Sheldon Teperman

U.S. surgeon and medical student attitudes toward organ donation.

BACKGROUND Nearly 100,000 people await an organ transplant in the U.S. Improved utilization of potential organ donors may reduce the organ shortage. Physician attitudes toward organ donation may influence donation rates; however, the attitudes of U.S. physicians have not been formally evaluated. METHODS Anonymous questionnaires were distributed to surgical attendings, surgical residents, and medical students at two academic medical centers. Willingness to donate ones own organs and family members organs was examined, as well as experience with transplant procedures and religious views regarding organ donation. RESULTS A total of 106 surveys were returned. Sixty-four percent of responders were willing to donate their own organs, and 49% had signed an organ donor card. Willingness to donate inversely correlated with professional experience. Eighty-four percent of those surveyed would agree to donate the organs of a family member, including 55% of those who refused to donate their own organs. Experience on the transplant service influenced 16% of those refusing donation, with the procurement procedure cited by 83% of this group. Sixteen percent refused organ donation on the basis of religious beliefs. CONCLUSIONS The surveyed U.S. physicians are less willing to donate their organs compared with the general public. Despite understanding the critical need for organs, less than half of physicians surveyed had signed organ donor cards. Previous experiences with the procurement procedure influenced several responders to refuse organ donation. As the lay public traditionally looks to physicians for guidance, efforts must be made to improve physician attitudes toward organ donation with the hope of increasing donation rates.

Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban Level I trauma center.

BACKGROUND Disparities in access to postdischarge services for trauma patients exist, and clinic follow-up remains an important avenue to ensure initial and continued access to postdischarge services. In addition, follow-up is vital to rigorous long-term trauma outcomes research. However, there is a relative paucity of literature specifically addressing clinic follow-up. The purposes of this study were to elucidate factors associated with clinic follow-up compliance and noncompliance after discharge from an urban Level I trauma center and to confirm the prevailing notion that follow-up in trauma clinic is poor. METHODS Our trauma registry was queried for all trauma service discharges of patients 18 years and older for a 2-year period. Patients with incomplete information were excluded. Demographic data such as race/ethnicity and insurance status were collected on all patients. Primary outcome was defined as trauma clinic follow-up within 4 weeks after discharge. Patients compliant with follow-up were compared with noncompliant patients. RESULTS After exclusion criteria were applied, there were 1,818 discharges included in the analysis, with 564 (31%) complying with follow-up (p < 0.001). Factors significantly associated with follow-up noncompliance included patients older than 35 years, white race, Medicaid/Medicare payers, blunt mechanism, extended hospital length of stay, and discharge to rehabilitation facilities. No insurance, penetrating mechanism, short hospital stay, discharge to home, and weekend discharge were all significantly associated with follow-up compliance. Discharge on weekends and to home were independent predictors of compliance, whereas, Medicaid/Medicare insurance status and operative intervention were independent predictors of noncompliance. CONCLUSION This study indentifies factors associated with trauma clinic follow-up compliance and confirms the notion that trauma clinic follow-up compliance at an urban Level I trauma center is alarmingly low. These findings may serve as targets to improve follow-up, thereby improving trauma outcomes research and long-term outcomes. Consequently, clinic follow-up compliance warrants further study and consideration as an essential trauma registry datum. LEVEL OF EVIDENCE Prognostic study, level III.

Hurricane Sandy and the greater New York health care system.

H urricane Sandy hit the New York tristate area in force on the night of Monday, October 29, 2012 (Fig. 1). The storm is widely considered by experts to be the most powerful in the Northeast in recorded history. An unusual combination of weather phenomena (warm Caribbean air, a high pressure system over Greenland, and a disturbance in the jet stream) combined with a full moon, caused a storm surge (‘‘spring tide’’) of more than 14 feet. Because many of New York City’s (NYC) medical centers and teaching hospitals are located near the water, this created a public health emergency. There were 64 deaths in New York State. All mass transitVincluding subway, rail, and busVwas shut down. Widespread power outages affected approximately 8.5 million people, and 90-mph winds downed more than 10,000 trees. The storm damaged or destroyed tens of thousands of residences and businesses, while creating widespread disruptions in the delivery of virtually all kinds of health services.

Daily Multidisciplinary Rounds To Implement the Ventilator Bundle Decreases Ventilator-Associated Pneumonia in Trauma Patients: But Does It Affect Outcome?

BACKGROUND The incidence of ventilator-associated pneumonia (VAP) in trauma patients can be decreased with use of the ventilator bundle (VAPB). Our VAP rate remained high despite the adoption of the VAPB. To better implement the VAPB, a multidisciplinary team composed of the surgical intensive care unit (SICU) nursing staff, physician, and respiratory therapist reviewed briefly a checklist of VAPB goals for each patient before morning attending rounds. We hypothesized that such daily goal rounds (GR) focused on the VAPB would decrease the VAP rate. METHODS A pre-GR ten-month period (November 2006 to August 2007) was compared with the ten-month period (September 2007 to June 2008) with daily GRs. The occurrence of VAPs was tallied prospectively in all intubated trauma patients using the National Nosocomial Infection Surveillance criteria. Patient characteristics and outcome data were obtained from our trauma registry and medical records. Patient characteristics were similar in the 85 pre-GR patients and the 89 GR patients. RESULTS The number of VAPs decreased 67% in the GR patients (15 pre-GR vs. 5 GR; p=0.02); however, the all-cause mortality rate remained similar (16.5% vs. 21.3%; p=0.41). When patients were divided into those with and without VAP, there was a significant increase in mean ventilator, SICU, and hospital days in patients with VAP (p=0.01 for all). There were only two deaths among trauma patients with VAP. CONCLUSION Daily multidisciplinary GRs focused on the VAPB can decrease the incidence of VAP significantly in trauma patients. Ventilator-associated pneumonia correlated with extended mean ventilator, SICU, and hospital days. Interestingly, despite a significant decrease in VAP, a decrease in the mortality rate was not observed. Given the small number of deaths in the VAP cohort, this study has insufficient statistical power to elucidate the true impact of GR intervention or VAP on the mortality rate in trauma patients.

Utility of the Military Acute Concussion Evaluation as a screening tool for mild traumatic brain injury in a civilian trauma population.

BACKGROUND Mild traumatic brain injury (mTBI) constitutes 75% of more than 1.5 million traumatic brain injuries annually. There exists no consensus on point-of-care screening for mTBI. The Military Acute Concussion Evaluation (MACE) is a quick and easy test used by the US Army to screen for mTBI; however, its utility in civilian trauma is unclear. It has two parts: a history section and the Standardized Assessment of Concussion (SAC) score (0–30) previously validated in sports injury. As a performance improvement project, our institution sought to evaluate the MACE as a concussion screening tool that could be used by housestaff in a general civilian trauma population. METHODS From June 2013 to May 2014, patients 18 years to 65 years old with suspected concussion were given the MACE within 72 hours of admission to our urban Level I trauma center. Patients with a positive head computed tomography were excluded. Demographic data and MACE scores were recorded in prospect. Concussion was defined as loss of consciousness and/or posttraumatic amnesia; concussed patients were compared with those nonconcussed. Sensitivity and specificity for each respective MACE score were used to plot a receiver operating characteristic (ROC) curve. An ROC curve area of 0.8 was set as the benchmark for a good screening test to distinguish concussion from nonconcussion. RESULTS There were 84 concussions and 30 nonconcussed patients. Both groups were similar; however, the concussion group had a lower mean MACE score than the nonconcussed patients. Data analysis demonstrated the sensitivity and specificity of a range of MACE scores used to generate an ROC curve area of only 0.65. CONCLUSION The MACE showed a lower mean score for individuals with concussion, defined by loss of consciousness and/or posttraumatic amnesia. However, the ROC curve area of 0.65 highly suggests that MACE alone would be a poor screening test for mTBI in a general civilian trauma population. LEVEL OF EVIDENCE Diagnostic study, level II.

Bronchobiliary fistula after penetrating thoracoabdominal trauma: case report and literature review.

We report a case of bronchobiliary fistula after penetrating thoracoabdominal trauma. Bronchobiliary fistula is a communication between the bronchial and biliary systems. It is most typically a rare complication of hydatid cyst rupture1 or hepatobiliary surgery2 but has also been reported in association with blunt trauma.3 To our knowledge, this is the second report of bronchobiliary fistula secondary to penetrating trauma.4 Multiple management strategies have been described though the optimal course has not been well defined because of the rarity of the problem. Management options described include both conservative and operative approaches to management, utilizing any or all of the endoscopic retrograde cholangiopancreatography (ERCP), resection of involved lung, repair of the diaphragm, and drainage of the chest and abdomen.3–5 However, the patient with head injuries may be too unstable to undergo definitive surgical therapy initially. In this case report, we describe a novel-staged method of diagnosis and management of a bronchobiliary fistula caused by penetrating thoracoabdominal trauma.

Penetrating neck trauma in children: an uncommon entity described using the National Trauma Data Bank

BACKGROUND Penetrating neck trauma is uncommon in children; consequently, data describing epidemiology, injury pattern, and management are sparse. The aim of this study was to use the National Trauma Data Bank (NTDB) to describe pediatric penetrating neck trauma (PPNT). METHODS The NTDB was queried for children (defined as <15 years old) with PPNT between years 2008 and 2012. Descriptive analysis was used to describe age groups (0–5, 6–10, and 11–14 years) and injury type categorized as aerodigestive, vascular, cervical spine, and nerve. RESULTS A total of 1,238 patients with penetrating neck trauma were identified among 434,788 children in the NTDB (0.28%). Mean age was 7.9 years, and 70.6% of patients were male. The most common mechanisms of injury were stabbing (44%) and gunshot/firearm (24%). Most patients were treated at a pediatric trauma center (65.8%). Computed tomographic scan was the most frequent (42.2%) diagnostic study performed, followed by laryngoscopy (27.0%) and esophagoscopy (27.4%). Almost a quarter of patients (23.7%) went directly to the operating room from the emergency department (ED). Aerodigestive injuries were most common and occurred more frequently in the youngest age group (p < 0.001). Operative procedures for aerodigestive type injuries were most common (82.7%). There were 69 deaths, yielding a mortality rate of 5.6%. When adjusting for age, admission to a pediatric trauma center, and injury type, only vascular injury (odds ratio, 3.92; 95% confidence interval, 2.19–7.24; p < 0.0001) and ED hypotension (odds ratio, 27.12; 95% confidence interval, 15.11–48.67; p < 0.0001) were found to be independently associated with death. CONCLUSION PPNT is extremely rare—0.28% reported NTDB incidence. Age seems to influence injury type but does not affect mortality. Computed tomographic scan is the dominant diagnostic study used for selective management. Vascular injury type and hypotension on presentation to the ED were independently associated with mortality. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.

1133: Weaning Directly From Airway Pressure Release Ventilation With Spontaneous Breathing Trials

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) D3, omega 3-fatty acids, glutamine, and progesterone) improves recovery and lowers mortality rate better than two drug therapy with vitamin D3 and progesterone alone (Bahram Aminmansour study). Methods: This study with 183 patients TBI patients was a prospective comparison study done at Grady Memorial Hospital, a Level I trauma center in Atlanta, Georgia from August 2009 through February 2012 versus the Bahram study. Mean vitamin D3 level was 18.76 ng/ml ± 10.1. Mean ICU length of stay was 8.43 days ± 13.77. Results: There were 18 deaths (six were excluded due to withdrawal of care/ support). Mortality rate after exclusion criteria was 6.6% which is 34.4% lower than the 10% mortality rate in the Aminmansour Bahran study. Our recovery to a GCS of 10 was 90% versus 60% in the Bahran study. Conclusions: Our study potentially shows that our 4 drug combination therapy is more effective, offers better recovery, and offers more neuroprotection than 2 drug therapy in the Bahran study. Further studies are needed to examine our 4 drug combination treatment in TBI patients.