Putting a halt to unnecessary transfers: Do patients with isolated subarachnoid hemorrhage and Glasgow Coma Scale of 13 to 15 need a trauma center?

OBJECTIVES: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care. METHODS: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy). RESULTS: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation. CONCLUSION: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention. LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.

Effects of Clinical Exposure to Osteopathic Manipulative Medicine on Confidence Levels of Medical Students.

CONTEXT: Training in osteopathic manipulative medicine (OMM) is a unique component of the osteopathic medical school curriculum. Indicators of successful OMM programming include student comfort in explaining and performing OMM as well as confidence in using OMM on future patients. Research on the amount of clinical exposure sufficient to achieve this goal is limited. OBJECTIVES: To gauge the impact of clinical OMM exposure on medical students' self-assessed understanding of OMM, their ability to discuss, explain, and perform OMM, and their plan to use OMM in their future practice. METHODS: Fourth-year osteopathic medical students were e-mailed surveys before (baseline), during, and after 4 weeks (postrotation) of an elective OMM rotation. Answers were scaled from 0 to 10, with 0 being not at all comfortable/confident and 10 being the most comfortable/confident. RESULTS: Thirty-five students participated in the survey. A significant mean (SD) increase was found between the baseline and postrotation scores for students' understanding of OMM principles (1.43 [0.51]; P<.001), comfort discussing OMM principles with patients (1.27 [0.88]; P<.001), comfort with explaining OMM to someone unfamiliar with it (1.32 [0.82]; P<.001), comfort with performing an osteopathic structural examination (2.23 [1.44]; P<.001), and confidence incorporating OMM into future practice (1.86 [0.47]; P<.001). CONCLUSION: Increased clinical exposure to OMM increased the confidence of osteopathic medical students in all dimensions surveyed. This observation can help guide the development of undergraduate osteopathic clinical programming as well as standards for entry of allopathic residents into ACGME programs with osteopathic designation.