Stop the Bleed® in medical schools: Early advocacy and promising results.

OBJECTIVE: We hypothesized that medical students would be empowered by hemorrhage-control training and would support efforts to include Stop the Bleed® (STB) in medical education. DESIGN: This is a multi-institution survey study. Surveys were administered immediately following and 6 months after the course. SETTING: This study took place at the Association of American Medical Colleges-accredited medical schools in the United States. PARTICIPANTS: Participants were first-year medical students at participating institutions. A total of 442 students completed post-course surveys, and 213 students (48.2 percent) also completed 6-month follow-up surveys. INTERVENTION: An 1-hour, in-person STB course. MAIN OUTCOMES MEASURES: Student empowerment was measured by Likert-scale scoring, 1 (Strongly Disagree) to 5 (Strongly Agree). The usage of hemorrhage-control skills was also measured. RESULTS: A total of 419 students (95.9 percent) affirmed that the course taught the basics of bleeding control, and 169 (79.3 percent) responded positively at follow-up, with a significant decrease in Likert response (4.65, 3.87, p < 0.001). Four hundred and twenty-three students (97.0 percent) affirmed that they would apply bleeding control skills to a patient, and 192 (90.1 percent) responded positively at follow-up (4.61, 4.19, p < 0.001). Three hundred and sixty-one students (82.8 percent) believed that they were able to save a life, and 109 (51.2 percent) responded positively at follow-up (4.14, 3.56, p < 0.001). Four hundred and twenty-five students (97.0 percent) would recommend the course to another medical student, and 196 (92.0 percent) responded positively at follow-up (4.68, 4.31, p < 0.001). Six students (2.8 percent) used skills on live patients, with success in five of the six instances. CONCLUSIONS: Medical students were empowered by STB and have used hemorrhage-control skills on live victims. Medical students support efforts to include STB in medical education.

Building capacity for ATLS trauma education: role of nurse practitioners and physician assistants.

Objectives: Advanced Trauma Life Support (ATLS) focuses on care of injured patients in the first hour of resuscitation. Expanded demand for courses has led to a concurrent need for new instructors. Nurse practitioners and physician assistants (NPs/PAs) work on trauma services and duties include patient, staff, and outreach education. The goal of this project was to assess NP/PA self-reported knowledge and skills pertinent to ATLS and identify potential barriers to becoming instructors. Materials: This was a voluntary 91-question survey emailed to NP/PA lists obtained from professional societies and online social media channels. NPs/PAs completed a survey reflecting self-reported knowledge, experience, comfort level, and barriers to teaching ATLS interactive discussions and skills. Responses were recorded using a Likert scale and results were documented as percentages. Number of years of experience versus perceived knowledge and comfort teaching were compared using a χ2 test of independence. Results: There were 1696 completed surveys. Most NPs/PAs thought they had adequate knowledge and experience to teach interactive discussions and skills. Those with more years of experience and those who completed more ATLS courses had higher percentages. The number 1 barrier to teaching was lack of formal teaching experience followed by perceived hierarchy concerns. Experience and comfort with skills that fell below 50% were pediatric airway (49.5%), needle and surgical cricothyrotomy (49.8% and 44.8%), diagnostic peritoneal lavage (21.6%), and venous cutdown (20.8%). Conclusion: NPs/PAs with experience in trauma reported having the knowledge and skill to teach ATLS. A majority are comfortable teaching interactive discussions and skills for which they are knowledgeable. The primary barrier to teaching was lack of formal teaching experience, which is covered in the ATLS Instructor course. Training NPs/PAs to become instructors would increase the instructor base and allow for increased promulgation of ATLS and trauma education. Level of evidence: IV.

Electric scooter sharing systems: An analysis of injury patterns associated with their introduction.

BACKGROUND: With the increasing popularity of electric scooters (ES) and the introduction of ES sharing systems in 2017, hospitals are seeing more ES-related injuries. The effects of sharing systems on traumatic injuries are lacking in the literature. We, therefore, sought to describe trends in ES injuries. METHODS: The Nationwide Inpatient Sample was queried for patients hospitalized with ES-related injuries in the United States from 2015 to 2019. Admissions due to ES were divided into two cohorts: before (≤2017) and after (>2018) the introduction of sharing systems. Patients were stratified by injuries sustained, age, gender, and race. Inpatient hospital charges and length of stay were compared. Exclusion criteria included patients older than 65 and patients with neurological disorders. Traumatic injuries were compared after adjusting for age, gender, and race in a multivariate logistic regression analysis. RESULTS: During the study period, there were 686 admissions, of which 220 remained due to exclusion criteria. There was a consistent increase in ES-related injuries over the years (r = 0.91, p = 0.017). Patients who were injured after the introduction of sharing systems were more likely to sustain facial fractures (OR, 2.63; 95%CI, 1.30-5.32; p = 0.007) after controlling for age, gender, and race. The incidence of lumbar and pelvic fractures was higher following the introduction of such systems (7.1% vs. 0%; p<0.05). CONCLUSIONS: The introduction of ES sharing systems resulted in increased incidence of facial, pelvic, and lumbar fractures. Federal and state regulations need to be implemented to mitigate the detrimental effects of ES sharing systems.

Integrating the Bleeding Control Basic course into medical school curriculum.

BACKGROUND: The American College of Surgeons has pioneered hemorrhage control through its lifesaving bleeding control (BCon) basics course. A gap exists in teaching these skills to medical students. We sought to integrate BCon into the medical school curriculum. METHODS: BCon programs taught to entering Year 1 medical students in Academic Years 2017-2018. Post-course surveys assessed effectiveness of teaching and learner confidence in performing skills. Refreshers in Year 2 and Year 3 of study were implemented to reinforce skills. RESULTS: Post-course surveys (n = 348) showed that 98% of students felt that they were effectively taught how to stop bleeding and 92% felt comfortable using these skills. CONCLUSION: The BCon program is feasible to implement in medical school. It is easily integrated into pre-existing curricula in addition to other life support skills taught to medical students. SUMMARY: Bleeding control is increasingly a topic of national concern with mass casualty incidents. We used a peer training model to teach BCon techniques to all our medical students on entry into medical school and these skills were refreshed longitudinally in the next two years. Combining BCon training with other basic life support skills training is feasible and medical students find this training effective.

Emergency abdominal surgery in patients presenting from skilled nursing facilities: Opportunities for palliative care.

BACKGROUND: Residents of skilled nursing facilities (SNF) with acute abdomen present with more comorbidities and frailty than community-dwelling (CD) counterparts. Outcomes in this population are poorly described. METHODS: We hypothesized that SNF patients have higher mortality and morbidity than CD patients. This retrospective review of the NSQIP database from 2011 to 2015 compared outcomes of SNF and CD patients presenting with bowel obstruction, ischemia and perforation. Primary outcomes were in-hospital and 30-day mortality and failure-to-rescue (FTR). RESULTS: 18,326 patients met inclusion criteria. 904 (5%) presented from SNF. In-hospital (26% vs 10%) and 30-day mortality (33% vs 26%) was higher in SNF patients (p < 0.001). The FTR rate was 34% for SNF patients and 20% for CD patients (p < 0.001). CONCLUSIONS: Presentation from SNF is an independent predictor of mortality and FTR. Presentation from SNF is a potential trigger for early, concurrent palliative care to assist surgeons, patients, and families in decision making and goal-concordant treatment.

Patients with End-Stage Renal Disease and Acute Surgical Abdomen: Opportunities for Palliative Care.

Background: End-stage renal disease (ESRD) is a life-limiting condition that is often complicated by acute abdominal emergency. Palliative care (PC) has been shown to improve the quality of life in patients with serious illness and yet is underutilized. We hypothesize that ESRD patients with abdominal emergency have high unmet PC needs. Objective: To characterize the outcomes of ESRD patients with acute surgical abdomen, define PC utilization patterns, and identify areas of unmet PC needs. Design: Retrospective study querying the National Inpatient Sample database (2009-2013). Setting and Subjects: Subjects were identified using ICD-9 codes for those aged ≥50 with preexisting diagnosis of ESRD with an acute abdominal emergency diagnosis of gastrointestinal perforation, obstruction, or ischemia. Measurements: Outcomes included PC rate, in-hospital mortality, discharge disposition, and intensity of care. Multivariable logistic regression analysis was used to identify predictors of PC. Results: A total of 9363 patients met the inclusion criteria; 24% underwent surgery, 16% died in hospital, and 43% were discharged to dependent living. Among in-hospital deaths, 23% received PC. Only 4% of survivors with dependent discharge received PC. Surgical mortality was 26%. PC was less utilized in surgical patients than nonsurgical patients. PC was associated with shorter hospital stay. Predictors of PC included increasing age, severity of underlying illness, white race, teaching hospitals, and the Western region. Conclusions: Patients with ESRD admitted for acute abdominal emergency have high risk for mortality and functional dependence. Despite this, few receive PC and have a high utilization of nonbeneficial life support at the end of life.

Outcomes and palliative care utilization in patients with dementia and acute abdominal emergency: opportunities for surgical quality improvement.

BACKGROUND: When patients with dementia develop acute surgical abdomen, patients, surrogates, and surgeons need accurate prognostic information to facilitate goal-concordant decision making. Palliative care can assist with communication, symptom management, and family and caregiver support in this population. We aimed to characterize outcomes and patterns of palliative care utilization among patients with dementia, presenting with abdominal surgical emergency. METHOD: We retrospectively queried the National Inpatient Sample for patients aged >50 years with dementia and acute abdominal emergency who were admitted nonelectively 2009-2013, utilizing ICD-9-CM codes for dementia and surgical indication. We characterized outcomes and identified predictors of palliative care utilization. RESULTS: Among 15,209 patients, in-hospital mortality was 10.2%, the nonroutine discharge rate was 67.2%, and 7.5% received palliative care. Patients treated operatively were less likely to receive palliative care than those who did not undergo operation (adjusted OR = 0.50; 95% CI 0.41-0.62). Only 6.4% of patients discharged nonroutinely received palliative care. CONCLUSION: Patients with dementia and acute abdominal emergency have considerable in-hospital mortality, a high frequency of nonroutine discharge, and low palliative care utilization. In this group, we discovered a large gap in palliative care utilization, particularly among those treated operatively and those who are discharged nonroutinely.