Background In order to understand how current surgical residents feel about their training, a survey focused on perceptions regarding early entry into a subspecialty and the adequacy of training was ...sent to selected residency programs in general surgery (GS). Study Design A 36-item online anonymous survey was sent to the program directors of 55 GS programs. The national sample consisted of 1,515 PGY 1 to PGY 5 categorical residents. Results The response rate was 45%. Overall, 80% were planning on pursuing a fellowship. The majority (63%) believed that the Residency Review Committee for Surgery and the American Board of Surgery should consider the shift to early subspecialty training. Almost 70% of respondents preferred a 3-year basic track followed by a 3-year subspecialty track. In response to the survey item, “Do you think a 5-year GS residency fully prepares you to practice GS?”, 38% of residents overall responded “no” or “unsure.” This figure decreased with each increasing year of residency training, from PGY 1 (53.3%) to PGY 5 (23%). Finally, 71% of residents who answered “no” or “unsure” to the above question believe there should be a change to a track system. Conclusions The choice of fellowship training for 80% of trainees partially reflects that 38% are not confident about their skills with 5 years of training in GS, including 23% of graduating chief residents. Training and certifying groups should update and strengthen the current curriculum for categorical residents in GS and continue their efforts to offer shortened independent or integrated residency training for those who will enter surgical specialties. Innovative solutions are needed to solve the logistic and financial problems involved.
Acute care surgery encompasses trauma, surgical critical care, and emergency general surgery (EGS). While the first two components are well defined, the scope of EGS practice remains unclear. This ...article describes the work of the American Association for the Surgery of Trauma to define EGS.
A total of 621 unique International Classification of Diseases-9th Rev. (ICD-9) diagnosis codes were identified using billing data (calendar year 2011) from seven large academic medical centers that practice EGS. A modified Delphi methodology was used by the American Association for the Surgery of Trauma Committee on Severity Assessment and Patient Outcomes to review these codes and achieve consensus on the definition of primary EGS diagnosis codes. National Inpatient Sample data from 2009 were used to develop a national estimate of EGS burden of disease.
Several unique ICD-9 codes were identified as primary EGS diagnoses. These encompass a wide spectrum of general surgery practice, including upper and lower gastrointestinal tract, hepatobiliary and pancreatic disease, soft tissue infections, and hernias. National Inpatient Sample estimates revealed over 4 million inpatient encounters nationally in 2009 for EGS diseases.
This article provides the first list of ICD-9 diagnoses codes that define the scope of EGS based on current clinical practices. These findings have wide implications for EGS workforce training, access to care, and research.
Abstract Background The objective of this study was to characterize potential disparities in academic output, NIH-funding, and academic rank among female surgical faculty and identify sub-specialties ...where these disparities may be more pronounced. Study Design Eighty metrics for 4,015 faculty members at the top-55 NIH funded departments of surgery were collected. Demographic characteristics, NIH funding details, and scholarly output were analyzed. A new metric, academic velocity (V), reflecting recent citations is defined. Results Overall, 21.5% of surgical faculty are women. The percentage of female faculty is highest in science/research (41%), surgical oncology (34%), and lowest in cardiothoracic surgery (9%). Female faculty are less likely to be full professors (22.7% vs. 41.2%) and division chiefs (6.2% vs. 13.6%). The fraction of women that are full professors is lowest in cardiothoracic surgery. Overall median publications/citations are lower for female faculty compared with male surgical faculty (21/364 vs. 43/723, p<0.001) and these differences are more pronounced for assistant professors. Women also have similar rates of current/previous NIH funding (21.3% vs. 24%, p=N.S). In certain subspecialties, female associate and full professors outperform male counterparts. Surgical departments with more female full professors have higher NIH funding ranking (R2 =0.14, p<0.05). Overall female authors have higher numbers of more recent citations. Conclusion Subspecialty involvement and academic performance differences by sex vary greatly by subspecialty type and are most pronounced at the assistant professor level. Identification of potential barriers for women into certain subspecialty entry, causes for the observed lower academic performance among female assistant professors, and obstacles for attaining leadership roles need to be determined.
Background Recent studies using thromboelastography indicate that patients are at risk for hypercoagulability early after injury. Pulmonary embolism (PE) is also well known to cause significant ...morbidity and mortality after injury and can occur within 72 hours of admission (early PE). Despite this risk, prophylactic anticoagulation is often delayed in patients with certain injuries due to concerns about bleeding. Study Design This was a retrospective study of injured patients with a PE from 2007 to 2013 at 3 level I trauma centers. Data collected included patient demographics, injury patterns, length of stay, timing of prophylaxis for deep vein thrombosis (DVT), and diagnosis of PE. Patients with early PE (≤3 days) were compared with those with late PE (>3 days) using bivariate and multivariable analysis. Results A total of 54,964 patients were admitted to the 3 centers during the study period, and 144 (0.26%) were diagnosed with a PE. Eleven were excluded from the study due to a lack of critical data, leaving 133 patients (43% early PE). Factors associated with early PE included long bone fractures in the lower extremity and an Abbreviated Injury Score (AIS) Extremity ≥3. Higher Injury Severity Score, severe chest and head trauma (AIS ≥ 3), and not receiving DVT prophylaxis within 48 hours of hospital admission were not associated with early PE. Conclusions Early PE is a significant clinical entity occurring in nearly half the patients who suffered a PE. Early PE is associated with long bone fractures and severe extremity trauma, but not severe thoracic injury. Timing of prophylactic anticoagulation had no impact on early PE. If further studies confirm this incidence of unsuspected early PE, all admitted trauma patients should be assessed for a hypercoagulable state after injury.
Many patients with blunt splenic injury are considered for nonoperative management and, with proper selection, the success rate is high. This paper aims to provide an update on the treatments and ...dilemmas of nonoperative management of splenic injuries in adults and to offer suggestions that may improve both consensus and patient outcomes.
Acute and chronic sleep deprivation are significantly associated with depressive symptoms and are thought to be contributors to the development of burnout. In-house call inherently includes frequent ...periods of disrupted sleep and is common among acute care surgeons. The relationship between in-house call and sleep deprivation among acute care surgeons has not been previously studied. The goal of this study was to determine prevalence and patterns of sleep deprivation in acute care surgeons.
A prospective study of acute care surgeons with in-house call responsibilities from 2 level I trauma centers was performed. Participants wore a sleep-tracking device continuously over a 3-month period. Data collected included age, sex, schedule of in-house call, hours and pattern of each sleep stage (light, slow wave, and rapid eye movement REM), and total hours of sleep. Sleep patterns were analyzed for each night, excluding in-house call, and categorized as normal, acute sleep deprivation, or chronic sleep deprivation.
There were 1,421 nights recorded among 17 acute care surgeons (35.3% female; ages 37 to 65 years, mean 45.5 years). Excluding in-house call, the average amount of sleep was 6.54 hours, with 64.8% of sleep patterns categorized as acute sleep deprivation or chronic sleep deprivation. Average amount of sleep was significantly higher on post-call day 1 (6.96 hours, p = 0.0016), but decreased significantly on post-call day 2 (6.33 hours, p = 0.0006). Sleep patterns with acute and chronic sleep deprivation peaked on post-call day 2, and returned to baseline on post-call day 3 (p = 0.046).
Sleep patterns consistent with acute and chronic sleep deprivation are common among acute care surgeons and worsen on post-call day 2. Baseline sleep patterns were not recovered until post-call day 3. Future study is needed to identify factors that affect physiologic recovery after in-house call and further elucidate the relationship between sleep deprivation and burnout.
Abstract Background Ligation of the significantly injured infrarenal inferior vena cava (IVC) is an accepted practice in the setting of damage control surgery. This is a report of inpatient ...management, outcomes, and long-term follow-up in 25 patients after IVC ligation. Methods The records of patients with injuries to the IVC treated in an urban level I trauma center from 1995 to 2008 were reviewed. Demographics, injury severity, and outcome data were recorded. In addition, outpatient records were reviewed and telephone interviews were conducted to assess for the presence and severity of long-term sequelae. Results One hundred patients had IVC injuries, and 25 (25%) underwent ligation. Location of injury was infrarenal in 54 patients, suprarenal in 21, retrohepatic in 15, and suprahepatic in 10. Twenty-two of 54 (41%) injuries to the infrarenal IVC and 3 of 21 (14%) injuries to the suprarenal IVC were ligated. Patients who underwent ligation had a significantly higher Injury Severity Score (ISS) (22 vs 15, P < .001), a higher transfusion requirement (26 U vs 12 U, P < .001), a longer hospital length of stay (78 days vs 26 days, P = .02), a longer intensive care unit length of stay (24 days vs 9 days, P < .001), and a higher mortality (59% vs 21%, P < .001). Ten of 13 early survivors of infrarenal IVC ligation received early below knee fasciotomy. Three other patients with normal compartment pressures were treated expectantly without development of a compartment syndrome. The 1 survivor of suprarenal ligation had below knee fasciotomies and had normal renal function by 1 month post injury, despite an initial creatinine elevation from .7 mg/dL to 3.2 mg/dL. Ten (40%) patients with IVC ligation survived to hospital discharge (9 infrarenal, 1 suprarenal), and long-term follow-up data are available in 8 patients (7 infrarenal, 1 suprarenal). At an average of 42 months (11–117 months), no patient has significant lower extremity edema or dysfunction. Conclusions (1) Ligation of the infrarenal IVC is an acceptable damage control technique, although it remains associated with a high mortality. Ligation of the suprarenal IVC may be done, if necessary, although few survivors of this technique exist. (2) Early fasciotomy is generally required, but occasional patients may be treated expectantly, based on measurements of compartment pressures. (3) Long-term sequelae in survivors of IVC ligation for trauma are rare.
Abstract Background The impact of immune status and surgical outcome in patients with HIV and acquired immunodeficiency syndrome (AIDS) remains unknown. Methods Clinical variables of HIV/AIDS ...patients undergoing abdominal surgery were examined for their impact on outcome. Results Major abdominal procedures were performed in 77 patients with a diagnosis of HIV/AIDS (55 males, mean age 41.1 years, mean CD4 count 210 mg/dL). A majority of operations (53%) were performed on an urgent basis. Patients undergoing urgent procedures had lower CD4 counts (129 ± 121 vs 303 ± 324, P = .002). The mean CD4 count was lower for patients with complications (146 ± 156 vs 288 ± 319, P = .013) and for those who died (112 ± 113 vs 251 ± 283, P = .026). On multivariate analysis, CD4 count was independently associated with an increased risk for complication, and urgent operation was associated with an increased risk for mortality. Conclusion Patients with HIV/AIDS who had lower CD4 counts were more likely to require an urgent operation and experience a complication with increased mortality.
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