to investigate differing perceptions of surgical residents and faculty in regard to preoperative preparation, intraoperative teaching, and postoperative feedback. METHODS A validated survey tool was slightly adapted, piloted, and then administered to the surgical residents and faculty of a university-based general surgery residency program. The wording of the survey was specific to either residents or faculty and consisted of similar questions with responses on a 5-point Likert scale (1: strongly disagree to 5: strongly agree). The responses of the 2 groups for each question were averaged and compared using Wilcoxon-Mann-Whitney test to determine significant differences. RESULTS In all, 27 residents and 30 faculty members completed the survey for a response rate of 100%. With respect to preoperative preparation, significant differences were found in perceptions about reading (4.22 vs 2.59; p < 0.001) and anatomy review (4.11 vs 2.31; p < 0.001) before the procedure. Considering intraoperative perceptions, significant differences were found with respect to teaching the operative steps (3.59 vs 4.06 p = 0.048), surgical skills (2.85 vs 3.78; p = 0.001), instrument handling (3.19 vs 4.00; p = 0.002), and surgical technique (3.44 vs 4.28; p < 0.001). Significant disagreement was found in the perceived effort of the faculty to act as a teacher in the operating room (3.56 vs 4.09; p < 0.007). Postoperatively, significant differences were found in perceptions of positive feedback (2.63 vs 3.34; p = 0.01) and feedback on areas to improve (2.78 vs 3.50; p = 0.009). CONCLUSIONS Although there is agreement on the need to improve intraoperative education, there is significant disparity in perceptions of preoperative preparation as well as intraoperative and postoperative feedback between residents and surgical faculty.

Educational Impact of the Electronic Medical Record

INTRODUCTION The electronic medical record (EMR) is commonly thought to improve the safety and quality of care; however, there is scant information on the impact the EMR has on graduate medical education (GME). METHODS A review of English language literature was performed using MEDLINE and OVID databases using or combining the terms, EMR, GME, electronic health record, education, medical student, resident, clinical decisions support systems, quality, and safety. RESULTS The EMR has a negative effect on teacher and learner interactions, clinical reasoning, and has an inconsistent impact on resident workflow. Data on the impact of the EMR on patient safety, quality of care, and medical finances are mixed. DISCUSSION Based on the literature to date, the EMR has not had as dramatic an effect on patient outcomes is commonly believed. While the overall impact of the EMR on education seems to be negative, there are actions that can be taken to mitigate this impact.

Oxalated pyridoxalated hemoglobin polyoxyethylene conjugate normalizes the hyperdynamic circulation in septic sheep.

OBJECTIVE Excessive production of nitric oxide significantly contributes to the hyperdynamic state associated with sepsis. The ability of hemoglobin to scavenge nitric oxide may therefore be beneficial in the treatment of sepsis. In this study, we determined the effects of different doses of the modified human pyridoxalated hemoglobin polyoxyethylene conjugate in an ovine model of hyperdynamic sepsis. DESIGN Prospective, experimental study. SETTING Large animal research laboratory at a university medical center. INTERVENTIONS Sheep (n = 23) were surgically prepared for chronic study. After a 5-day recovery period, all animals received a continuous infusion of live Pseudomonas aeruginosa (2.5 x 10(6) colony-forming units/min) for the next 48 hrs. After 24 hrs of sepsis, the animals were divided into four groups: a) six sheep were used as controls and received a bolus of 200-mL vehicle; b) three sheep received a bolus of 50 mg/kg hemoglobin; c) six sheep received 100 mg/kg of hemoglobin; d) six sheep received 200 mg/kg of hemoglobin. MEASUREMENTS AND MAIN RESULTS All animals that survived the first 24 hrs of sepsis (n = 21) developed a hyperdynamic circulation. All three doses of hemoglobin reversed this hyperdynamic state by increasing mean arterial pressure and systemic vascular resistance while decreasing cardiac index. Pulmonary arterial pressure increased after hemoglobin infusion. Increased pulmonary arterial pressure did not affect arterial oxygen saturation nor result in the development of pulmonary edema. Infusion of hemoglobin also caused a 30-fold increase in endothelin-1 plasma concentrations and significantly decreased nitrate and nitrite plasma concentrations. CONCLUSIONS The infusion of low doses of pyridoxalated hemoglobin polyoxyethylene conjugate in septic sheep reverses the hyperdynamic circulatory state. An increase in pulmonary arterial pressure was the only observed hemodynamic side effect; changes in the structure or function of other organ systems, or their biochemical correlates were not investigated in this study. In addition to a possible nitric oxide scavenging effect, pyridoxalated hemoglobin polyoxyethylene may affect the nitric oxide synthase and endothelin systems.

An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media.

PURPOSE Dismissal from residency is most commonly because of unprofessional conduct rather than cognitive failure. Disciplinary action by medical boards has also been associated with prior unprofessional behavior during medical school. Facebook is a social media network that has become ubiquitous in recent years and has the potential to offer an unvarnished view into the lives of residents using a public forum that is open to the public and program directors alike. The aim of this study was to evaluate the publically available Facebook profiles of surgical residents to determine the incidence and degree of unprofessional conduct. METHODS The American College of Surgeons Web site was used to identify general surgery residencies located in the Midwest. Resident rosters were then obtained using departmental Web sites. Facebook was then searched to determine which residents had profiles available for viewing by the public. The Accreditation Council for Graduate Medical Educations components of professionalism and the American Medical Associations report on professionalism in the use of social media were used to develop the following 3 categories: professional, potentially unprofessional, or clearly unprofessional. STATISTICAL ANALYSIS The chi-square test was used to determine significance. RESULTS A total of 57 residency programs were identified on the American College of Surgeons Web site, of which 40 (70.2%) provided an institutional Web site with a current resident roster. A total of 996 surgical residents were identified, of which 319 (32%) had identifiable Facebook profiles. Overall, 235 residents (73.7%) had no unprofessional content, 45 (14.1%) had potentially unprofessional content, and 39 (12.2%) had clearly unprofessional content. Binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act violations were the most commonly found variables in the clearly unprofessional group. There were no statistical differences in professionalism based on sex (p = 0.93) or postgraduate year status (p = 0.88). CONCLUSIONS Unprofessional behavior is prevalent among surgical residents who use Facebook, and this behavior does not appear to decrease as residents progress through training. This represents a risk to the reputations of hospitals and residency programs, and residents should be educated on the dangers of social media. Although it may be perceived as an invasion of privacy, this information is publically available, and program directors may benefit from monitoring these sites to identify gaps in professionalism that require correction.

A collaborative systems approach to rural burn care.

A collaborative systems approach was created between the regional verified burn center (BC) and the rural verified Level 1 trauma center (TC) to treat minor burns. This study assesses the feasibility of providing outpatient burn care at the TC. A retrospective review was performed from January 2000 to June 2005 of burn patients seen at the TC. Seven trauma/critical care surgeons and a dedicated burn nurse staffed the clinic twice a week. Burn surgeons from the BC provided consultation via email and telephone links and served as the regional resource. In the TC clinic, 314 injuries occurred in 311 patients. 196 patients were male with an average age of 34.5 ± 1.1 years. The mean burn TBSA was 2.9 ± 0.2%. Fourteen patients (4%) required skin grafts. Patients averaged 3.5 ± 0.1 clinic visits over a mean follow-up period of 42.9 ± 7.4 days from initial injury. There were 1252 scheduled appointments during the study period. Silver sulfadiazine or triple antibiotic ointment was applied in the majority of the cases. Thirty-one patients (9.9%) were documented to have complications, most of which were local wound infections. Long-term sequelae (scarring, chronic pain, and contractures) occurred in 13.4% of patients. Clinical success in outpatient burn care can be achieved at a non burn center with dedicated personnel. The successful collaboration between the BC and TC can unload some minor burn care from the burn center, while providing good clinical care to the local rural population.

BLUNT AND PENETRATING TRAUMA—HAS ANYTHING CHANGED?

Management of abdominal trauma has changed significantly in the last decade. The next decade will also see significant change as imaging and minimally invasive surgical techniques evolve and more approaches are examined in well-designed prospective studies.

The elderly trauma patient: an investment for the future?

BACKGROUND The cost of care in elderly (ELD) trauma patients is high compared with younger patients, but the association between age and reimbursement relative to cost is less clear. The purpose of this study was to explore the relationship between total costs (TC) and reimbursement in young (YNG) and ELD trauma patients. METHODS The National Trauma Registry of the American College of Surgeons was queried for patients admitted to a level I trauma center between January 2002 and December 2004. YNG patients (18-64 years) were compared with ELD patients (> or =65 years) for mechanism of injury, Injury Severity Score, and outcome variables. Data obtained from the hospital cost accounting system included TC, total payment, and net margin (P-L). Virtually, all patients were reimbursed based on the fixed diagnostic-related group payment. RESULTS There were 641 ELD and 3,470 YNG patients included in the study. ELD patients were more commonly injured via a blunt mechanism than the YNG patients (97% vs. 83%; p < 0.001). The ELD were more severely injured (Injury Severity Score 14.9 +/- 10.8 vs. 13.3 +/- 10.9), developed more complications (54% vs. 34%), and died more frequently (17% vs. 4.7%; all p < 0.05). TC for the ELD were significantly higher than the YNG (