Background A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, ...surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. Methods This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. Results There were 32 patients in the preservice group and 54 patients in the post-service group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. Conclusion Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.
Background Our understanding of traumatic diaphragmatic injury (TDI) is based primarily on outdated retrospective series. We sought to reexamine present day patterns of diagnosis, associated ...injuries, predictors of mortality, and long-term outcomes of this condition. Methods A prospectively entered trauma database from the Montréal General Hospital was reviewed for patients admitted with a TDI from 1993 to 2006. Hospital charts were reviewed, and patient characteristics, mechanism of injury, associated injuries, operative management, and postoperative outcomes were recorded. Logistic regression was used to identify predictors for mortality. Results Identified were 105 patients with TDI consisting of blunt in 37% and penetrating in 63%. Only 23% of TDI were diagnosed on initial chest roentgenogram. External wounds in penetrating TDI cases were found in the abdomen alone in 19%, in the chest alone in 46%, and in both in 35%, which was associated with intraabdominal organ injury in 83%, 55%, and 87%, respectively. Less than half of patients had a diaphragmatic hernia. Lung, chest wall, and thoracic organ injuries were more common in blunt trauma, but there was no significant difference between abdominal injuries in both mechanisms. Overall mortality from TDI was 18%, and there was no difference between blunt and penetrating injury. In blunt trauma, brain injury and an Injury Severity Score (ISS) exceeding 15 were independently associated with increased death. In penetrating trauma, only an ISS exceeding 15 predicted death. Conclusions Traumatic diaphragmatic injury remains a challenge to diagnose and treat, primarily due to the presence of associated injuries. The high incidence of intraabdominal organ injury, irrespective of the site of penetrating wound, dictates a transabdominal approach for exploration and repair. Severity of associated injuries (ISS) predicts death.
Abstract Introduction The script concordance test (SCT) is an innovative tool for clinical reasoning assessment. It has previously been shown to be a reliable and valid measure of clinical reasoning ...among general surgical residents. Purpose To determine if the SCT maintained its validity and reliability when administered on a national level. Methods The test was administered to 202 residents (51 R1, 45 R2, 45 R3, 28 R4, and 33 R5) in 9 general surgery programs across Canada. Results The optimized version of the test had a reliability (Cronbach alpha) of .85. Scores increased progressively from R1 (64.5 ± 7.6) to R2 (69.5 ± 5.8) to R3 (69.9 ± 6.7) to R4 (72.0 ± 6.2) with a dip in the R5s (68.3 ± 8.6). The test was able to differentiate junior (R1+ R2 = 66.8 ± 7.2) from senior residents (R3 + R4 + R5 = 70.0 ± 7.3, P = .001) across all the programs. Conclusions The SCT maintained its reliability and validity as a measure of intraoperative clinical reasoning among general surgical residents when administered across multiple centers. We believe that the SCT can be developed to measure clinical reasoning in high-stakes national examinations.
Background Ongoing gastrointestinal bleeding (GIB) following endoscopic therapy and deciding between mesenteric angiography and surgery often challenge surgeons. We sought to identify predictors of ...positive angiographic study (active contrast medium extravasation) and characterize outcomes of embolization for acute GIB. Methods We retrospectively analyzed angiographies for GIB at 2 teaching hospitals from January 2005 to December 2008. The χ2 , Wilcoxon rank sum and t tests determined significance. A Cox proportional hazards model was used for multivariate analyses. Results Eighteen of 83 (22%) patients had active extravasation on initial angiography and 25 (30%) were embolized. Patients with active extravasation had more packed red blood cell (PRBC; 5.3 v. 2.8 units, p < 0.001) and fresh frozen plasma (4.8 v. 1.7 units, p = 0.005) transfusions 24 hours preangiography and were more likely to be hemodynamically unstable at the time of the procedure (67% v. 28%, p = 0.001) than patients without active extravasation. Each unit of PRBC transfused increased the risk of a positive study by 30% (hazard ratio HR 1.3, 95% confidence interval CI 1.2–1.6 per unit). Embolization did not decrease recurrent bleeding (53% v. 52%) or length of stay in hospital (28.1 v. 27.5 d, p = 0.95), but was associated with a trend toward fewer emergency surgical interventions (13% v. 26%, p = 0.31) and greater 30-day mortality (33% v. 7%, p = 0.006) than nonembolization. Blind embolization was performed in 10 of 83 (12%) patients and was found to be an independent predictor of death in patients without active extravasation (HR 9.2, 95% CI 1.5–55.9). Conclusion The number of PRBC units transfused correlates with greater likelihood of a positive study. There was a significant increase in mortality in patients who underwent angioembolization. Large prospective studies are needed to further characterize the indications for angiography and blind embolization.
Abstract Background As the implementation of exclusive acute care surgery (ACS) services thrives, prognostication for mortality and morbidity will be important to complement clinical management of ...these diverse and complex patients. Our objective is to investigate prognostic risk factors from patient level characteristics and clinical presentation to predict outcomes including mortality, postoperative complications, intensive care unit (ICU) admission and prolonged duration of hospital stay. Methods Retrospective review of all emergency general surgery admissions over a 1-year period at a large teaching hospital was conducted. Factors collected included history of present illness, physical exam and laboratory parameters at presentation. Univariate analysis was performed to examine the relationship between each variable and our outcomes with chi-square for categorical variables and the Wilcoxon rank-sum statistic for continuous variables. Multivariate analysis was performed using backward stepwise logistic regression to evaluate for independent predictors. Results A total of 527 ACS admissions were identified with 8.1% requiring ICU stay and an overall crude mortality rate of 3.04%. Operative management was required in 258 patients with 22% having postoperative complications. Use of anti-coagulants, systolic blood pressure <90, hypothermia and leukopenia were independent predictors of in-hospital mortality. Leukopenia, smoking and tachycardia at presentation were also prognostic for the development of postoperative complications. For ICU admission, use of anti-coagulants, leukopenia, leukocytosis and tachypnea at presentation were all independent predictive factors. A prolonged length of stay was associated with increasing age, higher American Society of Anesthesiologists class, tachycardia and presence of complications on multivariate analysis. Conclusions Factors present at initial presentation can be used to predict morbidity and mortality in ACS patients.
OBJECTIVE:The purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.
METHODS:Using a cross-sectional study design, cyclists ...were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1–3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.
RESULTS:A total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44–47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47–52 vs. 44%, 95% CI 42–45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64–81), while young adults had the lowest (34%, 95% CI 30–37). Visible minorities were observed wearing a helmet 29% (95% CI 25–34) of the time compared to Caucasians, 47% (95% CI 46–49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10–15) of the time compared to riders with their own bike, 51% (95% CI 49–52).
CONCLUSIONS:Although above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.
Background The operative dictation (OD) is the cornerstone of surgical communication, yet there appears to be a lack of formal education of this skill by training programs. We conducted a review of ...the literature to assess the teaching and quality of OD in surgical residency programs. Study Design Multiple databases were searched for studies pertaining to “OD,” “surgical education,” and “formal teaching.” Of 50 the studies, 13 were retained and assigned to one or more of the following categories: (1) surveys of the surgical community evaluating current perceptions of formal OD education ( n = 5), (2) studies assessing the quality of OD performed by residents ( n = 5), and (3) educational interventions for improving OD skills ( n = 4). Results (1) Between 12% and 25% of survey respondents reported formal teaching of OD skills in their surgical programs. Surveyed residents and program directors were in favor of the implementation of structured teaching 60% to 91% of the time. (2) Multiple studies demonstrated significant deficiencies in residents’ ODs, with key information missing in up to 76% of cases. The completeness of OD did not consistently correlate with level of training. (3) In one of the studies, a formal educational session was found to improve OD quality scores (p < 0.001). In 2 studies, the use of synoptic report maximized the completion rate of OD up to 92% from less than 70%. Synoptic reports were significantly more complete than conventional ODs with regard to general information (p < 0.001) and procedural aspects (p < 0.001). A single randomized trial demonstrated an improvement in junior residents’ ODs after the implementation of a template (p = 0.02). Conclusion Current evidence suggests that only a small proportion of residency programs offer formal OD instruction, despite a demonstrable need for improvement in residents’ OD skills. Educational interventions and synoptic reporting present possible solutions, although this continues to be an area of evolving interest.
Objective To review the treatment of blunt thoracic aortic injuries (BAI) at a single institution over the past 12 years and compare pre-, peri-, and postoperative variables and outcomes of both open ...(OR) and thoracic endovascular (TEVAR) repair of these injuries. Methods All cases of confirmed BAI from 1994 to present were included in this retrospective review. Data collected included demographic data, injury severity score, Glasgow coma score, arrival hemodynamic variables, and associated injuries. Operative data included: type of procedure (OR or TEVAR), duration of procedure, need for and amount of blood transfused, use of anticoagulation, type of anesthesia, and service performing the procedure. Outcomes evaluated were: death, paraplegia, length of stay, days ventilated, and procedure related complications. Specific to EVAR; access, stent graft type and number, presence of endoleak and long-term clinical and radiologic follow-up were evaluated. Results Thirty cases of blunt thoracic aortic injury were identified. Two patients received no treatment and died, 28 patients were treated (OR 16, TEVAR 12) and included for comparison. There were no significant differences between groups with respect to preoperative variables with the exception of significantly more associated intra-abdominal injuries in the TEVAR group ( P = .03). Five patients in the OR group (31.2%) died in the perioperative period. There were no deaths in the TEVAR group ( P =.05). One OR patient (6.25%) suffered postoperative paraplegia. No paraplegia occurred in the TEVAR group. Intraoperative variables were similar between groups with the exception of mean units of blood transfused (OR 8.5 units, vs TEVAR 0.2 units, P = .002). Ten patients in the OR group either died or had a procedure related complication compared with none in the TEVAR group ( P = .001). There was no difference in length of stay or length of mechanical ventilation between the groups. There were no procedure or device related complications in the TEVAR group during follow-up (mean 15.3 months, range 1 to 53.5 months). Conclusions Endovascular repair of BAI results in significantly less combined mortality and morbidity when compared to OR. Significantly less blood is needed intraoperatively in the TEVAR group. No complications from stent graft insertion have been observed during follow-up. Endovascular repair is replacing open repair as the treatment of choice for BAI at our institution.
Summary In 2012 Quebec limited continuous in-hospital duty to 16 consecutive hours for all residents regardless of postgraduate (PGY) level. The new restrictions in Quebec appeared to have a ...profound, negative effect on the quality of life of surgical residents at McGill University and a perceived detrimental effect on the delivery of surgical education and patient care. Here we discuss the results of a nationwide survey that we created and distributed to general surgery residents across Canada to capture and compare their perceptions of the changes to duty hour restrictions.
Summary The burden of surgical disease in low-income countries remains significant, in part owing to continued surgical workforce shortages. We describe a successful paradigm to expand Rwandan ...surgical capacity through the implementation of a surgical education partnership between the National University of Rwanda and the Centre for Global Surgery at the McGill University Health Centre. Key considerations for such a program are highlighted.
PDF
