Pack the chest: Damage control strategy for management in thoracic trauma.

BACKGROUND: Damage control surgery aims to control hemorrhage and contamination in the operating room (OR) with definitive management of injuries delayed until normal physiology is restored in the intensive care unit (ICU). There are limited studies evaluating the use of damage control thoracotomy (DCT) in trauma, and the best method of temporary closure is unclear. METHODS: A retrospective review of trauma patients at two level I trauma centers who underwent a thoracotomy operation was performed. Subjects who underwent a thoracotomy after 24 h, age less than 16, expired in the trauma bay, or in the OR prior to ICU admission were excluded. One-way ANOVA and Kruskal-Wallis test were used to compare continuous and categorical variables between DCT and definitive thoracotomy (DT) patients. RESULTS: 207 trauma patients underwent thoracotomy, 76 met our inclusion criteria. DCT was performed in 30 patients (39%), 46 (61 %) underwent DT operation. Techniques for temporizing the chest varied from skin closure with suture (8), adhesive dressing (5), towel clamps (2), or negative pressure devices (12). Compared to definitive closure, DCT had more derangements in HR, pH, (110 vs. 95, p = 0.04; 7.05 vs 7.24, p < 0.001), and injury severity score (41 vs 25, p < 0.001), and required more blood transfusions (40 vs 6, p < 0.001). Eleven (36.7 %) DCT patients survived to discharge compared to 38 patients (95.0 %) in the DT group. DCT showed significantly higher differences in cardiac arrest and unplanned returns to the OR rates. No differences were observed in ventilator days, or ICU length of stay. CONCLUSIONS: DCT is a viable option for management of patients in extremis following thoracic trauma. DCT was associated with higher mortality rates, likely due to differences in injury and physiologic derangement. Despite this, DCT was associated with similar rates of complications, ICU stay, and ventilator days.

Caring for Incarcerated Patients: Can it Ever be Equal?

BACKGROUND: Incarcerated patients represent one of the most vulnerable populations in the United States healthcare system. Studying disparities in care they receive, however, has been difficult due to a history of abuse at the hands of medical researchers rendering this population excluded from most current medical research. Due to incarceration, these patients are frequently maintained in shackles and under constant guard when receiving healthcare. There is a paucity of literature on the influence these measures exert on healthcare workers and the care they provide. Our study aimed to measure surgical trainee's perception of health inequities and disparities in incarcerated individuals undergoing surgical care. METHODS: An anonymous cross-sectional survey was administered at our single institution to all general surgery trainees assessing perceptions in delivering care to incarcerated patients within our hospital system. The survey consisted of 10 items, nine of which were yes or no responses, and 1 open-ended text question. Survey results were averaged, and percentages were reported. RESULTS: Of all current general surgery residents (n = 60), 40 (66%) completed the survey. Almost all respondents (n = 39, 97.5%) have cared for a patient that was incarcerated or in police custody. Most respondents (n = 25, 62.5%) have operated on an incarcerated patient with an armed guard present in the operating room. Similarly, most respondents (n = 26, 65%) have cared for a patient intubated and sedated that was shackled to a bed. The majority of respondents (n = 30, 75%) recalled incidents where a trauma patient was actively questioned by law enforcement during the primary/secondary survey during initial trauma evaluation. At the time of hospital discharge, a quarter (n = 10, 25%) of respondents reported being unable to prescribe all of the medications that a non-imprisoned patient would receive with the same condition. In addition, 18 (45%) respondents felt they were unable to arrange outpatient follow-up with physical or occupational therapy and/or the patient's primary/consulting physician due to patient's incarcerated status. Strikingly, half of respondents (n = 19, 47.5%) believed that the incarcerated patient received substandard care, and the majority of respondents (n = 28, 72%) agreed that the holding areas for incarcerated patients in the emergency room provide substandard patient care. CONCLUSIONS: The current status of caring for incarcerated patients within our system represents an urgent and needed area for quality improvement. Surgical trainees report difficulty caring for these patients, and they perceive these individuals receive substandard care. Though our cross-sectional study did not assess the origin of this disparity, the challenges trainees face in caring for incarcerated patients, from assessment to diagnosis and treatment, as well as in follow-up signals an area requiring further research and study.