Management of Major Blunt Renal Injury: A Twelve-Year Review at an Urban, Level I Trauma Hospital.

The aim of this study was to describe the management of severe blunt renal injuries at a Level I trauma hospital. Data were collected through a record review of patients admitted from January 1, 2000, to December 31, 2011. These data were compiled as part of our hospital's participation in the Nonoperative Management of Grade IV and V Blunt Renal Injuries: A Research Consortium of New England Centers for Trauma Study. Thirty-six patients with severe blunt renal injuries were identified. Twenty-nine (80.6%) underwent nonoperative management (NOM) for their injuries. Seven (19.4%) received an immediate operation because of hemodynamic instability or CT findings of large hemoperitoneum or extravasation. No significant differences were observed on Injury Severity Score, Glasgow Coma Scale, injury grade, or systolic blood pressure on arrival to the emergency department. On arrival, the operative patients had higher heart rates and lower hematocrit and hemoglobin values relative to the NOM patients. The kidney was salvaged in three of the seven operative patients and was either saved or partially saved in all except one NOM patient. Three NOM patients died; none because of renal injuries. All other patients were successfully managed. None of the operative patients died. NOM management of high-grade renal injury was successful for these patients and should be considered in the management of grade IV and V blunt renal trauma.

Initial Steps in Training the Public about Bleeding Control: Surgeon Participation and Evaluation.

BACKGROUND: With increasing active shooter and intentional mass casualty events, as well as everyday injuries resulting in severe bleeding, there have been calls for the public to learn bleeding control techniques. The aims of this project were to offer bleeding control training to surgeons attending the Clinical Congress of the American College of Surgeons (ACS), to determine if the trained surgeons believe that teaching bleeding control to the public should be a priority of the ACS, and to assess the surgeon trainees' perceptions regarding the appropriateness of the course for a public audience. STUDY DESIGN: This was an educational program with a post-course evaluation to determine if the bleeding control course is appropriate for a public audience. RESULTS: Three hundred forty-one surgeons were trained. All were trained and successfully performed a return demonstration. Regarding perceptions of the participating surgeons that teaching bleeding control to the public should be a priority of the ACS, 93.79% of the 322 surgeons responding indicated agreement with this proposition. Regarding whether or not the training was at an appropriate level of difficulty for the public, 93.13% of the 320 respondents to this item agreed that it was appropriate. CONCLUSIONS: The surgeons who were trained were very much in favor of making training the public a priority of the ACS. With additional training of surgeons and other health care professionals as trainers, and the engagement of the public, the goal of having a citizenry prepared to stop bleeding can be achieved.

Use of a Tourniquet by LIFE STAR Air Medical Crew: A Case Report.

For many years tourniquets were perceived as dangerous due to the belief that they led to loss of limb because of ischemia. Their use in civilian and military environments was discouraged. Emergency medical responders were not taught about tourniquets and commercial tourniquets were not available. However, research by the United States military during the wars in Iraq and Afghanistan has demonstrated that tourniquets are safe life-saving devices. As a consequence, they have been widely deployed in combat situations and there are now calls for the use of tourniquets in the civilian prehospital setting. This article presents a report of the successful application of a tourniquet by the LIFE STAR crew to control bleeding that local emergency medical services (EMS) personnel could not control with direct pressure. Tourniquets should be readily available in public places and carried by all EMS.

The use of simulation procedural training to improve self-efficacy, knowledge, and skill to perform cricothyroidotomy.

The pre-eminent requirement for surgical education is that it is effective and efficient. We sought to determine if the addition of low-fidelity simulation to our standard method of teaching cricothyroidotomy improves Postgraduate Year 1 residents' self-efficacy, knowledge, and skill to perform cricothyroidotomy. The teaching methods were standard education using a lecture and video compared with standard education plus low-fidelity simulation instruction and practice on a mannequin. The methods were randomly assigned. After the assigned teaching in the morning and completion of pre- and posttests of self-efficacy and knowledge, the residents were evaluated on performance of cricothyroidotomy during the afternoon on euthanized swine. Time to complete the procedure and complications were recorded. Nineteen residents participated. Time to complete cricothyroidotomy was significantly less (P = 0.047) and performance scores were significantly higher (P = 0.01) in the simulation group. This group had four (36.4%) complications and the no simulation group had one (12.5%) complication (P = 0.34). Both groups improved on self-efficacy from pre- to posteducation (P < 0.05). Low-fidelity simulation can improve time and skill to perform cricothyroidotomy.

The Hartford Consensus to improve survivability in mass casualty events: Process to policy.

OBJECTIVE: The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was formed to make recommendations to improve survival from intentional mass casualty incidents. This article describes the development of the Hartford Consensus and the process used to disseminate and implement its findings. MAIN OUTCOME: Members of the Committee included individuals from select public safety organizations. The first meeting of the Committee was held on April 2, 2013, and a second meeting was held on July 11, 2013. Attendance at the second meeting was enlarged and included representatives from the Federal Emergency Management Agency and the National Security Staff of the Office of the President. The results of these meetings became known as the Hartford Consensus. RESULTS: The ideas generated at the meetings produced two documents, one from each meeting. These are referred to as Hartford Consensus I and II. Hartford Consensus I is a concept document and Hartford Consensus II is a call to action that no one should die from uncontrolled bleeding. The recommendations are being incorporated into training programs and have been endorsed by many organizations whose members are involved in the response to mass casualty incidents. CONCLUSION: The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was successful in stimulating policy to bring about change. Training and resources including tourniquets and hemostatic dressing are being directed to help ameliorate the unfortunate reality of intentional mass injury.

Management of major blunt liver injury at Hartford Hospital: a ten-year review.

The purpose of this study was to describe the management of patients at Hartford Hospital with major blunt liver injuries. The medical records of patients admitted to Hartford Hospital between January 1, 2000 through January 31, 2010 with blunt trauma that resulted in a laceration with significant hepatic disruption were reviewed. One hundred forty-eight patients were identified from the Trauma Registry. Of those, 133 patient records were examined. Twenty-one patients (15.8%) died in the emergency department and three were transferred to other facilities. Of the 109 patients treated at Hartford Hospital, most (60.2%) had agrade IV or V liver injury; 19 had an operation and 90 were managed nonoperatively. Those managed with an operation were more severely injured and had higher mortality, P < .05. Most patients requiring an operation were identified and operated upon in a timely manner.

Development and implementation of an interactive, objective, and simulation-based curriculum for general surgery residents.

OBJECTIVE: A Steering Committee of residents and faculty initiated a systematic approach to curriculum development, focusing on competency-based education and emphasizing both resident and faculty engagement in the didactic process. SETTING: Integrated General Surgery Residency Program at the University of Connecticut School of Medicine, Farmington, Connecticut. PARTICIPANTS: Postgraduate year (PGY) 1 through 5 general surgery categorical and preliminary residents. METHODS: A Core Curriculum consisting of 45-minute blocks and 2.5 hours of resident time per week was developed by a steering committee composed of faculty and residents. Each block is assigned a faculty and resident moderator, and has defined competency and knowledge-based objectives. An anonymous online evaluation tool collected residents' perceptions of value and satisfaction with the curriculum utilizing 15 5-point Likert items focusing on conferences, objectives, preparation, and quality of presentations, and materials. Measures were taken at the close of the previous academic year (baseline) and at 6 months and 1 year after implementation. The analysis focused on the percent responding in the 2 highest Likert categories (good/excellent, almost always/always, agree/strongly agree). The resulting dichotomous outcomes were compared with time point using χ(2)-tests of proportion; Kruskal-Wallis statistic was also used to compare the full distribution of responses. All analyses were done using SPSS v. 14 with α = 0.05. RESULTS: One hundred two surveys were completed on-line (42 at baseline, 38 at 6 months, and 22 at 1 year). All 15 items showed increases from baseline to 1-year follow-up; 9 of the 15 were statistically significant with conferences and presentation quality and interaction showing the greatest improvement. CONCLUSIONS: Resident satisfaction with the core curriculum, and their self-reported clinical and academic abilities showed improvement after a systematic collaborative faculty-resident approach to curriculum development and implementation.

Creating a culture of patient safety in a primary-care physician group.

Typically risk-management strategies have been applied to the inpatient setting. In 2003, a comprehensive risk-management program was introduced to ProHealth Physicians, one of the largest primary-care practice groups in Connecticut. The program included strategies for education, practice change, incentive and compliance. Performance metrics for clinician participation and compliance were prespecified. Clinicians' attitudes and behavior change were assessed after introduction of the program. Audits were conducted by external reviewers to assess compliance. Financial data from before-to-after program implementation were compared. Results showed fewer claims and substantial cost savings. A strong commitment to the implementation of a comprehensive risk-management program can create a culture of safety in an outpatient setting.