Richard A. Sidwell

The burden of unhelmeted and uninsured ATV drivers and passengers.

Objective: Injured all-terrain vehicle (ATV) riders contribute to the national trauma burden. The importance of helmet use on injury severity and outcomes in ATV drivers versus passengers that receive care is unknown along with the association of payor status and helmet use in this population. An investigation of whether helmet use protects ATV drivers and passengers resulting in less severe injuries, better outcomes, and a lower cost burden to society is to be conducted. Methods: A retrospective review of injured ATV riders in the National Trauma Data Bank from the United States for 2000–2004. Results: Helmet use status was recorded for 5897 drivers and 836 passengers; 83 percent of drivers were male; 41 percent of passengers were female. Helmets were not widely worn (35% of drivers, 19% of passengers, p < .0001) and were less common among female than male drivers who crashed and received care (26% versus 37%, p < .0001). Drivers were older than passengers (p < .0001) and had more thorax, spine, and upper extremity injuries (p < .05). Helmets protected drivers and passengers: decreased head injuries, face injuries, injury severity, and mortality with increased likelihood of being discharged home rather than elsewhere (p < .0001). Personal insurance was more frequent in helmeted riders: 66 percent versus 55 percent of helmeted versus nonhelmeted drivers (p < .0001) and 69 percent versus 55 percent of helmeted versus nonhelmeted passengers (p = .03). Conclusions: Helmets are frequently not worn by ATV riders. Helmets protect ATV drivers and passengers and decrease societal costs associated with ATV crashes.

Stretch and Wrap Style Tourniquet Effectiveness With Minimal Training

UNLABELLED The objective was to determine if proper application of the Stretch, Wrap, and Tuck Tourniquet (SWAT-T) would stop arterial flow and would occur with minimal training. METHODS Fifteen undergraduates watched a 19 second video three times, practiced twice, and applied the tourniquet to volunteers at 10 locations: 3 above the elbow or knee and 2 below. RESULTS Successful occlusion (60 second Doppler signal elimination) was more frequent than proper stretch (96 versus 75), more frequent on arms than legs (59 versus 37), and achieved before completed application (16 +/- 8 versus 33 +/- 8 seconds; each p < 0.05). Proper stretch (correct alteration of shapes printed on the tourniquet) was more frequent on legs than arms (30 versus 45; p <0.05). Applications were rated Easy (101), Challenging (37), Difficult (12) with discomfort None (53), Little (62), Moderate (34), Severe (1). The 8 appliers with <70% proper stretch rates received 10 minutes additional training and then retested at mid upper arm, mid-thigh, and below knee (24 applications) for improved proper stretch and occlusion (5 versus 18 and 10 versus 20; p < 0.01). CONCLUSIONS Proper application of the SWAT-T is easy and can stop extremity arterial flow but requires some training for many appliers.

Clinical indicators of midface fracture in patients with trauma

BACKGROUND/AIM Midface fractures are commonly present and difficult to diagnose in trauma patients. The objective of this study was to determine clinically accessible indicators of midface fracture. MATERIAL AND METHODS A case-control study design was used to determine clinical indicators of midface fracture. Population source was a level I trauma center registry for years 2007-2009. Cases had a documented midface fracture. Patient and trauma characteristics were compared between cases and controls. Multivariate logistic regression analysis determined significant indicators of midface fracture. RESULTS Study sample included 83 cases and 83 frequency-matched controls. Cases had a total of 211 fractures with a median of two midface fractures per person. Common fractures were orbital (41%), malar and maxillary (28%), and nasal bones (19%). Patients with midface fracture were significantly different than patients without midface fracture in severity of injury and were more likely to have a traumatic brain injury. Significant clinical indicators of fracture were maxillary sinus opacification, ethmoid sinus opacification, forehead laceration, periorbital contusion, epistaxis, and injury mechanism (P < 0.05). Patients with midface fracture had a 63 times greater odds for maxillary sinus opacification. The multivariable model correctly classified the presence and absence of midface fracture in 95% of study sample. CONCLUSIONS Determined indicators of midface fracture provided a high level of discrimination in fracture status. Indicators can be used by clinicians to help detect possible midface fractures. Future prospective research on midface fracture indicators can assist in establishing their generalizability and impact on fracture detection, care, and outcomes.

Utility and Relevance of Diagnostic Peritoneal Lavage in Trauma Education

OBJECTIVES During the last 2 decades, the advent of new technologies in trauma patient care may have resulted in a decreased number of diagnostic peritoneal lavage (DPL) evaluations. In this study, it is hypothesized that fewer DPL are being performed at a midwestern trauma center. Such negative trends may make the inclusion of DPL in current trauma education potentially outdated and no longer universally appropriate in trauma evaluation algorithms. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational study of a level I trauma center includes patients from January 1998 through September 2010. The total number of trauma-related DPL procedures performed annually during the study period was determined along with accompanying facility and trauma patient level data. RESULTS A total of 24 DPLs were performed at the target trauma center during the study period. There was a significant decrease (p = 0.0018) in the use of DPL despite a significant increase (p < 0.0001) in the proportion of trauma patients with an injury severity score > 15. CONCLUSIONS Study data demonstrated a decrease in the use of DPL as a diagnostic modality in the evaluation of blunt abdominal trauma patients at a medium-sized midwestern center. These data provide historic facility-level evidence of a practice change. Such information may support a recommendation that the American College of Surgeons revisit its current curriculum for Advanced Trauma Life Support (ATLS). Specifically, we propose the American College of Surgeons consider changing DPL instruction to an optional component of ATLS. COMPETENCIES: Patient Care, Medical Knowledge, Practice Based Learning and Improvement.

Cardiac Risk Stratification and Protection

The goal of preoperative cardiac evaluation is to screen for undiagnosed cardiac disease or to find evidence of known conditions that are poorly controlled to allow management that reduces the risk of perioperative cardiac complications. A careful history and physical examination combined with the procedure-specific risk is the cornerstone of this assessment. This article reviews a brief history of prior cardiac risk stratification indexes, explores current practice guidelines by the American College of Cardiology and the American Heart Association Task Force, reviews current methods for preoperative evaluation, discusses revascularization options, and evaluates perioperative medication recommendations.

Hospital discharge destinations for Hispanic and non-Hispanic white patients treated for traumatic brain injury.

Purpose: To examine hospital discharge destinations for Hispanic and non-Hispanic white patients treated for traumatic brain injury. Methods: Retrospective cohort study with patient matching. Findings: Ethnicity status not determined a significant predictor of discharge destination (P = .2150). Patient hospital length of stay determined a significant predictor of discharge destination (P = .0072), with every 1 day increase in length of stay, resulting in a 12% increase in odds of being discharged to care facility. Conclusions: Study data suggest that length of stay can predict discharge destination for both Hispanic and non-Hispanic white patients in a medium-sized trauma center in the Midwest.

Imaging of the Cervical Spine in Injured Patients

Cervical spine injury can be excluded by clinical examination, without the need for radiographic study, in many patients. For those who require study, computed tomography of the cervical spine with sagittal and coronal reconstruction is the best modality for both screening and diagnosing cervical spine injury. Optimal evaluation of the obtunded patient remains controversial.

Trauma patients over-triaged to helicopter transport in an established midwestern state trauma system

PURPOSE To characterize helicopter transport use in a mature Midwestern trauma system located in a low population density state, examine characteristics of patients over-triaged to helicopter transport, and determine predictors of over-triage to helicopter transport. METHODS A retrospective observational study conducted using State Trauma Registry data for years 2008-2009. Study sample included patients with medical helicopter transportation. Bivariate analyses compared patients defined and not defined as over-triaged to helicopter transport. Multivariate regression was used to determine predictors of over-triage. FINDINGS Of the 2,084 helicopter-transported study patients, 552 (26%) were defined as over-triaged. Differences in patients based on over-triaged status included race, age, injury mechanism, injury type, and injury intent (P < .05). Multivariate-based significant predictors of over-triage were transfer status, patient age, and injury mechanism (P= .0223; <.0001; and .0007, respectively). Patients transported from scene had a greater odds (OR: 1.29; 95% confidence interval: 1.04, 1.60) of being over-triaged to helicopter transport than interfacility transfers. Younger patients were also more likely to be over-triaged. Interactions between patient age and injury mechanism demonstrated varied likelihoods for over-triage. Younger patients injured in falls were more likely over-triaged than younger patients injured in a motor vehicle crash or by other non-fall causes. CONCLUSION Study data showed over-triage to helicopter transport was substantial in a mature trauma system. It is recommended that trauma systems develop and monitor compliance with criteria for appropriate use of air medical transport. These actions can assist in refinements to prehospital and interfacility transfer protocols.

A Multicenter Prospective Comparison of the Accreditation Council for Graduate Medical Education Milestones: Clinical Competency Committee vs. Resident Self-Assessment

OBJECTIVE The Accreditation Council for Graduate Medical Education requires accredited residency programs to implement competency-based assessments of medical trainees based upon nationally established Milestones. Clinical competency committees (CCC) are required to prepare biannual reports using the Milestones and ensure reporting to the Accreditation Council for Graduate Medical Education. Previous research demonstrated a strong correlation between CCC and resident scores on the Milestones at 1 institution. We sought to evaluate a national sampling of general surgery residency programs and hypothesized that CCC and resident assessments are similar. DESIGN Details regarding the makeup and process of each CCC were obtained. Major disparities were defined as an absolute mean difference of ≥0.5 on the 4-point scale. A negative assessment disparity indicated that the residents evaluated themselves at a lower level than did the CCC. Statistical analysis included Wilcoxon rank sum and Sign tests. SETTING CCCs and categorical general surgery residents from 15 residency programs completed the Milestones document independently during the spring of 2016. RESULTS Overall, 334 residents were included; 44 (13%) and 43 (13%) residents scored themselves ≥0.5 points higher and lower than the CCC, respectively. Female residents scored themselves a mean of 0.08 points lower, and male residents scored themselves a mean of 0.03 points higher than the CCC. Median assessment differences for postgraduate year (PGY) 1-5 were 0.03 (range: -0.94 to 1.28), -0.11 (range: -1.22 to 1.22), -0.08 (range: -1.28 to 0.81), 0.02 (range: -0.91 to 1.00), and -0.19 (range: -1.16 to 0.50), respectively. Residents in university vs. independent programs had higher rates of negative assessment differences in medical knowledge (15% vs. 6%; P = 0.015), patient care (17% vs. 5%; P = 0.002), professionalism (23% vs. 14%; P = 0.013), and system-based practice (18% vs. 9%; P = 0.031) competencies. Major assessment disparities by sex or PGY were similar among individual competencies. CONCLUSIONS Surgery residents in this national cohort demonstrated self-awareness when compared to assessments by their respective CCCs. This was independent of program type, sex, or level of training. PGY 5 residents, female residents, and those from university programs consistently rated themselves lower than the CCC, but these were not major disparities and the significance of this is unclear.

Residency Surgical Training at an Independent Academic Medical Center

Independent academic medical centers have been training surgeons for more than a century; this environment is distinct from university or military programs. There are several advantages to training at a community program, including a supportive learning environment with camaraderie between residents and faculty, early and broad operative experience, and improved graduate confidence. Community programs also face challenges, such as resident recruitment and faculty engagement. With the workforce needs for general surgeons, independent training programs will continue to play an integral role.