Early Psychiatric Consultation Is Associated With Decreased Cost and Length of Stay in the Patient Population at a Level I Trauma Center.

Introduction Psychiatric illness impacts nearly one-quarter of the US population. Few studies have evaluated the impact of psychiatric illness on in-hospital trauma patient care. In this study, we conducted a retrospective cohort study to evaluate hospital resource utilization for trauma patients with comorbid psychiatric illnesses. Methodology Trauma patients admitted to a level I center over a one-year period were included in the study. Patients were categorized into one of three groups: (1) no psychiatric history or in-hospital psychiatric service consultation; (2) psychiatric history but no psychiatric service consultation; and (3) psychiatric service consultation. Time to psychiatric service consultation was calculated and considered early if occurring on the day of or the day following admission. Patient demographics, outcomes, and resource utilization were compared between the three groups. Results A total of 1,807 patients were included in the study (n = 1,204, 66.6% no psychiatric condition; n = 508, 28.1% psychiatric condition without in-hospital psychiatric service consultation; and n = 95, 5.3% in-hospital psychiatric service consultation). Patients requiring psychiatric service consultation were the youngest (P < .001), with the highest injury severity (P = .024), the longest hospital length of stay (P < .001), and the highest median hospital cost (P < .001). Early psychiatric service consultation was associated with an average saving in-hospital length of stay of 2.9 days (P = .021) and an average hospital cost saving of $7,525 (P = .046). Conclusion One-third of our trauma population had an existing psychiatric diagnosis or required psychiatric service consultation. Resource utilization was higher for patients requiring consultation. Early consultation was associated with a savings of hospital length of stay and cost.

Moving From Organ Donation to Knowledge Donation: A Novel Opportunity for Surgical Education Following Organ Donation.

The objective of this article is to share how our institution implemented the use of organ donors for surgical education following organ recovery. Despite technological advances, realistic surgical simulation models are lacking, leaving little opportunity to practice a procedure prior to performance on a living patient. Utilization of organ donors following organ donation offers an opportunity for life-like surgical simulation. We developed a pathway to use organ donor tissue in the post-recovery period for robotic simulation. We obtained support from our local Institutional Review Board, Ethics Committee, and organ procurement organization to create a "knowledge donor" program. Our knowledge donation program provided learners hands-on experience with a novel procedure and also provided organ donors another opportunity to express their altruism. We found that the process was well accepted by donor families and learners. We implemented a knowledge donation program at our hospital that provides valuable surgical experience. We discuss future directions for knowledge donation at our institution.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2 min. The mean time to aortic occlusion for all surgeons was 111 s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

Pneumomediastinum in blunt trauma: If aerodigestive injury is not seen on CT, invasive workup is not indicated.

BACKGROUND: Pneumomediastinum following blunt trauma is often observed on CT imaging, and concern for associated aerodigestive injury often prompts endoscopy and/or fluoroscopy. In recent years, adoption of multi-detector CT technology has resulted in high resolution images that may clearly identify aerodigestive injuries. The purpose of this study was to evaluate the utility of multi-detector CT in the identification of blunt aerodigestive injuries. METHODS: Over five years, patients with pneumomediastinum following blunt trauma were identified from the registry of a level 1 trauma center. All CT imaging of trauma patients during this time period was accomplished with 64-slice scanners. RESULTS: 127 patients with blunt traumatic pneumomediastinum were identified. Five airway injuries were identified, and all injuries were evident on CT imaging. No patient was found to have airway injury by endoscopy that was not evident on CT. No patient had an esophageal injury. CONCLUSION: Multi-detector CT imaging identifies aerodigestive injuries associated with pneumomediastinum following blunt trauma. The absence of a recognizable aerodigestive injury by CT effectively rules out the presence of such injury.

Saccadic eye movement metrics reflect surgical residents' fatigue.

OBJECTIVE: Little is known about the effects of surgical residents' fatigue on patient safety. We monitored surgical residents' fatigue levels during their call day using (1) eye movement metrics, (2) objective measures of laparoscopic surgical performance, and (3) subjective reports based on standardized questionnaires. BACKGROUND: Prior attempts to investigate the effects of fatigue on surgical performance have suffered from methodological limitations, including inconsistent definitions and lack of objective measures of fatigue, and nonstandardized measures of surgical performance. Recent research has shown that fatigue can affect the characteristics of saccadic (fast ballistic) eye movements in nonsurgical scenarios. Here we asked whether fatigue induced by time-on-duty (~24 hours) might affect saccadic metrics in surgical residents. Because saccadic velocity is not under voluntary control, a fatigue index based on saccadic velocity has the potential to provide an accurate and unbiased measure of the resident's fatigue level. METHODS: We measured the eye movements of members of the general surgery resident team at St. Joseph's Hospital and Medical Center (Phoenix, AZ) (6 males and 6 females), using a head-mounted video eye tracker (similar configuration to a surgical headlight), during the performance of 3 tasks: 2 simulated laparoscopic surgery tasks (peg transfer and precision cutting) and a guided saccade task, before and after their call day. Residents rated their perceived fatigue level every 3 hours throughout their 24-hour shift, using a standardized scale. RESULTS: Time-on-duty decreased saccadic velocity and increased subjective fatigue but did not affect laparoscopic performance. These results support the hypothesis that saccadic indices reflect graded changes in fatigue. They also indicate that fatigue due to prolonged time-on-duty does not result necessarily in medical error, highlighting the complicated relationship among continuity of care, patient safety, and fatigued providers. CONCLUSIONS: Our data show, for the first time, that saccadic velocity is a reliable indicator of the subjective fatigue of health care professionals during prolonged time-on-duty. These findings have potential impacts for the development of neuroergonomic tools to detect fatigue among health professionals and in the specifications of future guidelines regarding residents' duty hours.

A rare opportunity for conservative treatment in a case of blunt trauma to the supradiaphragmatic inferior vena cava.

Injuries to the inferior vena cava (IVC) secondary to blunt trauma are rare and occur in only 1-10% of all blunt trauma patients. Management of these injuries has not been subjected to major studies, but several case reports and small retrospective studies have demonstrated that management can be tailored to the hemodynamic status of the patient; this is similar to the management of blunt liver injuries. Stable patients whose injuries have achieved local venous tamponade have been successfully treated without surgical intervention, while unstable patients require operative management. Regardless of patient status, however, IVC injuries are highly fatal with mortality rates between 70 and 90%. This report describes the case of a patient with a blunt traumatic injury to the supradiaphragmatic IVC with development of a pseudoaneurysm who was successfully managed conservatively.