The Relationship Between an Individual's Birthday and Admission for Traumatic Injury.

BACKGROUND: Birthdays provide an opportunity to celebrate; however, they can also be associated with various adverse medical events. This is the first study to examine the association between birthdays and in-hospital trauma team evaluation. METHODS: This retrospective study analyzed trauma registry patients 19-89 years of age, who were evaluated by in-hospital trauma services from 1/1/2011 to 12/31/2021. RESULTS: 14,796 patients were analyzed and an association between trauma evaluation and birthdays was found. The strongest incidence rate ratios (IRRs) were on the day of birth (IRR: 1.78; P < .001) followed by ±3 days of the birthday (IRR: 1.21; P = .003). When incidence was analyzed by age groups, 19-36 years of age had the strongest IRR (2.30; P < .001) on their birthday, followed by the >65 groups (IRR: 1.34; P = .008) within ±3 days. Non-significant associations were seen in the 37-55 (IRR: 1.41; P = .209) and 56-65 groups (IRR: 1.60; P = .172) on their birthday. Patient-level characteristics were only significant for the presence of ethanol at trauma evaluation (risk ratio: 1.83; P = .017). DISCUSSION: Birthdays and trauma evaluations were found to have a group-dependent association, with the greatest incidence for the youngest age group being on their birthday, and the oldest age group within ±3 days. The presence of alcohol was found to be the best patient-level predictor of trauma evaluation.

Defining a specialty through its literature: A bibliometric analysis of acute care surgery 2005 to 2020.

Background: Acute care surgery (ACS) has grown and evolved since it was conceived in 2005. However, ACS is not recognized in the National Library of Medicine's Medical Subject Heading thesaurus. This article uses bibliometrics to help define an identity for ACS as a subspecialty of surgery and argue for its addition to the Medical Subject Heading thesaurus. Methods: The terms "Acute Care Surgery," "Wounds and Injuries," "General Surgery," and "Critical Care" were searched with and without the Text Word [TW] modifier using PubMed. The intersections of search sets were identified with the AND conjunction to determine the proportion of ACS literature relevant to each subject term and calculate the penetration of ACS as a keyword term into each subject domain. Results: A [Medical Subject Heading] limited search on the term "Acute Care Surgery" yielded a predictable return of 0 article. Search of the cohesive term "Acute Care Surgery" [All Fields], restricted to MEDLINE-indexed, English-language articles yielded 2,351 articles published between 2005 and 2020, inclusive. Using ACS as [Text Word] yielded 517 articles. There was a progressive increase in the rate of annual publications. The frequency of subject terms in the ACS [All Fields] set was as follows: Critical Care, 49.70%; General Surgery, 23.26%; and Wounds and Injuries, 20.88%. The frequency of subject terms in the ACS [TW] set was as follows: Critical Care, 32.88%; General Surgery, 43.52%; and Wounds and Injuries, 15.28%. Of this set, 8.32% of articles were not tagged or did not contain a reference to any of these 3 major subjects. Conclusion: This study demonstrates that ACS as a subject matter is being increasingly expressed in the literature. Adding ACS as a dedicated term into the National Library of Medicine's Medical Subject Heading thesaurus of controlled vocabulary as a specialty of Surgery would facilitate indexing and retrieval of the literature most relevant to acute care surgeons.

Obesity in trauma: outcomes and disposition trends.

BACKGROUND: Obesity's effect on the outcomes of trauma patients remains inconclusive. METHODS: A retrospective review of all falls, motor vehicle collisions (MVCs), and penetrating trauma patients admitted from January 2008 to December 2012 was performed. The outcomes evaluated included mortality, length of stay at hospital, and discharge disposition. Patients were grouped according to the body mass index (BMI) and stratified by injury severity scores. RESULTS: Two thousand one hundred ninety six patients were analyzed; 132 penetrating, 913 falls, and 1,151 MVCs. Penetrating traumas had no significant difference in outcomes. In falls, obese patients had a lower mortality (P = .035). In MVCs, obese patients had longer hospitalizations (P = .02), and mild and moderate MVC injuries were less likely to be discharged home (P = .032 and .003). Obese patients sustained fewer head injuries in falls and MVCs (P = .005 and .043, respectively). CONCLUSIONS: In falls, a higher BMI may benefit patients. However, an increasing BMI is associated with a longer length of stay at hospital, and decreased likelihood of discharge to home.

Surgical pulmonary embolectomy in a community hospital.

BACKGROUND: Surgical pulmonary embolectomy (SPE) is indicated for a pulmonary embolism associated with hemodynamic instability. A review of the literature demonstrates that most studies of SPE are conducted at large academic medical centers. This series is from a 325-bed community hospital. METHODS: A retrospective chart review was performed of patients undergoing SPE from January 2008 to December 2012. All patients aged >18 years were reviewed for 30-day mortality, length of hospital stay, comorbidities, and preoperative hemodynamic parameters. RESULTS: Fifteen patients (7 men and 8 women; median age, 55.5 years; range, 20-72 years) underwent SPE. There were 2 deaths (13.3%). Four of the patients underwent catheter-directed interventions before SPE. The mean length of hospital stay was 12 days. CONCLUSIONS: These data suggest that SPE is associated with favorable outcomes in the appropriate community setting, and the mortality rate seen in this study compares favorably with the nationwide average of 27.2%.

The storage lesion of packed red blood cells affects coagulation.

BACKGROUND: The storage lesion of packed red blood cells (PRBCs) consists of biochemical changes associated with increased inflammatory mediators and decreased oxygen-carrying capacity. The effect of storage on the coagulation system is less well studied. The purpose of this study is to determine how PRBC storage time affects the activated coagulation time (ACT), using an in vitro model. METHODS: Type-matched PRBCs and fresh-frozen plasma were mixed, warmed to 37°C, and recalcified. The microsample ACT was repeatedly determined by 2 methods (ACT+ and ACT-LR) at 1 week, 3 weeks, and 5 weeks after date of donation. Hematocrit, pH, and ionized calcium were measured to assess how the model compared to physiologic circumstances. Statistical analysis was performed using the Student 2-tailed t-test with unequal variance. RESULTS: Hematocrit, pH, and ionized calcium were successfully maintained within narrow ranges. The model was notably acidotic, consistent with circumstances of shock and massive transfusion. There was no significant difference in the ACT+ between week 1 and week 3 (P = .183), but there was a significant difference between week 3 and week 5 (P = .029) and between week 1 and week 5 (P = .007). The ACT-LR showed a significant difference between week 1 and week 3 (P = .001), but not between week 3 and week 5 (P = .286). There was again a strong difference between week 1 and week 5 results (P = .011). CONCLUSION: In an isolated in vitro model, the storage lesion of PRBCs is associated with decreased coagulation. This may have relevance for transfusion practices in coagulation-sensitive circumstances such as trauma.

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

BACKGROUND: The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery was approved by the Joint Commission Board of Commissioners in July 2003 and became effective July 1, 2004. It requires the performance of a preprocedural verification process, marking of the procedure site, and performing a "time out" immediately before the start of a procedure. Compliance with the Universal Protocol requirements remains cumbersome because of the inherent characteristics of the surgical work flow process. METHODS: By working directly with the Joint Commission, their medical staff, perioperative nursing staff, and members of the hospital quality department, the authors were able to develop an innovative anatomic marking form, which serves as a surrogate for marking patients. RESULTS: The marking form has been used on 112,500 patients over 4.5 years, with a single implementation error that led to minimal patient harm. CONCLUSION: This article describes the development of the anatomic marking form and the practical implications the process has on patient safety.

The effect of red blood cell age on coagulation.

BACKGROUND: Packed red blood cell (PRBC) units stored and unused at community hospitals are transferred to trauma centers near the end of their shelf storage life, because of a higher likelihood of utilization before expiration without consideration of coagulation system effects. This study was conducted to determine if the stored age of PRBC units has an effect on coagulation. METHODS: Single-donor citrate/phosphate/dextrose-preserved, PRBCs, and fresh frozen plasma (FFP) were recalcified in an in vitro model. The activated clotting time (ACT) was measured using the microsample method on days 3, 19, 20, and 33 from the date of donation. RESULTS: The ACT was prolonged as the age of PRBCs increased while other factors were held constant. ACTs on days 19, 20, and 33 were prolonged relative to day 3. Measurements taken on day 33 were significantly prolonged relative to day 20. CONCLUSIONS: Increasing age of PRBCs measured from the date of donation adversely affects the global coagulation status. This study suggests that we should re-evaluate current blood banking and transfusion practices in trauma care.

If a picture is worth a thousand words, what is a trauma computerized tomography panel worth?

BACKGROUND: There has been a progressive increase in the use of computerized tomography (CT) scans for evaluating trauma patients. The purpose of this study was to quantify that trend and consider the implications it holds for resource use. METHODS: Data were combined from the trauma registry and the radiology department's administrative information system at a level I trauma center to define the radiographic use patterns applied to all trauma activations during a 3-month sampling period in each of 4 years. RESULTS: Trauma activations increased by 21% whereas total radiographic studies increased by 82%. The proportion of CT scans to total studies increased progressively from 18% to 27%. The average number of CT studies per patient increased from 2.68 +/- 3.09 to 6.88 +/- 7.50. CT use increased for patients presenting by primary or secondary transport, regardless of triage classification. In the final sampling period, CT scans alone generated an average of 3,726 images per day to be reviewed. CONCLUSIONS: Increasing use of multi-image studies is facilitated by improvements in technology and medical-legal pressures. However, extensive imaging can stress overburdened trauma systems. Additional studies are needed to assess the implications of increasing radiographic use on trauma outcomes.

Economic modeling comparing trauma and general surgery reimbursement.

BACKGROUND: The viability of trauma care as a surgical subspecialty is continually challenged by economic pressures related to reimbursement and opportunity costs. METHODS: The literature was examined for articles focused on economic implications of a trauma focused surgical practice. Economic forecasting techniques were applied using a recalculating spreadsheet to examine charge and revenue generation comparing the effects of numerous variables affecting a trauma or general surgical service. RESULTS: Elective general surgery practices derive the majority of revenues from procedural services, whereas trauma practices derive the majority of revenues from evaluation and management. Only centers with high admission volume can expect trauma surgeons to cover salary and expenses, predictably in association with high opportunity costs. CONCLUSION: The differences in time, effort, and patient volume required for a trauma surgeon to generate revenues comparable to an elective practice are dramatic. The current system creates disincentives for surgeons to participate in trauma care.

A review of surgical simulation with attention to validation methodology.

The use of simulation technology for teaching and evaluating surgical skills has gained considerable attention in recent years. This is driven by interest in quality of care, concerns over increasing operative complexity, constraints on the use of animal models, limited available patient material, medicolegal pressures, and fiscal mandates for cost-effective performance. Traditional mechanical models are yielding to techniques dependent on electronic technology, including virtual reality. Data to support the validity of simulation techniques for surgical training, assessment, and certification represent only a fraction of the literature available on the subject. Literature searches were conducted in MEDLINE and ERIC, covering the period from 1966 to the present. The electronic and bioengineering literature was not surveyed due to the extensive literature on technology development, distinct from assessment of context specific validity. The search results and the bibliographies of key review articles were examined to identify articles that contained original data, measured performance between cohorts, defined performance measures, and described a standard against which performance was compared. Most of the literature pertaining to simulation techniques for surgical training has been published within the past 5 years and consist of review, opinion, and feasibility articles. There is an emerging body of evidence to establish the validity of simulation techniques for assessing surgical skills. Further refinement of simulation techniques, identification of specific performance measures, longitudinal evaluations, and comparison to practice outcomes are still needed to establish the validity and the value of surgical simulation for teaching and assessing surgical skills prior to considering implementation for certification purposes.

Laparoscopic cholecystectomy in the presence of lymphangiomyomatosis.

A 49-year-old woman with a history of generalized lymphangiomyomatosis or lymphangioleiomyomatosis (LAM), including angiomyolipomas of the liver and kidney and known LAM of the lung, presented with symptomatic cholelithiasis. She underwent an uneventful laparoscopic cholecystectomy and was discharged home the following day. Careful patient selection, preoperative stratification, and optimization of pulmonary status are all necessary prior to electing to operate on patients with known LAM. A CT scan of the abdomen is of value to delineate the anatomy of the angiomyolipomas and their proximity to the operative site. These preliminary precautions, combined with careful surgical technique, are essential for a successful outcome with minimal morbidity.

Traumatic abdominal wall hernia: same-admission laparoscopic repair.

Traumatic abdominal wall hernias are uncommon. They are traditionally treated with open surgery. We report a case repaired using laparoscopic technique and prosthetic reinforcement.

Primary repair of blunt pancreatic transection.

A 19-year-old female patient with blunt traumatic transection of the pancreas underwent successful primary repair of the pancreas and main pancreatic duct. A literature review revealed 14 previously reported such cases. Primary repair of the main pancreatic duct is feasible in selected patients. A wider experience will help to determine the method's role among such established surgical procedures as distal pancreatectomy, internal drainage, and minimally invasive transpapillary stent techniques.

Quantitative tracheal lavage versus bronchoscopic protected specimen brush for the diagnosis of nosocomial pneumonia in mechanically ventilated patients.

BACKGROUND: No gold standard method exists for the diagnosis of ventilator-associated pneumonia despite the availability of multiple techniques. METHODS: A prospective, crossover study was performed on mechanically ventilated patients meeting with suspected pneumonia. Eighteen paired samples were obtained on 15 patients, comparing the results of quantitative tracheal lavage (QTL) to bronchoscopic protected brush specimen (PSB) by quantitative culture and gram stain examination. RESULTS: The sensitivity, specificity, positive and negative predictive values, and accuracy are affected by the growth density threshold selected, and whether the same organisms are expected by both methods. There is a significant relationship between QTL and PSB (P = 0.0048; R = 0.632), gram stain and PSB (P <0.001; R = 0.791), and gram stain and QTL (P = 0.0125; R = 0.575), by Spearman rank order correlation. CONCLUSIONS: QTL may have a role for diagnosing and directing treatment of ventilator-associated pneumonia, allowing reservation of bronchoscopic PSB for secondary, high risk and refractory cases.

Intraoperative detection of traumatic coagulopathy using the activated coagulation time.

Traumatic coagulopathy manifests as a hypocoagulable state associated with hypothermia, acidosis, and coagulation factor dilution. The diagnosis must be made clinically because traditional coagulation tests are neither sensitive nor specific and take too long to be used for intraoperative monitoring. We hypothesized that the activated coagulation time (ACT) would reflect the global coagulation status of traumatized patients and would become elevated as coagulation reserves become exhausted. A prospective protocol was used to study 31 victims of major trauma who underwent immediate surgical Intervention. Victims of major head trauma were excluded and patients were selected at random over an 8-month period. At least two serial intraoperative blood samples were obtained at 15-min intervals via indwelling arterial catheters. A Hemochron model 801 coagulation monitor was used to measure the ACT. Of the 31 patients studied, 7 became clinically coagulopathic and 24 did not. The ACT measurements of coagulopathic and noncoagulopathic trauma patients were significantly different by multiple statistical comparisons. Both groups differed from normal, nontraumatized patients. The coagulopathic trauma patients had significantly elevated values when compared with other trauma patients or to normal values. We conclude that a low ACT reflects the initial hypercoagulability associated with major trauma and an elevated ACT is an objective indicator that the coagulation system reserve is near exhaustion. An elevated ACT may represent an indication for considering damage control maneuvers or more aggressive resuscitation.