Early Comfort Care Following Operative Intervention for Traumatic Injury.

BACKGROUND: Several studies have described the population of adult trauma patients who undergo withdrawal of life-sustaining treatments (WLST); however, no study has looked specifically at trauma patients who undergo WLST following surgery. METHODS: This was a retrospective chart review of all trauma patients who underwent surgery at our trauma center between January 1 and December 31, 2017. Demographics were collected along with injury patterns and advance directives. Charts of all patients who died or who were discharged to hospice were analyzed to determine whether WLST occurred. Statistics included Fisher's exact test and Mann-Whitney U test. RESULTS: Three thousand and twenty-five adult trauma patients received care and 1495 (49.4%) had operations. Thirty (2.0%) patients underwent WLST, 15 (50.0%) of whom died in the hospital and 15 (50.0%) of whom were discharged to hospice. Twenty-six (86.7%) patients had a palliative care consult and 12 (40.0%) had prior advance directives. The most common injuries were femur fractures and subdural hematomas. Adjusting for age, white race, and age-adjusted CCI, femur fracture patients had, on average, 8.8 more hours between presentation and surgery (95% CI 2.1-15.4, P = .01) and 39 fewer hours between surgery and WLST (95% CI -107-29, P = .26) than traumatic brain injury patients. DISCUSSION: The short time between surgery and WLST in this cohort of patients may demonstrate that surgery was not aligned with patients' goals of care. A patient-centered approach that includes surgeon-driven palliative care discussions may help avoid nonbeneficial surgery in the last few days of life.

Postoperative surgical trainee opioid prescribing practices (POST-OPP): A national survey.

BACKGROUND: Increasing opioid-related deaths have heightened focus on combating the opioid epidemic. The impact of surgical trainees on opioid-related deaths is unclear, and there is little data examining the association between trainee pain management education and opioid prescribing practices. METHODS: An anonymous, online survey was distributed to members of the Resident and Associate Society of the American College of Surgeons. The survey covered five themes: education and knowledge, prescribing practices, clinical case scenarios, policy, and beliefs and attitudes. Linear mixed models were used to evaluate the influence of respondent characteristics on reported morphine milligram equivalents (MME) prescribed for common general surgery clinical scenarios. RESULTS: Of 427 respondents, 54 percent indicated receiving training in postoperative pain management during medical school and 66 percent during residency. Only 35 percent agreed that they had received adequate training in prescribing opioids. There was a significant association between undergoing formal pain management training in medical school and prescribing fewer MME for common outpatient general surgery scenarios (94 ± 15.2 vs 108 ± 15.0; p = 0.003). Similarly, formal pain management training in residency was associated with prescribing fewer MME in the survey scenarios (92.6 ± 15.2 vs 109 ± 15.2; p = 0.002). CONCLUSION: In this survey, nearly two-thirds of surgical residents felt that they were inadequately trained in opioid pre-scribing. Our findings additionally suggest that improving education may result in increased resident comfort with man-aging surgical pain, potentially leading to more responsible opioid prescribing. Further work will facilitate residency pro-grams' development of educational curricula for opioid prescribing best practices.

Bicycle commuter injury prevention: it is time to focus on the environment.

BACKGROUND: Few data exist on the risk of injury while commuting to work or school by bicycle. The proportion of commuters choosing to travel by bike is increasing in the United States, and information on injury incidence and the influences of rider characteristics and environmental factors may suggest opportunities for prevention actions. METHODS: Bicycle commuters in the Portland, OR, metropolitan area were recruited via the websites and community advertising to participate in a 1-year study. Riders completed an initial online survey along with 12 monthly surveys describing their commutes and injury events from September 2007 to August 2008. A traumatic event was considered a serious traumatic event if medical attention was sought. RESULTS: Nine hundred sixty-two adult bicyclists (52% men and 48% women) with a mean age of 36.7 ± 0.4 years (range, 22-70 years) commuted an average of 135 miles (range, 7-617) per month. There were 225 (23%) beginner, 256 (27%) intermediate, and 481 (50%) advanced riders. Four hundred twenty (44%) had a prior traumatic event. Over the 1-year period, 164 (18%) riders reported 192 traumatic events and 49 (5%) reported 50 serious traumatic events. The incidence rates of traumatic events and serious traumatic events were 15.0 (95% CI, 13.2-17.5) and 3.9 (95% CI, 2.9-5.1) per 100,000 miles commuted. There were no differences in age, gender, safety practices, and experience levels between commuters who experienced a traumatic event and those who did not. CONCLUSIONS: Approximately 20% of bicycle commuters experienced a traumatic event and 5% required medical attention during 1 year of commuting. Traumatic events were not related to rider demographics, safety practices, or experience levels. These results imply that injury prevention should focus on improving the safety of the bicycle commuting environment.