Medical student clerkship performance and career selection after a junior medical student surgical mentorship program.

BACKGROUND: The impact of early medical school mentorship in students' clerkships performance and career selection is unknown. METHODS: We administered Introduction to Surgery, a resident-directed, semester-long, preclinical elective to junior medical students who answered a Likert-type survey after residency application. Elective participants (EPs) were compared with nonparticipant applicants (EAs), medical school class (MS), and national match outcomes (USA). RESULTS: All 18 EPs (7 M1's, 11 M2's) completed the elective and survey. EP reported more confidence and improved surgical skills, especially attributed to resident mentorship (F(13,237) = 2.3, P = 8*10(-3)). EP "honored" the clerkship more than MS (P = .05); 55.6% of EP, 37.5% of EA, and 27.7% of MS chose surgical fields, yielding a relative risk of 2.0 for EP vs MS (95% confidence interval: 1.3 to 3.2, P = 4*10(-3)). EP "strongly agree" with future mentorship programs (4.6/5), and 1 EP reported the course to be the "main reason" for applying to general surgery. CONCLUSIONS: Introduction to Surgery provides a model for a multifaceted junior medical student mentorship program, which has the potential to retain interested students for surgical career selection.

Delayed partial liquid ventilation shows no efficacy in the treatment of smoke inhalation injury in swine.

In an earlier neonatal porcine model of smoke inhalation injury (SII), immediate postinjury application of partial liquid ventilation (PLV) had dramatic beneficial effects on lung compliance, oxygenation, and survival over a 24-h period. To explore the efficacy of PLV following SII, we treated animals at 2 and 6 h after SII and followed them for 72 h. Pigs weighing 8-12 kg were sedated and pharmacologically paralyzed, given a SII, and placed on volume-cycled, pressure-limited ventilation. Animals were randomized to three groups: group I (+SII, no PLV, n = 8), group II (+SII, PLV at 2 h, n = 6), and group III (+SII, PLV at 6 h, n = 7). Ventilatory parameters and arterial blood gasses were obtained at scheduled intervals. The PLV animals (groups II and III) followed a worse course than group I (no PLV); PLV groups had higher peak and mean airway pressures, oxygenation index, and rate-pressure product (a barotrauma index) and lower lung compliance and arterial partial pressure of oxygen-to-inspired oxygen fraction ratio (all P < 0.05). PLV conferred no survival advantage. The reported beneficial effects of PLV with other models of acute lung injury do not appear to extend to the treatment of SII when PLV is instituted in a delayed manner. This study was not able to validate the previously reported beneficial effects of PLV in SII and actually found deleterious effects, perhaps reflecting the predominance of airway over alveolar disease in SII.

Thermally injured patients are at significant risk for thromboembolic complications.

BACKGROUND: The incidence of thromboembolic complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE) in thermally injured patients is considered sufficiently uncommon that routine prophylactic measures are not warranted. Nevertheless, the incidence of DVT/PE may be increasing. METHODS: The records of 1,300 patients admitted to our unit from January 1990 to June 1995 were reviewed. RESULTS: Twenty-three patients developed a clinically significant DVT, eight patients developed a PE, and two patients developed both a DVT and a PE, for an overall DVT/PE incidence of 2.9%. Four of 10 PEs were felt to be fatal. The DVT/PE patients were older (mean age, 42.6 vs. 28.7; p < 0.001) and had larger burns (37% vs. 18%, p < 0.001) than patients without evidence of DVT/PE. Body weight appeared to also influence DVT/PE rates, with obese patients (>30% over ideal body weight) having a higher incidence than patients with low or normal body weight (7.2 vs. 2.7%, p < 0.015). Age and total body surface area (TBSA) burn had a synergistic effect on DVT/PE risk, with the sum of age and TBSA burn exerting the strongest independent effect when discriminant function analysis was performed (p < 0.001). CONCLUSION: One can identify a population at increased risk of DVT/PE on the basis of the sum of age and TBSA burn, but prospective screening trials that assess all risk factors for DVT/PE should be performed before routine prophylaxis is used in thermally injured patients.

Acute respiratory failure that complicates the resuscitation of pediatric patients with scald injuries.

Respiratory failure that requires endotracheal intubation is an uncommon but potentially fatal complication of scald burns in children. Because scalds are rarely associated with a direct pulmonary injury, the pathophysiology of respiratory failure is unclear. A possible mechanism may be upper airway edema, diminished pulmonary compliance secondary to fluid resuscitation, or both. To identify an at-risk population for intubation after a scald injury, the hospital courses of 174 consecutive patients under the age of 14 years who were admitted after a scald injury to a single burn center during a 6-year period were examined. Seven of these patients (4%) required endotracheal intubation. No patient older than 2.8 years or who had a scald injury that covered less than 19% of the total body surface area required intubation. Patients who required intubation were younger (mean age, 1.4 vs. 2.8 years, P<.001), had a larger mean burn size (29.9% vs. 12.3% total body surface area, P<.001), and required more fluid resuscitation (7.66 vs. 4.07 cc/kg per percentage of total body surface area burned, P<.001) than patients who did not require intubation. Examination of the adequacy of resuscitation revealed that the intubated patients had an average hourly urine output of 0.84 cc/kg during the first 24 hours, suggesting that resuscitation was not excessive. Multivariate analysis demonstrated that both larger burn size (P = .041) and younger age (P = .049) were independent predictors of the need for intubation. Young patients with large body surface area burns that required large volumes of resuscitation comprise an at-risk group for respiratory failure after a scald injury. Increased vigilance is merited during the resuscitation of these patients.

Elder abuse: a call to action.

An estimated 2 million people a year are victims of elder abuse, which ranges from neglect and mistreatment to physical abuse. By the year 2020, a full 22% of the population will be aged 65 or older. This demographic explosion demands that we identify and protect those at risk. To investigate the incidence of elder abuse or neglect (EAN) and to determine clinician awareness of associated risk factors, we conducted a 1-year retrospective review of thermally injured patients aged 60 or older. Data included age, total body surface area burned, mechanism of injury, length of hospital stay, mortality, abuse or neglect risk factors, and referral to the appropriate social agency. We found that our elderly patients (n = 28) were poorly screened for EAN. While 64% to 96% of patients were screened for cognitive impairment, overall health, and financial resources, none were screened for risk factors of emotional isolation. None of the patient's caregivers, including any spouses, roommates, or guardians, were screened for risk factors of substance abuse, familial violence, dependency needs, or external stresses. With the use of available data, we were able to place 11 patients on the following levels of abuse or neglect: 1) low risk for abuse; 2) self-neglect; 3) neglect; and 4) abuse. By this scale, 7 patients (64%) were victims of self-neglect, 3 patients (27%) were victims of neglect, and 1 patient (9%) was a victim of abuse. Adult Protective Services intervened in 2 cases. Recognizing that all cases of EAN should be preventable, we cannot accept the socioeconomic impact of this entity. The 11 patients identified as victims of neglect, self-neglect, or abuse accounted for 135 hospital days and 8 fatalities. Before we can address EAN, health care personnel must be made aware of the problem and routine screening for risk factors must be implemented. The true incidence of EAN is likely underestimated because health care providers have difficulty recognizing its features. A standard assessment tool to screen for neglect or abuse should be used for each older adult admission.

Body habitus as a predictor of burn risk in children: do fat boys still get burned?

Previous research at this institute has demonstrated that heavy-for-age boys are more burn prone than their normal sized counterparts. As this study is now 26 years old, we reexamined the anthropomorphic indices of 372 children admitted to one burn center between January 1991 and July 1997 to determine if this trend was still evident. Male children were over-represented in the < or =5th and >95th percentiles for both height (p < 0.001, p < 0.05) and weight (p < 0.01, p < 0.001). Female children were over-represented in the < or =5th and > 95th percentiles for height (p < 0.01, p < 0.05). Twenty-eight percent of boys at or below the 5th percentile for weight were burned as a result of known or suspected intentional injury, compared to 5.9% of the entire pediatric burn population. (p < 0.0004). 'Fat boys' continue to be over-represented in the pediatric burn population. Additionally, in the more recent time period, boys at or below the 5th percentile for height or weight and girls= < 5th percentile or >95th percentile for height are also over-represented. The increased frequency of burn injury in small-for-age children may reflect an increased risk of burn injury secondary to neglect or nonaccidental trauma.

Management of the burn wound.

Few features of the burn victim attract more attention than the damage or destruction of the skin from thermal injury. Management of the resultant burn wound is the systematic application of knowledge and technique to promote and facilitate closure of integumentary disruption. The role of the professional nurse in the management of burn wounds, often within the milieu of critical care, can be uniquely challenging and especially rewarding. This article reviews management of the burn wound with emphasis on methods, techniques, and procedures used in contemporary burn wound treatment. The article also includes nursing care plans of selected nursing diagnoses for organizing and facilitating the nursing care process.