From the Operating Room to Online: Medical Student Surgery Education in the Time of COVID-19.

BACKGROUND: On March 17, 2020 the Association of American Medical Colleges recommended dismissal of medical students from clinical settings due to the COVID-19 pandemic. Third-year (M3) and fourth-year (M4) medical students were at home, M4s were interested in teaching, and residents and faculty had fewer clinical responsibilities due to elective surgery cancellations. To continue M3 access to education, we created a virtual surgery elective (VSE) that aimed to broaden students' exposure to, and elicit interest in, general surgery (GS). METHODS: Faculty, surgical residents, and M4s collaborated to create a 2-wk VSE focusing on self-directed learning and direct interactions with surgery faculty. Each day was dedicated to a specific pathology commonly encountered in GS. A variety of teaching methods were employed including self-directed readings and videos, M4 peer lectures, case-based learning and operative video review with surgery faculty, and weekly surgical conferences. A VSE skills lab was also conducted to teach basic suturing and knot-tying. All lectures and skills labs were via Zoom videoconference (Zoom Video Communications Inc). A post-course anonymous survey sent to all participants assessed changes in their understanding of GS and their interest in GS and surgery overall. RESULTS: Fourteen M3s participated in this elective over two consecutive iterations. The survey response rate was 79%. Ninety-one percent of students believed the course met its learning objectives "well" or "very well." Prior to the course, 27% reported a "good understanding" and 0% a "very good" understanding of GS. Post-course, 100% reported a "good" or "very good" understanding of GS, a statistically significant increase (P = 0.0003). Eighty-two percent reported increased interest in GS and 64% reported an increase in pursuing GS as a career. CONCLUSIONS: As proof of concept, this online course successfully demonstrated virtual medical student education can increase student understanding of GS topics, increase interest in GS, and increase interest in careers in surgery. To broaden student exposure to GS, we plan to integrate archived portions of this course into the regular third-year surgery clerkship and these can also be used to introduce GS in the preclinical years.

Management and Outcomes after Upper Versus Lower Extremity Vascular Trauma.

BACKGROUND: While significant literature exists regarding peripheral vascular injury management, the vast majority focuses on lower extremity arterial injury. As a result, clinical management of arterial injury in the upper extremities is often guided by literature specific to lower extremity vessel injury. The purpose of this study is to use the largest series of patients reported in the literature to compare management and outcomes of upper and lower extremity traumatic vascular injuries. METHODS: Patients who underwent operative repair of traumatic vascular injuries of the extremities were identified from the trauma registry of a level I trauma center. A retrospective chart review (2011-2019) was conducted. Demographics, mechanism of injuries, operative techniques, and outcomes were compared between patients with upper versus lower extremity vascular injuries. RESULTS: Five hundred thirty-five patients were included with 234 (43.8%) patients undergoing repair of upper extremity vascular injuries. Patients with upper extremity vascular injuries were more likely to be female (16.7% vs. 9%, P = 0.007), have a pre-hospital tourniquet (21.8% vs. 12%,P = 0.002), have associated nerve injuries (40.2% vs. 4.7%, P < 0.0001) or present with bleeding (76.1% vs. 64.1%, P = 0.002) but were less commonly associated with concomitant fractures (25.6% vs. 39.9%, P = 0.0006). There was no difference in age, race, or mechanism of injury. In regards to operative management, upper extremity injuries were more likely to be managed with vessel ligation (38% vs. 17.6%, P < 0.0001) or primary reanastomosis (12.4% vs. 5.6%, P = 0.009) and were less frequently associated with concomitant fasciotomies (13.3% vs. 56.5%, P < 0.0001). Postoperatively, upper extremity injuries were associated with persistent nerve deficits (21.7% vs. 10%, P = 0.0002) while lower extremity injuries had a higher incidence of 30-day limb loss (5.7% vs. 1.3%, P = 0.008). There were no differences in mortality or graft-patency rates between groups. CONCLUSIONS: Upper extremity injuries are associated with a lower limb-loss rate but increased prevalence of neurological deficits after vascular trauma compared to lower extremities. A high level of suspicion is paramount to intraoperative identify associated nerve injuries to improve postoperative functional outcomes.

Economic burden and clinical impact of preoperative opioid dependence for patients undergoing lower extremity bypass surgery.

OBJECTIVE: Surgeons' prescription practices and the opioid epidemic have received significant attention in the media. Limited data exist, however, on the impact of prior or coexistent opioid use on vascular surgery outcomes. This study aimed to quantify the incidence, economic burden, and clinical impact of pre-existing opioid dependency in patients undergoing lower extremity bypass (LEB) surgery. METHODS: Data were collected from 1,132,645 weighted (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample for the years 2002 to 2015. Patients with a concomitant diagnosis of opioid abuse or dependency were identified using International Classification of Diseases, Ninth Revision codes. Matched cohorts of patients with (n = 606 unweighted) and without (n = 32,343 unweighted) opioid dependence were created using coarsened exact matching to control for patient demographics. Linear regression was used to control for hospital-level factors and to identify differential outcomes for patients with opioid dependency. Our primary end points were hospital cost and length of stay. Our secondary end points were surgical complications and in-hospital mortality. RESULTS: There were 1,132,645 (230,858 unweighted) patient admissions for LEB in the National Inpatient Sample during 2002 to 2015. There were 3190 (0.3%) patients (643 unweighted) who had a diagnosis of pre-existing opioid dependency. The incidence of opioid dependency rose over time (2002, 0.13%; 2015, 0.63%; R2 = 0.90; P < .001). Before matching, opioid-dependent patients were younger (53.9 ± 12.3 years vs 66.7 ± 12.1 years; P < .001) and more likely to be male (65.2% vs 61.9%; P < .001), to be nonwhite (37.9% vs 24.1%; P < .001), to pay with Medicaid (29.6% vs 7.4%; P < .001), and to fall in the lowest income quartile based on ZIP code (39.6% vs 27.5%; P < .001). After matching, opioid-dependent patients (n = 606 unweighted vs n = 32,343 unweighted nonopioid-dependent patients) were at increased risk of surgical site infections (odds ratio [OR], 1.61; P = .006), major bleeding (OR, 1.56; P = .04), acute kidney injury (OR, 1.46; P = .02), and deep venous thrombosis (OR, 2.53; P = .005). Linear regression of matched cohorts revealed that opioid-dependent patients had an increased length of hospital stay (11.76 days vs 9.80 days; P < .001) and an increased mean inflation-adjusted in-hospital cost of U.S. $7032 ($37,522 vs $30,490; P < .001). CONCLUSIONS: The incidence of pre-existing opioid dependency in patients undergoing LEB continues to rise. Patients with opioid use disorder undergoing LEB surgery have substantial increases in length of hospital stay and costs. These findings highlight the importance of early preoperative recognition of this disorder in vascular surgery patients and open the opportunity for early intervention in that cohort.