Development of Korean Teaching Model for Surgical Procedures in Trauma -Essential Surgical Procedures in Trauma Course-

PURPOSE@#The Essential Surgical Procedures in Trauma (ESPIT) course was developed as a model to teach necessary surgical procedures to trauma physicians. Its goals are to improve knowledge, self-confidence, and technical competence.@*METHODS@#The ESPIT course consisted of five lectures and a porcine lab operative experience. The ESPIT course has been run seven times between February 2014 and April 2016. ESPIT participants completed a questionnaire to assess self-efficacy regarding essential surgical procedures in trauma before and immediately after taking the ESPIT course. Sixty-three participants who completed both pre- and post-course questionnaires on self-efficacy were enrolled in this study.@*RESULTS@#The overall post-ESPIT mean self-efficacy score was higher than the pre-ESPIT mean self-efficacy score (8.3±1.30 and 4.5±2.13, respectively) (p5 years) were also statistically significant (p<0.001).@*CONCLUSIONS@#The data of the ESPIT participants indicated that they felt that the ESPIT course improved their self-efficacy with regard to essential surgical procedures in trauma. The ESPIT course may be an effective strategy for teaching surgical procedures, thus promoting better management of traumatic injuries.

Clinical Effects of Intra-Abdominal Pressure in Critically Ill Trauma Patients

PURPOSE@#There is increasing interest in intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) in critically ill patients. This study investigated the effects and outcomes of elevated IAP in a trauma intensive care unit (ICU) population.@*METHODS@#Eleven consecutive critically ill patients admitted to the trauma ICU at Pusan National University Hospital Regional Trauma Center were included in this study. IAP was measured every 8–12 hours (intermittently) for 72 hours. IAP was registered as mean and maximal values per day throughout the study period. IAH was defined as IAP ≥12 mmHg. Abdominal compartment syndrome was defined as IAP ≥20 mmHg plus ≥1 new organ failure. The main outcome measure was in-hospital mortality.@*RESULTS@#According to maximal and mean IAP values, 10 (90.9%) of the patients developed IAH during the study period. The Sequential Organ Failure Assessment (SOFA) score was significantly higher in patients with IAP ≥20 mmHg than in those with IAP <20 mmHg (16 vs. 5, p=0.049). The hospital mortality rate was 27.3%. Patients with a maximum IAP ≥20 mmHg exhibited significantly higher hospital mortality rates (p=0.006). Non-survivors had higher maximum and mean IAP values.@*CONCLUSIONS@#Our results suggest that an elevated IAP may be associated with a poor prognosis in critically ill trauma patients.

Comparison of medical resources usage between young adult patients and elderly patients: a single center, retrospective observational study

OBJECTIVE@#Under the overcrowding conditions of large emergency departments, the proportion of elderly patients is increasing in Korea. This paper describes the necessity of the preparedness of Korean emergency departments and society for the rapidly aging population.@*METHODS@#This was a retrospective observational study. Patients who presented to a tertiary hospital emergency department (ED) in one year were included. The use of medical resources between young adult (≥20 and <65 years of age) and elderly patients (≥65 years of age) was compared.@*RESULTS@#This study included 26,712 patients. The young adult group and the elderly group was 15,021 (56.2%) and 11,691 (43.8%), respectively. The ratio of firehouse ambulance visit mode (28.6%) and inter-facility transfer visit mode (18.9%) of the elderly group was higher compared to those of the young adult group (26.4% and 10.6%, P<0.001). The elderly group visited more at daytime (P<0.001). With aging, the admission ratios of the elderly group to the general ward (38.9%) and intensive care unit (13.0%) were higher than the young adult group (9.8% and 4.3%, P<0.001). The mean ED length of stay and mean length of hospitalization of the elderly group was longer than that of the young adult group (P<0.001). The medical cost of the elderly group was approximately three times higher than that of the young adult group.@*CONCLUSION@#Elderly patients required more emergency medical resources in both the prehospital and hospital stages. Korean emergency departments and society require efforts for not only expansion but also the appropriate use of medical resources in a rapidly aging population.

Surgical Outcome of Posterior Pelvic Fixation Using S1, S2 Screws in Vertically Unstable Pelvic Ring Injury

PURPOSE: Iliosacral screw fixation is an effective and less invasive method that is used widely for the definitive treatment of unstable pelvic ring injuries. On the other hand, fixation failures after iliosacral screw fixation have been reported in vertically unstable pelvic ring injuries. This study examined the surgical outcomes of posterior pelvic fixation using S1 and S2 screws in vertically unstable pelvic ring injuries. MATERIALS AND METHODS: Between January 2011 and April 2016, 17 patients with vertically unstable pelvic ring injuries who met the minimum 1 year follow-up criteria were treated with internal fixation using posterior pelvic S1 and S2 screws. Their mean age was 43.9 years. According to the AO/OTA classification, 10 patients had C1, 6 had C2, and 1 had C3 injuries. Surgical treatments of single or multiple steps, where necessary, were performed by two surgeons. The clinical and radiologic outcomes were assessed retrospectively using radiographs and medical records. RESULTS: Overall, 16 patients had bone healing without screw loosening; however, one patient could not maintain anterior pelvic fixation because of an open fracture and deep infection in the anterior pelvic ring. Of five patients who complained of neurological symptoms after injury, three had partially recovered from their neurological deficit. At the last follow-up, the clinical outcomes according to the Majeed score were excellent in 5, good in 6, fair in 4, and poor in 2 patients. The postoperative radiologic outcomes by Matta and Tornetta's method were excellent in 5, good in 8, and fair in 4 patients. Malposition of the S2 screw was identified in one case. The mean time to union was 14.6 weeks after surgery. CONCLUSION: S1 and S2 screw fixation can be an effective treatment option for posterior pelvic stabilization in vertically unstable pelvic ring injuries when considering the surgical outcomes, such as screw loosening and loss of reduction.

CT Findings of Perforation of the Stomach after Ingestion of Glacial Acetic Acid

The ingestion of corrosive substances often leads to severe morbidity and mortality. Acids produce coagulation necrosis with a lesser degree of penetration, whereas alkalis produce liquefactive necrosis with penetration. Acetic acid is a clear, colorless organic acid with a pungent, vinegar-like odor. The ingestion of highly concentrated acetic acid (glacial acetic acid) may cause a range of complications. On the other hand, perforation of the stomach is extremely rare but it has a high mortality rate. This paper reports a case of perforation of the stomach after the ingestion of glacial acetic acid with suicidal intent in an otherwise healthy 76-year-old woman.

Stab Wound Extension for the Eviscerated Small Bowel with Severe Ischemic Changes

An abdominal stab wound with evisceration is an indication of an emergency laparotomy. We encountered a case of a very severe ischemic change in the eviscerated small bowel as a result of stabbing. The patient was considered to have a high possibility of progressing to strangulation of the small bowel. Therefore, a stab wound extension was performed as a decompression in the emergency department before definite surgery in the operating room. Most of the small bowel could be saved except for the segment with the damage caused by the stab injury. The patient was discharged without complications.

PARK Formula Can Replace “Guide to Medical Certificate” Published by Korean Medical Association in Deciding the Treatment Duration

PURPOSE@#Many doctors have difficulty in deciding the treatment duration in trauma patients to write in the casualty medical certificate. We tried to find a solution for this problem by using abbreviated injury scale (AIS).@*METHODS@#A total of 39 patients treated in our regional trauma center who requested an author to write treatment duration on casualty medical certificate from January 2014 to April 2017 were included. And the treatment duration was decided based on the PARK Formula (AIS). PARK Formula (AIS)=(AIS×2) ~ ([AIS×2]+2)@*RESULTS@#Among 39 patients included and 36 (92.3%) had treatment duration on casualty medical certificate within the range of treatment duration calculated by PARK Formula (AIS). Compared to the PARK Formula (AIS), the mean value was 0.13 week (0.90 day) smaller. Comparing the treatment duration between Korean Medical Association (KMA) guideline and PARK Formula (AIS), only 22 patients (56.4%) showed agreement. The mean value was 1.02 week (7.18 days) smaller in KMA guideline.@*CONCLUSIONS@#For the decision of the treatment duration in trauma patients, utilizing worldwide used AIS scoring system is very efficient. Using PARK Formula (AIS), doctors can document the treatment duration in the casualty medical certificate with ease. KMA should provide more practical ‘treatment duration of each diagnosis in writing casualty medial certificate’ for the doctors. We recommend PARK Formula (AIS) as a good alternative for KMA guide.

Delayed Pneumatosis Intestinalis Induced by Blunt Trauma in a Strangulated Small Intestine

An ischemia-reperfusion injury of the intestine due to blunt trauma is very rare. Low blood flow can result in an incarceration and an ischemia-reperfusion injury of the small intestine. A 63-year-old woman fell, producing a splenic rupture. Despite the successful angio-embolization of the splenic rupture, the patient continued to suffer from hypotension. During laparotomy to identify the bowel injury, no intestinal perforation was found. However, we found a hemorrhagic infarction of the small intestine with congestion of the submucosal blood vessels. The part of bowel with the hemorrhagic infarction was resected and reconstructed with a jejuno-colic anastomosis. After surgery, she recovered from the trauma and was discharged without complications. We present this ischemia-reperfusion injury of the intestine due to blunt trauma. Meticulous examination and computed tomography scan is mandatory for diagnosis and assessment of treatment outcome.

Successful Endovascular Management of Post-Traumatic Phlegmasia Cerulea Dolens from Rupture of the External Iliac Vein

We report a rare case of a 47-year-old male with posttraumatic phlegmasia cerulea dolens caused by a ruptured right external iliac vein and treated with an endovascular venous stent graft. The patient was the victim of motor vehicle accident, and suffered direct injuries to the head and abdomen. The patient had a cyanotic and swollen right lower leg. Abdominal and lower extremity computed tomography angiography revealed a large retroperitoneal hematoma caused by a ruptured right external iliac vein, and grade I liver injury. The right external iliac vein rupture was successfully treated with a venous stent graft, followed by inferior vena cava filtering, because a venous thrombus was identified below the stent graft. He initially was hemodynamically unstable but recovered following treatment. The patient was comatose when presenting at the emergency department. He was discharged, fully recovered, on hospital day 18.

Feature of Visiting Patients to a Wide Regional Emergency Center According to Insurance Status

PURPOSE: In Korea, emergency department overcrowding in large hospitals have caused social concern. Moreover, patients with low socioeconomic status visit the emergency department more frequently. This kind of visitation also causes a burden on the national budget, but emergent patient should be treated in emergency department regardless of economic state. So, on establishment of policy about the patient with low socioeconomic status, the frequency of emergency visitation alone is difficult to obtain a sufficient basis for policy-making. METHODS: We retrospectively analyzed adult patients with a disease who visited the Pusan Wide-regional Emergency Center in 2015. Korean Triage and Acuity Scale level I, II or III were defined as emergency, and level IV or V was defined as non-emergency. The ratio of emergency and non-emergency was compared in the National Health Insurance and Medicaid database. RESULTS: The number of patients with National Health Insurance was 16,208 (90.3%) and with Medicaid was 1,737 (9.7%). Among those with National Health Insurance, there were 12,720 (78.5%) emergency cases and 3,488 (21.5%) non-emergency cases. Among those with Medicaid, 1,379 (79.4%) emergency cases and 358 (20.6%) non-emergency cases. Between National Health Insurance and Medicaid, there was no statistically significant difference in the ratio of emergency and non-emergency (p=0.380) CONCLUSION: Accessibility of emergency and non-emergency patients with National Health Insurance and Medicaid to Pusan Wide-regional Emergency Center was not different.

A Distribution Weighted Prognostic Scoring Model for Node Status in Advanced Rectal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: There are various lymph node-based staging systems. Nevertheless, there is debate over the use of parameters such as the number of involved lymph nodes and the lymph node ratio. As a possible option, the distribution of metastatic lymph nodes may have a prognostic significance in rectal cancer. This study is designed to evaluate the impact of distribution-weighted nodal staging on oncologic outcome in rectal cancer. MATERIALS AND METHODS: From a prospectively maintained colorectal cancer database of our institution, a total of 435 patients who underwent a curative low anterior resection for mid and upper rectal cancer between 1995 and 2004 were enrolled. Patients were divided into 3 groups according to the location of apical metastatic nodes. A location-weighted prognostic score was calculated by a scoring model using a logistic regression test for location based-statistical weight to number of lymph nodes. All cases were categorized in quartiles from lymph node I to lymph node IV using this protocol. RESULTS: The location of lymph node metastasis was an independent factor that was associated with a poor prognostic outcome (p<0.001). Based on this result, the location-weighted-nodal prognostic scoring model did not show lesser significant results (p<0.0001) in both overall survival and cancer-free survival analyses. CONCLUSION: The location of apical nodes among the metastatic nodes does not have a lesser significant impact on oncologic result in patients with advanced rectal cancer. A location-weighted prognostic scoring model, which considered the numbers of involved lymph nodes as the rate of significance according to the location, may more precisely predict the survival outcome in patients with lymph node metastasis.