Surgical education: Lessons from parenthood Burlew, Clay Cothren
The American journal of surgery,
December 2017, 2017-Dec, 2017-12-00, 20171201, Volume:
214, Issue:
6
Journal Article
Peer reviewed
Although one might think surgery and parenting have little in common, there are clear parallels. Historically there has been little formal education for either role. Educators and parents relied on ...modelling the behavior of others, or trial and error techniques. Mentorship and role models have played a critical role in professional development and continue to have a profound impact. Over the past two decades there has been a marked increase in the resources that are available. Coaching, debriefing, deliberate practice, and formal training are now incorporated in residency programs. Specific lessons from parenthood that can be applied to surgical education include: providing a framework, learning through graduated responsibility, communicating expectations, creating a culture, setting the example, encouraging resilience, promoting autonomy, providing feedback, and navigating failure. The final lesson from parenthood: trust that you have taught them well. And you have to let them go.
Plasma is integral to haemostatic resuscitation after injury, but the timing of administration remains controversial. Anticipating approval of lyophilised plasma by the US Food and Drug ...Administration, the US Department of Defense funded trials of prehospital plasma resuscitation. We investigated use of prehospital plasma during rapid ground rescue of patients with haemorrhagic shock before arrival at an urban level 1 trauma centre.
The Control of Major Bleeding After Trauma Trial was a pragmatic, randomised, single-centre trial done at the Denver Health Medical Center (DHMC), which houses the paramedic division for Denver city. Consecutive trauma patients in haemorrhagic shock (defined as systolic blood pressure SBP ≤70 mm Hg or 71–90 mm Hg plus heart rate ≥108 beats per min) were assessed for eligibility at the scene of the injury by trained paramedics. Eligible patients were randomly assigned to receive plasma or normal saline (control). Randomisation was achieved by preloading all ambulances with sealed coolers at the start of each shift. Coolers were randomly assigned to groups 1:1 in blocks of 20 according to a schedule generated by the research coordinators. If the coolers contained two units of frozen plasma, they were defrosted in the ambulance and the infusion started. If the coolers contained a dummy load of frozen water, this indicated allocation to the control group and saline was infused. The primary endpoint was mortality within 28 days of injury. Analyses were done in the as-treated population and by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01838863.
From April 1, 2014, to March 31, 2017, paramedics randomly assigned 144 patients to study groups. The as-treated analysis included 125 eligible patients, 65 received plasma and 60 received saline. Median age was 33 years (IQR 25–47) and median New Injury Severity Score was 27 (10–38). 70 (56%) patients required blood transfusions within 6 h of injury. The groups were similar at baseline and had similar transport times (plasma group median 19 min IQR 16–23 vs control 16 min 14–22). The groups did not differ in mortality at 28 days (15% in the plasma group vs 10% in the control group, p=0·37). In the intention-to-treat analysis, we saw no significant differences between the groups in safety outcomes and adverse events. Due to the consistent lack of differences in the analyses, the study was stopped for futility after 144 of 150 planned enrolments.
During rapid ground rescue to an urban level 1 trauma centre, use of prehospital plasma was not associated with survival benefit. Blood products might be beneficial in settings with longer transport times, but the financial burden would not be justified in an urban environment with short distances to mature trauma centres.
US Department of Defense.
Degradation of the endothelial glycocalyx, a glycosaminoglycan (GAG)-rich layer lining the vascular lumen, is associated with the onset of kidney injury in animal models of critical illness. It is ...unclear if similar pathogenic degradation occurs in critically ill patients.
To determine if urinary indices of GAG fragmentation are associated with outcomes in patients with critical illnesses such as septic shock or acute respiratory distress syndrome (ARDS).
We prospectively collected urine from 30 patients within 24 hours of admission to the Denver Health Medical Intensive Care Unit (ICU) for septic shock. As a nonseptic ICU control, we collected urine from 25 surgical ICU patients admitted for trauma. As a medical ICU validation cohort, we obtained serially collected urine samples from 70 patients with ARDS. We performed mass spectrometry on urine samples to determine GAG (heparan sulfate, chondroitin sulfate, and hyaluronic acid) concentrations as well as patterns of heparan sulfate/chondroitin sulfate disaccharide sulfation. We compared these indices to measurements obtained using dimethylmethylene blue, an inexpensive, colorimetric urinary assay of sulfated GAGs.
In septic shock, indices of GAG fragmentation correlated with both the development of renal dysfunction over the 72 hours after urine collection and with hospital mortality. This association remained after controlling for severity of illness and was similarly observed using the inexpensive dimethylmethylene blue assay. These predictive findings were corroborated using urine samples previously collected at three consecutive time points from patients with ARDS.
Early indices of urinary GAG fragmentation predict acute kidney injury and in-hospital mortality in patients with septic shock or ARDS. Clinical trial registered with www.clinicaltrials.gov (NCT01900275).
Abdominal compartment syndrome (ACS) and damage control surgery (DCS) have long been thought of as features of the trauma patient. In the last two decades, however, the pathology of ACS and the ...utility of damage control techniques have been increasingly recognized in general surgery. Indeed the physiology of the ill emergency general surgery patient often mimics that of the hemorrhaging trauma victim. Utilizing the lessons learned from the decades of trauma research and mapping them appropriately to general surgery should help improve outcomes and standardize care. This review will examine the diagnosis and management of ACS, the indications for DCS, and management of the open abdomen.
Background Preperitoneal pelvic packing/external fixation (PPP/EF) for controlling life-threatening hemorrhage from pelvic fractures is used widely in Europe but has not been adopted in North ...America. We hypothesized that PPP/EF arrests hemorrhage rapidly, facilitates emergent operative procedures, and ensures efficient use of angioembolization (AE). Study Design In 2004 we initiated a PPP/EF guideline for pelvic fracture patients with refractory shock requiring ongoing blood transfusion at our regional trauma center. Results Among 1,245 patients admitted with pelvic fractures, 75 consecutive patients underwent PPP/EF (age 42 ± 2 years and injury severity score 52 ± 1.5). Emergency department systolic blood pressure was 76 ± 2 mmHg and heart rate 119 ± 2 beats/min. Time to operation was 66 ± 7 minutes, and 65 patients (87%) underwent 3 ± 0.3 additional procedures. Blood transfusion before PPP/EF compared with the first postoperative 24 hours was 10 ± 0.8 units versus 4 ± 0.5 units (p < 0.05). The fresh frozen plasma–red blood cell ratio was 1:2. After PPP/EF, 10 patients (13%) underwent angioembolization with a documented blush; time to angioembolization was 10.6 ± 2.4 hours (range 1 to 38 hours). Mortality for all pelvic fractures was 8%, with 21% mortality in this high-risk group. There were no deaths due to acute hemorrhage. Conclusions PPP/EF was effective in controlling hemorrhage from unstable pelvic fractures. None of these high-risk patients died due to pelvic bleeding. Secondary angioembolization was needed in a minority, permitting selective use of this resource-demanding intervention. Additionally, PPP/EF temporizes arterial hemorrhage, providing valuable transfer time for facilities without angiography. With other urgent operative interventions required in >85% of patients, combining these procedures with PPP/EF for operative pelvic hemorrhage control appears to optimize patient care.
Abstract The open abdomen is a necessary sequela after damage-control surgery or abdominal compartment syndrome. Management of the patient in the intensive care unit continues to evolve, with ...considerations of fluid resuscitation, enteral nutrition, and supportive care. Management of the abdominal contents incorporates several basic techniques and considerations: appropriate temporary covering, enteric injury repair in most patients, placement of an anastomosis in an area of the abdomen with minimal manipulation without exposure to the atmosphere, acquiring enteral access for initiation of enteral nutrition, and ultimate abdominal closure. An understanding of these complex factors is instrumental for the practicing surgeon.
High-grade liver injuries with extravasation (HGLI + Extrav) are associated with morbidity/mortality. For low-grade injuries, an observation (OBS) first-strategy is beneficial over initial ...angiography (IR), however, it is unclear if OBS is safe for HGLI + Extrav. Therefore, we evaluated the management of HGLI + Extrav patients, hypothesizing IR patients will have decreased rates of operation and mortality.
HGLI + Extrav patients managed with initial OBS or IR were included. The primary outcome was need for operation. Secondary outcomes included liver-related complications (LRCs) and mortality.
From 59 patients, 23 (39.0%) were managed with OBS and 36 (61.0%) with IR. 75% of IR patients underwent angioembolization, whereas 13% of OBS patients underwent any IR, all undergoing angioembolization. IR patients had an increased rate of operation (13.9% vs. 0%, p = 0.049), but no difference in LRCs (44.4% vs. 43.5%) or mortality (5.6% vs. 8.7%) versus OBS patients (both p > 0.05).
Over 60% of patients were managed with IR initially. IR patients had an increased rate of operation yet similar rates of LRCs and mortality, suggesting initial OBS reasonable in appropriately selected HGLI + Extrav patients.
•Comparable LRC rates between HGLI patients managed initially with OBS vs. IR.•Comparable mortality rates between HGLI patients managed initially with OBS vs. IR.•Initial OBS strategy reasonable for appropriately selected patients with HGLI + Extrav.
Current severity of disease in the Covid-19 population As of 26 March 2020, the Centers for Disease Control and Prevention (CDC) reported 68 440 total confirmed plus presumptive cases of Covid-19 in ...the USA, with 994 deaths.1 These numbers are expected to change daily as more data are collected and more testing for the virus is performed. In Wuhan, China, 40 of 138 hospitalized patients were healthcare providers who were infected from presumed hospital spread.6 With the current pandemic, significant attention has been focused on the safety of healthcare workers, and many organizations have published guidance on infection prevention and control for these essential personnel.9–12 Considerations for indications and timing Surgeons should consider both short-term and long-term outcomes of tracheostomy along with the risks of exposure of the clinical team. In all patients with Covid-19 who need a tracheostomy, an acceptable strategy is to wait for the disease to become non-transmissible* prior to performing a high-risk aerosol-generating procedure such as tracheostomy. *See CDC recommendations for discontinuation of transmission-based precautions.16 Procedural guidance for Open and Percutaneous Tracheostomy Here we provide practical guidance for the performance of OT and PT in patients with known or suspected Covid-19 infection. If an AIIR is not available, avoid entry into room by non-essential personnel for up to 3 hours due to persistence of viable virus in aerosols.18 Limit the number of participants in the room to essential personnel only.19 An experienced attending surgeon or other experienced practitioner should perform the procedure.
Abstract Background We implemented expanded screening criteria for blunt cerebrovascular injuries (BCVIs) in an attempt to capture the remaining 20% of patients not historically identified with ...earlier protocols. We hypothesized that these expanded criteria would capture the additional 20% of BCVI patients not previously identified. Methods Screening criteria for BCVI were expanded in 2011 after identifying new injury patterns. The study population included 4 years prior (2007 to 2010; classic) and following (2011 to 2014; expanded) implementation of expanded criteria. Results BCVIs were identified in 386 patients: 150 during the classic period (2.36% incidence) and 236 in the expanded period (2.99% incidence). In the expanded period, 155 patients were imaged based on classic screening criteria, 62 on expanded criteria (21 complex skull fractures, 20 upper rib fractures, 6 mandible fractures, 2 scalp degloving, 1 great vessel injury, and 12 combination), and 19 for other injuries and symptoms. Conclusions There was a significant increase in the identification of BCVI following the adoption of expanded screening criteria, resulting in a substantial reduction of missed injuries. Expanded criteria should be adopted when screening for BCVI.
BACKGROUND: Massive transfusion (MTP) protocol design is hindered by lack of accurate assessment of coagulation. Rapid thrombelastography (r‐TEG) provides point‐of‐care (POC) analysis of clot ...formation. We designed a prospective study to test the hypothesis that integrating TEG into our MTP would facilitate goal‐directed therapy and provide equivalent outcomes compared to conventional coagulation testing.
STUDY DESIGN AND METHODS: Thiry‐four patients who received more than 6 units of red blood cells (RBCs)/6 hours who were admitted to our Level 1 trauma center after r‐TEG implementation (TEG) were compared to 34 patients admitted prior to TEG implementation (Pre‐TEG). Data are presented as mean ± SEM.
RESULTS: Emergency department pre‐TEG versus TEG shock, and coagulation indices, were not different: systolic blood pressure (94 mmHg vs.101 mmHg), temperature (35.3°C vs. 35.9°C), pH (7.16 vs. 7.11), base deficit (−13.0 vs. −14.7), lactate (6.5 vs. 8.1), international normalized ratio (INR; 1.59 vs. 1.83), and partial thromboplastin time (48.3 vs. 57.9). Although not significant, patients with Injury Severity Score range 26 to 35 were more frequent in the pre‐TEG group. Fresh‐frozen plasma (FFP) : RBCs, platelets : RBCs, and cryoprecipitate (cryo) : RBC ratios were not significantly different at 6 or 12 hours. INR at 6 hours did not discriminate between survivors and nonsurvivors (p = 0.10), whereas r‐TEG “G” value was significantly associated with survival (p = 0.03), as was the maximum rate of thrombin generation (MRTG; mm/min) and total thrombin generation (TG; area under the curve) (p = 0.03 for both). Patients with MRTG of more than 9.2 received significantly less components of RBCs, FFP, and cryo (p = 0.048, p = 0.03, and p = 0.04, respectively).
CONCLUSION: Goal‐directed resuscitation via r‐TEG appears useful for management of trauma‐induced coagulopathy. Further experience with POC monitoring could result in more efficient management leading to a reduction of transfusion requirements.
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