Emergency Department SpO2/FiO2 Ratios Correlate with Mechanical Ventilation and Intensive Care Unit Requirements in COVID-19 Patients.

Background: Patients with coronavirus 2019 (COVID-19) are at high risk for respiratory dysfunction. The pulse oximetry/fraction of inspired oxygen (SpO2/FiO2) ratio is a non-invasive assessment of respiratory dysfunction substituted for the PaO2:FiO2 ratio in Sequential Organ Failure Assessment scoring. We hypothesized that emergency department (ED) SpO2/FiO2 ratios correlate with requirement for mechanical ventilation in COVID-19 patients. Our objective was to identify COVID-19 patients at greatest risk of requiring mechanical ventilation, using SpO2/FiO2 ratios. Methods: We performed a retrospective review of patients admitted with COVID-19 at two hospitals. Highest and lowest SpO2/FiO2 ratios (percent saturation/fraction of inspired O2) were calculated on admission. We performed chi-square, univariate, and multiple regression analysis to evaluate the relationship of admission SpO2/FiO2 ratios with requirement for mechanical ventilation and intensive care unit (ICU) care. Results: A total of 539 patients (46% female; 84% White), with a mean age 67.6 ± 18.6 years, met inclusion criteria. Patients who required mechanical ventilation during their hospital stay were statistically younger in age (P = 0.001), had a higher body mass index (P < .001), and there was a higher percentage of patients who were obese (P = 0.03) and morbidly obese (P < .001). Shortness of breath, cough, and fever were the most common presenting symptoms with a median temperature of 99°F. Average white blood count was higher in patients who required ventilation (P = <0.001). A highest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for mechanical ventilation. A lowest obtained ED SpO2/FiO2 ratio of ≤300 was associated with a requirement for intensive care unit care. There was no statistically significant correlation between ED SpO2/FiO2 ratios >300 and mechanical ventilation or intensive care unit (ICU) requirement. Conclusion: The ED SpO2/FiO2 ratios correlated with mechanical ventilation and ICU requirements during hospitalization for COVID-19. These results support ED SpO2/FiO2 as a possible triage tool and predictor of hospital resource requirements for patients admitted with COVID-19. Further investigation is warranted.

Burnout in trauma and orthopaedic surgeons: can the UK military stress management model help?

The recent coronavirus disease (COVID-19) pandemic has increased doctors' stresses at work and at home, putting them at increased risk of burnout. Considering this, we recently conducted the British Orthopaedic Association (BOA) Burnout and Wellbeing Survey which showed that, from 1298 respondents (approximately 25% of the membership of the BOA), 40% reported burnout and a further 50% were just below the threshold. The burnout rates were found to be higher in Black, Asian and minority ethnic (BAME), female and LGBTQ+ groups (45.6%) compared to white, heterosexual males (33.6% - p < 0.001) and also higher in trainees (49.1%) and associate specialists (52.1%) compared to consultants (35.7% - p < 0.001). We discuss what can be learned from the experience of the UK Armed Forces in their programme for stress management, their mental resilience training and their campaign to destigmatize mental wellbeing, that may mitigate burnout in our profession. We also put forward the case for appropriate resources to be allocated to tackling burnout in orthopaedic doctors and introduce the BOA's Wellbeing Initiative.

Evaluation of physician burnout at a major trauma centre using the Copenhagen burnout inventory: cross-sectional observational study.

BACKGROUND: Healthcare workers are susceptible to burnout owing to the demanding nature of their profession. The sequela of this is an increased incidence of medical errors and decreased job satisfaction. AIMS: This study aimed to assess the degree of burnout among physicians of different grades and specialties in a major trauma centre. METHODS: This study was performed in a UK tertiary trauma centre (Brighton and Sussex University Hospitals) in which 165 doctors from four medical specialties working with acute admissions were given the Copenhagen burnout inventory questionnaire via email and responses were received anonymously. Mean scores were calculated, and a two-tailed P test was performed to assess for statistically significant difference between patient- and work-related factors. RESULTS: The response rate was 77.57% (n = 165). General surgeons had the highest total burnout mean score of 50.00 with an SD of 12.78 followed by emergency medicine, acute medicine and finally orthopaedics. Junior doctors had an overall score of 53.42 with a standard deviation of 5.21, followed by consultants and registrars. The total burnout scores showed that 7.0% (n = 9) had low burnout scores while 56.3% (n = 72) had moderate burnout and 36.7% (n = 47) had high burnout scores. A two-tailed P test revealed a statistically significant difference between the work-related and patient-related subscales (P < 0.0001). CONCLUSIONS: Ninety-three percent of responders demonstrated either moderate or high levels of burnout in this study. Work-related factors appeared to contribute more to occurrence of burnout rather than the patient-related or doctor-patient interactions.

Stress fractures of the tibia and medial malleolus.

Tibial diaphyseal stress fractures are rare in the general population, but are more frequently seen in the athletic and military communities. The diagnosis of this problem may be problematic and needs to be considered in all athletes and military recruits who present with shin or ankle pain. The female triad in athletes (low-energy availability/disordered eating, amenorrhea, and osteoporosis/osteopenia) should be considered in those women who sustain this injury. Management is usually conservative with a variety of rehabilitation programs suggested, but a pragmatic approach is to manage the patient symptomatically.

The epidemiology of sports-related fractures in adolescents.

OBJECTIVE: To examine the epidemiology of sports-related fractures in adolescents aged 10-19 years. METHODS: All fractures in adolescents presenting to the Royal Hospital for Sick Children and the Royal Infirmary of Edinburgh in a one-year period were prospectively documented and all sports-related fractures retrospectively examined. These two hospitals have a defined population facilitating epidemiological studies. RESULTS: There were 408 adolescent sports-related fractures giving an overall incidence of 5.63/1000/year. The gender ratio was 87/13% male/female and 84% were upper limb fractures. Thirty sports produced 22 different fracture types. Football, rugby and skiing accounted for 66.2% of the fractures. The commonest fractures were in the finger phalanges (28.7%), distal radius and ulna (23.0%) and metacarpus (12.7%). CONCLUSIONS: Sport-related fractures are common in adolescents, particularly in males. They tend to be low-energy injuries affecting the upper limb in particular. Few require operative treatment although their frequency means that they impose significant demands on orthopaedic surgeons and health systems.