Pay for performance - motivation to succeed in Advanced Trauma Life Support courses - a question of background or funding?

Objective: To correlate students' performance with their professional background and motivation to take part in Advanced Trauma Life Support (ATLS) courses. We base our analysis on the self-determination theory that differentiates intrinsic (ambition to perform by individual itself) from extrinsic motivation (incentive by external stimuli). Design: We present a non-blinded, monocentric, non-randomized descriptive study of 376 students taking part in an ATLS course at one course site in Germany. Part of a two-day ATLS course are two written tests; we correlate test scores with background information provided by the students in a questionnaire of 13 items (age, sex, adress, board certification, specialty, subspecialty, position, hospital level of care, hospital operator and hospital participation in trauma network, motivation, funding source, condition of funding). Setting: The students were recuited at the BG Trauma Center Ludwigshafen (Germany), a large 528-bed trauma center and one of 13 ATLS course sites in Germany. Participants: 449 ATLS course students taking part in ATLS courses at the above-mentioned course site from February 2009 to May 2010 were sent a questionnaire asking for their background. All 449 course students were eligible to participate. 376 (83.7%) questionnaires were returned, pre- and post-test results of all students aquired and included into our calculations. 312 (83%) were male and 64 (17%) female. The majority (59.3%) of recruited students came from trauma surgery, 21.8% from anesthesiology, 8% from general surgery, 4% from abdominal surgery, 0.5% from vascular or thoracic surgery each and 5.9% from other specialties. Results: Neither age, sex, subspecialty, hospital level of care, hospital operator, or hospital participation in trauma network played a role with respect to motivation or test results. The high degree of intrinsic motivation of consultants (92.3%) had no impact on their test results. Anesthesiologists were higher motivated (75.6% intrinsically motivated) in contrast to all surgical colleagues (63.6%), which showed significant differences in the pre- (89.8% vs. 85.3%, p=0.03) but not the post-test. Of all 13.6% students who were self-payers, 94.1% were intrinsically motivated; the 86.2% whose course fee was accounted for were less likely to be intrinsically motivated (63.9%). Sponsoring however did not have a negative impact on test results. Conditional funding (sponsored only on passing both tests) was detrimental to motivation: 0% of these individuals were intrinsically motivated and they scored significantly lower (82.5%) than all other students in the post-test (86.9%, p=0.002). Overall, intrinsically motivated students overtopped extrinsically motivated students in the post-test (88.0% vs. 83.4%, p<0.001). Conclusions: ATLS course participation is not compulsory for medical doctors in Germany. Intrinsic motivation to take part in these courses is a key prerequisite to increase performance, irrespective of the background of the students. Intrinsically motivated students are ready to invest into their education and vice versa. Conditional funding (course fee only sponsored on passing the course) evokes no intrinsic motivation at all and causes worse results.

Is dopexamine superior to dopamine in the treatment of multiple trauma patients--a prospective, double-blind, randomised study.

BACKGROUND: The goal of this prospective, randomised, double-blind clinical trial study was to assess the effects of dopexamine hydrochloride on organ failure, inflammatory mediators and splanchnic oxygenation in blunt multiple trauma patients at high risk of multiple organ dysfunction syndrome (MODS). METHODS: We performed a prospective randomised controlled trial on 30 consecutive blunt multiple trauma patients with ISS>or=16, age 18-60 years and initial blood pressure >or=120 mmHg initially admitted to our level I trauma centre. Patients were randomised to treatment with dopamine (n=15) or dopexamine (n=15) for 48 h after admission. Outcome in terms of mortality, MODS, splanchnic perfusion, complications, duration of stay was statistically analysed. RESULTS: Dopexamine treatment was associated with impaired organ function and an increased duration of ventilation and ICU stay compared with patients who received dopamine treatment. The acute inflammatory response was increased in the Dopexamine group while a decreased pHi and MEGX formation and increased serum lactate levels were measured. CONCLUSIONS: The indication to use dopexamine hydrochloride appears questionable. In the absence of an antiinflammatory effect, dopexamine demonstrated a disadvantageous ICU course in regards to the organ function and the duration of treatment. In addition, a decreased pHi and MEGX formation suggested a deterioration of splanchnic oxygenation.

30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution.

The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n=1469) and 1985-1994 (decade II; n=1937) and 1995-2004 (decade III; n=1443) were compared. 65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death. These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.

Hindlimb growth after a transphyseal reconstruction of the anterior cruciate ligament: a study in skeletally immature sheep with wide-open physes.

BACKGROUND: There is a lot of controversy in the recent literature with regard to the optimal treatment of anterior cruciate ligament (ACL) injuries during growth. Iatrogenic growth disturbance due to physeal damage is a potential complication, forcing many orthopaedic surgeons to treat these injuries conservatively. HYPOTHESIS: It is possible to perform a fully transphyseal ACL reconstruction in an ovine model with wide-open physes without creating growth disturbances. STUDY DESIGN: Descriptive laboratory study. MATERIALS AND METHODS: Four-month-old skeletally immature sheep underwent a transphyseal ACL reconstruction of the right knee. The surgical technique followed the criteria known to be essential to avoid growth disturbances in humans; the tibial tuberosity was spared to prevent a genu recurvatum, thermal damage to the growth plates was avoided, the physes were perforated with a small-diameter drill in the center of the growth plate, a soft tissue graft was used, graft fixation was achieved far away from the growth plates, the perforated growth plates were filled by the soft tissue graft, and the graft was moderately pretensioned before fixation. The left knee served as a control. A computer-assisted evaluation of long radiographs (frontal and sagittal plane) of the exarticulated hindlimbs was performed to exactly evaluate the limb alignment, joint orientation, and leg length. The animals were sacrificed in groups of 6 after 3, 6, 12, and 24 weeks. RESULTS: No angular deformities or leg-length discrepancies occurred after this transphyseal ACL reconstruction procedure throughout the remaining growth. CONCLUSION: This large-animal study supports the clinical observation that it is possible to perform an ACL reconstruction without creating growth disturbances as long as a number of key principles are followed. CLINICAL RELEVANCE: Previous animal studies argued against ACL reconstruction in skeletally immature patients. This large-animal study provides support for early operative treatment of ACL ruptures even in young patients with open physes.

Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective.

BACKGROUND: We wished to determine the characteristics of patients with pelvic ring fractures (PGs) in England and Wales, make comparisons to major trauma patients without pelvic injury (NPGs), and determine factors predicting mortality, including the impact of presence of pelvic reconstruction facilities in the receiving hospitals on outcome. METHODS: Prospective data from 106 trauma receiving hospitals forming the Trauma Audit and Research Network were studied. Between January 1989 and December 2001 data of 159,746 trauma patients were collected in the Trauma Audit and Research Network database. Because of incomplete data, 1,610 pelvic fracture patients and 13,499 patients without pelvic fracture were excluded from detailed analysis. In total, 11,149 patients in the PG and the remaining 133,486 patients in the NPG (control) group were included in the final analysis. RESULTS: There were statistically significantly more patients with an Injury Severity Score >15 in the PG group (n = 3,576; 32.1%) than in NPG group (n = 19,238; 14.4%) (p < 0.001), indicating that pelvic injuries were more often associated with other injuries. The majority of patients sustained Abbreviated Injury Score (AIS) 2 pelvic injuries (65.0%), whereas AIS 4 and 5 injuries were found in less than 10% of patients. Pelvic ring injuries were most commonly associated with chest trauma with >AIS 2 severity in 21.2% of the patients, head injuries (>AIS 2) in 16.9%, liver or spleen injuries in 8.0%, and two or more long bone fractures in 7.8%. The 3-month cumulative mortality rate of the patients with pelvic injuries was 14.2% (1,586 patients) versus 5.6% (7,465 patients) of the NPG group. CONCLUSION: Age, early physiologic derangement, and presence of other injuries (head or trunk) were associated with reduced survival rates. When the expertise to deal with such a group of patients is not available, early transfer under safe conditions should be considered to improve survival rates.

Femoral biologic plate fixation.

UNLABELLED: New techniques of fracture fixation such as indirect reduction, careful soft tissue handling, and elastic fixation are being used in place of older methods of mechanical stabilization. These new techniques led to the concept of biologic plate fixation. We systematically reviewed the literature and provide an overall evaluation of femoral biologic fixation for fracture treatment. We analyzed 19 studies with 687 patients with 697 femoral fractures. Twenty-three percent of the fractures were subtrochanteric, 29% were diaphyseal, and 48% were supracondylar. Twenty-two percent were open fractures. The majority (81%) were comminuted and AO Types B and C. The overall union rate was 98.4%, with a mean time to union ranging from 10.7 to 24 weeks. Primary or secondary bone-grafting procedures were reported in all but one study with a frequency ranging from 0-55%. The most frequently recorded complications were malunion (0-29%) and reoperation (0-23%). The high union rate, low infection rate (2%), and occasional need for bone graft indicate biologic plate fixation is a viable alternative to modern nailing techniques, particularly in patients with polytrauma. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo.

Pelvic fracture associated with liver trauma is not an uncommon injury combination in multiple trauma and is associated with high morbidity and mortality. The aim of this study was to examine the characteristics of this specific patient group, to describe the diagnostic and treatment protocols and finally to analyse risk factors associated with mortality. Data were collected over a 6-year period, ending in 2001. The pelvic injury was graded according to the Tile classification system and the hepatic injury was scored using the organ injury scale (OIS). Treatment protocol, associated injuries, complications, length of ICU/Hospital stay and mortality were recorded and analysed. A total of 140 patients (40% female) with a mean age of 35.1+/-15.9 years and a median ISS of 41 were included in this study. The overall mortality rate was 40.7%. Binomial logistic regression analysis revealed age, initial blood pressure, transfusion requirement as well as the severity of head, chest, spleen and liver injury as independent parameters predicting reduced survival rates. This deadly duo of injuries presents a challenge to the trauma surgeon. Rapid assessment and treatment is required to prevent death by haemorrhage. The presence of concomitant injuries renders the patient very sensitive to ongoing or additional physiological disturbance. The principles of 'damage control surgery' must be applied to avoid complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).

Impact of hypothermia on the immunologic response after trauma and elective surgery.

An Hypothermia is defined as a decrease in core temperature below 35 degrees C. The well-described deleterious effects of accidental hypothermia on outcome in multiple-trauma patients contrast the beneficial effect of controlled hypothermia on organ function during ischemia in elective surgery. Experimental studies have shown that induced hypothermia during hemorrhagic shock might have beneficial effects on outcome. The beneficial effects of induced hypothermia appear to be partly mediated by the prolongation of the "golden hour" with prevention of hypoxic organ dysfunction. However, hypothermia also has been thought to have an impact on the immunologic response after trauma and elective surgery. Induction of hypothermia seems to decrease the release of pro-inflammatory cytokines believed to influence distant organ damage positively, and is mediated by the interaction of polymorphonuclear leucocytes (PMNL) and capillary endothelial cells. Nevertheless, the incidence of posttraumatic infectious complications may be increased after induction of hypothermia due to an overexpression of anti-inflammatory cytokines. Together with this immunosuppressive profile, coagulopathy and bleeding might limit the use of induced hypothermia after multiple trauma and elective surgery. The purpose of this Chapter is to highlight current knowledge regarding the interaction of hypothermia and posttraumatic immune reactivity. A better understanding of these mechanisms would assist the introduction of preventive and therapeutic strategies into clinical practice.

L-selectin shows time and gender dependency in association with MODS.

BACKGROUND: Recent investigations have demonstrated gender related immunologic alterations after trauma. These complications arise due to polymorphonuclear granulocytes (PMN) interacting with endothelium via L-selectin. Therefore, the purpose of this study was to investigate gender related differences in the expression of L-selectin in relation to posttraumatic multiple organ dysfunction syndrome (MODS). METHODS: Multiply injured patients were prospectively entered in the study. MODS was determined using the Denver score. The concentration of L-selectin on the surface of PMN was determined using flow cytometry during a 14 days' period. RESULTS: 48 patients were included in the study. The kinetics of L-selectin were different comparing male and female patients. Male patients with MODS initially showed a rapid decrease of surface L-selectin from 80 to 20 ng/ml. A return to admission levels was related to MODS. Male patients without MODS displayed elevated L-selectin levels up to 140 ng/ml. Female patients, however, all showed an initial rapid decrease of L-selectin to 20 ng/ml. Women who developed posttraumatic MODS had significantly increased levels up to 110 ng/ml before development of MODS developed. CONCLUSIONS: We feel that a gender related dimorphism in the initial L-selectin expression following trauma exists and is associated with MODS. These findings indicate new therapeutic means for the treatment of MODS. Therapies should be timely and gender dependently coordinated.