William S. Miles

A thoracostomy tube guideline improves management efficiency in trauma patients.

BACKGROUND Thoracostomy tube (TT) placement constitutes primary treatment for traumatic hemopneumothorax. Practice patterns vary widely, and criteria for management and removal remain poorly defined. In this cohort study, we examined the impact of implementation of a practice guideline (PG) on improving management efficiency of thoracostomy tube. METHODS We developed a PG aimed at standardizing the management of TTs in critically ill patients admitted to a Level I trauma center. During the 9-month period before (Pre-PG) and 3 months after (Post-PG) implementation, practice parameters including prophylactic antibiotics, duration of TT therapy, preremoval chest radiographs with associated charges, and complications were evaluated. Differences between groups were assessed by Mann-Whitney rank sum and chi(2) with Yates correction. RESULTS There were 61 patients, 14 in the Pre-PG group and 47 in the Post-PG group. The groups were matched in age and Injury Severity Scores. The Post-PG cohort averaged 3 fewer days of TT therapy. After implementation of the PG, 21 patients did not have preremoval chest radiography, representing a

Efficacy and Safety of Pneumococcal Revaccination after Splenectomy for Trauma

3000 reduction in radiology fees. Complication rates (retained pneumothorax, hemothorax, and empyema) were not different between the two groups. CONCLUSION Implementation of a thoracostomy tube practice guideline was associated with improved management efficiency in trauma patients.

The role of blinded interviews in the assessment of surgical residency candidates

OBJECTIVE To assess the outcome of patient education after splenectomy and vaccination and to determine the safety and efficacy of pneumococcal revaccination 2 or more years after primary vaccination. MAIN OUTCOME MEASURES Titers to serotype no. 6 and no. 23 pneumococcus and cutaneous and systemic reaction to revaccination. RESULTS A total of 112 consecutive postsplenectomy patients receiving pneumococcal vaccine were identified; 45 were contacted and offered revaccination; 24 patients demonstrated a lack of understanding of the postsplenectomy state (unaware of splenectomy n = 2, unaware of splenectomy risk n = 8, unaware of vaccine n = 23); 3 patients had infections requiring hospitalization (pneumonia, strep throat and tonsillitis, pneumonia and bacteremia); 40 patients agreed to revaccination, and 33 patients returned for follow-up titers; 16 of 33 (48%) demonstrated at least a two-fold increase in at least one titer. Only 15% described the revaccination as worse than a tetanus shot. CONCLUSIONS (1) Despite physician-patient conversations, pamphlets, and Medic Alert bracelets, patient retention was poor. (2) All splenectomy patients should be revaccinated and reeducated between two and six years after splenectomy. (3) Revaccination after two years was well tolerated. (4) There were no fatal episodes of pneumococcal sepsis in over 200 patient years.

Identification of traumatic, right-sided diaphragm rupture in a patient with newly diagnosed situs inversus.

BACKGROUND Interview assessments of surgical residency candidates may be biased by prior knowledge of objective data. METHODS Each candidate (site 1: n = 88; site 2: n = 44) underwent two interviews, one by faculty members informed only of a candidates medical school, the second with prior knowledge of the complete application. Interviewers (site 1: n = 28; site 2: n = 14) independently rated candidates overall and on nine qualitative characteristics. RESULTS At site 1 only, overall ratings were significantly more favorable for unblinded than blinded interviews (23.0 +/- 17.7 versus 32.6 +/- 23.1, P < 0.01). Blinded and unblinded overall ratings correlated -0.01 (P = 0.90) and 0.31 (P = 0.05) at sites 1 and 2, respectively. At site 1 only, overall ratings correlated significantly with USMLE scores, but in opposite directions for blinded (r = 0.32, P = 0.003) versus unblinded interviews (r = -0.32, P = 0.003). CONCLUSION Interview assessments may be influenced by objective data, and faculty and program variables. The value of blinded interviewing may vary as a function of individual program characteristics.

Gender-related outcomes in trauma

A 29-YEAR-OLD MAN presented to the emergency department after a motor vehicle collision. He voiced complaints of diffuse, right-sided pain of his chest and abdomen. Of interest, the patient’s heart sounds were auscultated on the right side of the chest. A standard chest radiograph was obtained demonstrating situs inversus (Fig 1). The presence of situs inversus was further confirmed via the focused abdominal sonogram for trauma and computed tomography (CT) scan. Other documented injuries included a right clavicle fracture, right rib fractures, pelvic fractures, subarachnoid hemorrhage, right pulmonary contusion with hemothorax, and a grade I spleen laceration. Evacuation of the right hemothorax was achieved following placement of a 36-French right thoracostomy tube. On postinjury day 10, while preparations were being made for disposition, the patient developed