Assessing the Impact of Hands-Free Georgia on Serious Motor Vehicle Accidents.

BACKGROUND: Hands-Free Georgia Law (HB673) was designed to prevent motor vehicle collisions (MVCs) by banning drivers from using their hands for non-driving-related activities, including cell phone use. We investigate HB673 effect on trauma activations secondary to MVCs in Georgia. METHODS: The Georgia Trauma Registry (GTR) was queried for MVCs from 2017 to 2019, representing the 18 months prior and following implementation of HB673. The number of MVCs for each period and severity of MVC designated by the average injury severity score (ISS) for each trauma activation were collected. RESULTS: Prior to implementation, a total of 43 080 traumas were recorded in GTR, 11 111 (25.8%) were attributed to an MVC. Following implementation, 12 130 (23.6%) occurred secondary to MVCs. Statewide MVC-related traumas per 1000 residents increased from 1.07 to 1.14 with increased mortality rate and unchanged median ISS per MVC. CONCLUSIONS: The Hands-Free Georgia Law seems to have not had a major reduction in mortality in its early implementation.

Burnout reduction in acute care surgeons: Impact of faculty schedule change at a level 1 trauma and tertiary care center.

BACKGROUND: Acute care surgeons are prone to burnout because of heavy workload, concurrent clinical responsibilities, and busy in-house call. Modifiable burnout factors have been identified, but few studies have looked for longitudinal effects after change is implemented. We hypothesized that optimizing faculty workflow could decrease burnout without compromising productivity. METHODS: We streamlined the faculty schedule at our institution to eliminate 24-hour call by creating weekly blocks of 12-hour day and night call, free from other clinical obligations. Protected academic time was added. The Maslach Burnout Inventory and Areas of Worklife Survey for health care providers were given to faculty, as well as close friends or family, at baseline, 6 months, and 12 months. Maslach Burnout Inventory and Areas of Worklife Survey proprietary formulas were used to assess change in factors contributing to burnout. Our primary outcome measure was the presence of factors contributing to burnout. Chart delinquency, relative value units, and academic projects were secondary outcome measures assessing clinical productivity change. RESULTS: Survey completion rates were 92% for faculty and 80% for family. All burnout risk factors improved at 6 and 12 months. In surgeon and family groups, the following improvements were noted in the mean scores of risk factors at 1 year: workload (74%, 68%), control (38%, 16%), reward (14%, 24%), fairness (69%, 22%), emotional exhaustion (27.5%, 24%), depersonalization (37.5%, 14%), personal accomplishment (12.5%, 2%), community (3%, 5%), values (10%, 15%), and over-all burnout (12.5%, 23.3%). There was a reduction in charts reaching delinquent status. Relative value unit production did not decrease. CONCLUSION: This study demonstrates that implementing a weekly, 12-hour call schedule can improve factors leading to burnout. Improvements were noted in surgeon and family groups alike, signifying both subjective improvements and observed change in the surgeons' behavior, without compromising clinical productivity. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The Accuracy of Point-of-Care Ultrasound in the Diagnosis of Acute Cholecystitis.

PURPOSE: Acute cholecystitis (AC) affects 50-200 000 patients per year. Early surgery is the treatment of choice for AC. Therefore, timely diagnosis is important to begin proper management. Recently, emergency departments have adopted point-of-care ultrasound (POCUS) for the initial evaluation of AC. The accuracy of POCUS for AC has not been well studied. METHODS: Patients receiving POCUS for evaluation of AC in the emergency department at our tertiary care institution for 2 years were considered. Patients with previous biliary diagnoses were excluded. Patients were deemed to have AC from a recorded POCUS result or 2/3 of the following POCUS findings: pericholecystic fluid, gallbladder wall hyperemia, and sonographic Murphy's sign. Formal ultrasound and final diagnosis from surgical and pathology reports were used as gold standards for comparison. RESULTS: In total, 147 patients met inclusion criteria. POCUS had a sensitivity and specificity of .4 (95% CI: .1216-.7376) and .99 (.9483-.9982), respectively, when compared to a final diagnosis and .33 (.0749-.7007) and .94 (.8134-.9932) when compared to formal US. The modified Tokyo guidelines for suspicion of AC had a sensitivity of .2 (.0252-.5561) and specificity of .88 (.8173-.931) compared to the final diagnosis. CONCLUSION: Point-of-care ultrasound was not a better screening test than the modified Tokyo guidelines. We recommend a simplified screening approach for AC using clinical findings and laboratory data, followed by confirmatory formal imaging. This strategy could prevent unnecessary delays in surgical management and use of physician resources.

Accelerated Biologic Aging, Chronic Stress, and Risk for Sepsis and Organ Failure Following Trauma.

Chronic stress and accelerated aging have been shown to impact the inflammatory response and related outcomes like sepsis and organ failure, but data are lacking in the trauma literature. The purpose of this study was to investigate potential relationships between pretrauma stress and posttrauma outcomes. The hypothesis was that pretrauma chronic stress accelerates aging, which increases susceptibility to posttrauma sepsis and organ failure. In this prospective, correlational study, chronic stress and accelerated biologic aging were compared to the occurrence of systemic inflammatory response syndrome, sepsis, and organ failure in trauma patients aged 18-44 years. Results supported the hypothesis with significant overall associations between susceptibility to sepsis and accelerated biologic aging (n = 142). There were also significant negative associations between mean cytokine levels and chronic stress. The strongest association was found between mean interleukin-1ß (IL-1ß) and human telomerase reverse transcriptase (hTERT), r(101) = -0.28), p = .004. Significant negative associations were found between mean cytokine levels, IL-12p70, r(108) = -0.20, p = .034; and tumor necrosis factor-α (TNF-α), r(108) = -0.20, p = .033, and positive life events via the behavioral measure of chronic stress. Results may help identify individuals at increased risk for poor outcomes of trauma and inform interventions that may reduce the risk for sepsis and organ failure.

The Use of the Abdominal Aortic and Junctional Tourniquet Versus Combat Gauze in a Porcine Hemicorporectomy Model.

BACKGROUND: Junctional hemorrhage is a potentially preventable cause of death. The Abdominal Aortic and Junctional Tourniquet (AAJT) compresses major vascular structures and arrests blood flow in exsanguinating hemorrhage. In a human model, the AAJT was effective in stopping blood flow in the femoral arteries via compression of the distal aorta. This study compares the ability of AAJT and Combat Gauze (CG) to stop hemorrhagic bleeding from a hemicorporectomy in a swine model. METHOD: Six anesthetized swine were used. Carotid arterial catheters were placed for continuous mean arterial pressure (MAP) readings. A hemicorporectomy was accomplished with a blade lever device by cutting the animal through both femoral heads transecting the proximal iliac arteries and veins. Hemorrhage control was attempted with the AAJT and regular Kerlix gauze or CG packing and direct pressure followed by Kerlix gauze placed over the CG. The primary outcome measure was survival at 60 minutes. RESULTS: The 60-minute survival was 100% for the AAJT and 0% for the CG group. During the 60-minute monitoring period, only one CG animal achieved hemostasis. For the AAJT group, the mean time to hemostasis was 30 seconds. Initial MAP was higher in the AAJT group (mean, 87mmHg) than the CG group (mean, 70mmHg). The mean 60-minute MAP was 73mmHg for the AAJT group. Mean blood loss at 5 minutes and mean total blood loss were greater in the CG group than in the AAJT group. CONCLUSION: AAJT is superior to CG in controlling hemorrhage in a junctional wound in a swine model.

The promise and problems of non-physician practitioners in general surgery education: Results of a multi-center, mixed-methods study of faculty.

BACKGROUND: Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems. METHODS: General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns. RESULTS: NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures. CONCLUSIONS: NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes.

Assessing the 16 hour intern shift limit: Results of a multi-center, mixed-methods study of residents and faculty in general surgery.

BACKGROUND: The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts. METHODS: Questionnaire response rates were 76% for residents (N = 291) and 71% for faculty (N = 279) in 13 general surgery residency programs. Results include means, percentage in agreement, and statistical tests for 15 questionnaire items. Semi-structured interviews conducted with 39 residents and 43 faculty were analyzed for main themes. RESULTS: Few view the intern shift limit as a positive change. Views differ (P < 0.01) for residents and faculty on 12 of 15 item means and across PGY levels on all 15 items. Interviews indicate concerns about losses with respect to education and professional development, difficulties when interns transition to their second year, and how intern shifts may be more fatiguing than expected. CONCLUSIONS: The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and faculty.

Peritoneal cavity lavage reduces the presence of mitochondrial damage associated molecular patterns in open abdomen patients.

BACKGROUND: Mitochondrial damage-associated molecular patterns (mtDAMPs), such as mitochondrial DNA and N-formylated peptides, are endogenous molecules released from tissue after traumatic injury. mtDAMPs are potent activators of the innate immune system. They have similarities with bacteria, which allow mtDAMPs to interact with the same pattern recognition receptors and mediate the development of systemic inflammatory response syndrome (SIRS). Current recommendations for management of an open abdomen include returning to the operating room every 48 hours for peritoneal cavity lavage until definitive procedure. These patients are often critically ill and develop SIRS. We hypothesized that mitochondrial DAMPs are present in the peritoneal cavity fluid in this setting, and that they accumulate in the interval between washouts. METHODS: We conducted a prospective pilot study of critically ill adult patients undergoing open abdomen management in the surgical and trauma intensive care units. Peritoneal fluid was collected daily from 10 open abdomen patients. Specimens were analyzed via quantitative polymerase chain reaction (qPCR) for mitochondrial DNA (mtDNA), via enzyme immunoassay for DNAse activity and via Western blot analysis for the ND6 subunit of the NADH: ubiquinone oxidoreductase, an N-formylated peptide. RESULTS: We observed a reduction in the expression of ND6 the day after lavage of the peritoneal cavity, that was statistically different from the days with no lavage (% change in ND6 expression, postoperative from washout: -50 ± 11 vs. no washout day, 42 ± 9; p < 0.05). Contrary to expectation, the mtDNA levels remained relatively constant from sample to sample. We then hypothesized that DNAse present in the effluent may be degrading mtDNA. CONCLUSION: These results indicate that the peritoneal cavity irrigation reduces the presence of mitochondrial DAMPs in the open abdomen. It is possible that increased frequency of peritoneal cavity lavage may lead to decreased systemic absorption of mtDAMPs, thereby reducing the risk of SIRS. LEVEL OF EVIDENCE: Prospective study, Case Series, Level V.

Professionalism in the Twilight Zone: A Multicenter, Mixed-Methods Study of Shift Transition Dynamics in Surgical Residencies.

PURPOSE: Duty hours rules sparked debates about professionalism. This study explores whether and why general surgery residents delay departures at the end of a day shift in ways consistent with shift work, traditional professionalism, or a new professionalism. METHOD: Questionnaires were administered to categorical residents in 13 general surgery programs in 2014 and 2015. The response rate was 76% (N = 291). The 18 items focused on end-of-shift behaviors and the frequency and source of delayed departures. Follow-up interviews (N = 39) examined motives for delayed departures. The results include means, percentages, and representative quotations from the interviews. RESULTS: A minority (33%) agreed that it is routine and acceptable to pass work to night teams, whereas a strong majority (81%) believed that residents exceed work hours in the name of professionalism. Delayed departures were ubiquitous: Only 2 of 291 residents were not delayed for any of 13 reasons during a typical week. The single most common source of delay involved a desire to avoid the appearance of dumping work on fellow residents. In the interviews, residents expressed a strong reluctance to pass work to an on-call resident or night team because of sparse night staffing, patient ownership, an aversion to dumping, and the fear of being seen as inefficient. CONCLUSIONS: Resident behavior is shaped by organizational and cultural contexts that require attention and reform. The evidence points to the stunted development of a new professionalism, little role for shift-work mentalities, and uneven expression of traditional professionalism in resident behavior.

Identification and Referral of Patients at Risk for Post-traumatic Stress Disorder: A Literature Review and Retrospective Analysis.

Post-traumatic stress disorder (PTSD) is a well-established psychological disorder after severe traumatic injury but remains poorly recognized. Recent changes in the "Resources for Optimal Care of the Injured Trauma Patient 2014" stress the need for comprehensive screening and referral for PTSD and depression after injury. Our purpose was to review the current PTSD literature and perform a retrospective chart review to evaluate screening at our institution. We hypothesized a lack of documentation and thus referral of these patients to mental health professionals. We performed a literature review of 43 publications of risk factors for PTSD in the civilian adult population followed by a retrospective review. Records were analyzed for basic demographics, risk factors found in the literature, and referrals to mental health providers. Risk factors included amputation, dissociative symptoms, female gender, history of mental health disorder, and peri-traumatic emotionality. Traumatic amputation status and gender were recorded in all patients. History of mental health disorder was present in 11.5 per cent patients, absent in 80.75 per cent, and not recorded in 7.75 per cent with an overall documentation of 91.75 per cent. Dissociative symptoms and peri-traumatic emotionality were recorded in 0.5 per cent and 1.0 per cent of patients, respectively. Only 13 patients of 400 (3.25%) were referred to mental health professionals. Despite extensive evidence and literature supporting risk factors for the development of PTSD, identification and treatment at our level 1 trauma center is lacking. There is a need for consistent screening among trauma centers to identify PTSD risk factors and protocols for risk reduction and referrals for patients at risk.

Verification of resident bedside-procedure competency by intensive care nursing staff.

BACKGROUND: Recent efforts by the Accreditation Council for Graduate Medical Education to standardize resident education and demonstrate objective clinical proficiency have led toward more accurate documentation of resident competencies. Particularly with regard to bedside procedures, hospitals are now requiring certification of competency before allowing a provider to perform them independently. The current system at our institution uses a time-consuming, online verification system. This study provided an alternative method through an identification card with a list of bedside procedures. Our aim was an easier verification method for nurses, allowing fewer delays of bedside procedures and more time for nursing to patient care. METHODS: We performed a prospective, controlled study, using general surgical residents and surgical intensive care nurses. Subjects performed an initial survey of their experience with the current online system in place to identify resident bedside procedure competency. Phase I involved educating the subjects about this current system followed by another survey. Phase II involved introducing our proficiency card. After 3 months, we conducted a final survey to evaluate opinions on the proficiency card, comparing it with the online verification method. RESULTS: Nursing postintervention responses indicated that significantly less time was required to validate a resident's proficiency (P = .04). Prior to the introduction of the proficiency card, only 15% of nurses reported a verification time of 5 minutes or less, compared with 64% postintervention. In addition, nurses rated the card validation as an easier, more efficient method of verification (P = .02). CONCLUSIONS: We believe that its continued use will not only improve the adherence to a mandatory hospital policy but also result in a less-cumbersome verification process, allowing more time for physician and nurse-to-patient care.

"It takes a village" to raise research productivity: Impact of a Trauma Interdisciplinary Group for Research (TIGR) at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, lab technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies like the National Institutes of Health (NIH). This paper describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an on-going NIH-funded study. METHODS: We utilized a pre-test/post-test design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, threats) analysis was used to develop the intervention which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected N=150). Pre/Post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from N =12 to N=42; (~ 400%). Research proposals for federal funding increased from N=0 to N=3, with success rate of 66%. Participant screenings for the NIH-funded study increased from N=40 to N=313. Consents increased from N=14 to N=70. Lab service fees were reduced from $300/participant to $5/participant. CONCLUSIONS: Adding diversity to our scientific team via TIGR was exponentially successful in 1) improving research productivity, 2) reducing research costs, and 3) increasing research products and mentoring activities that the team prior to TIGR had not entertained. The team is now well-positioned to apply for more federally funded projects and more trauma clinicians are considering research careers than before.

"It takes a village" to raise research productivity: impact of a Trauma Interdisciplinary Group for Research at an urban, Level 1 trauma center.

BACKGROUND: Few interdisciplinary research groups include basic scientists, pharmacists, therapists, nutritionists, laboratory technicians, as well as trauma patients and families, in addition to clinicians. Increasing interprofessional diversity within scientific teams working to improve trauma care is a goal of national organizations and federal funding agencies such as the National Institutes of Health (NIH). This article describes the design, implementation, and outcomes of a Trauma Interdisciplinary Group for Research (TIGR) at a Level 1 trauma center as it relates to increasing research productivity, with specific examples excerpted from an ongoing NIH-funded study. METHODS: We used a pretest/posttest design with objectives aimed at measuring increases in research productivity following a targeted intervention. A SWOT (strengths, weaknesses, opportunities, and threats) analysis was used to develop the intervention, which included research skill-building activities, accomplished by adding multidisciplinary investigators to an existing NIH-funded project. The NIH project aimed to test the hypothesis that accelerated biologic aging from chronic stress increases baseline inflammation and reduces inflammatory response to trauma (projected n = 150). Pre-TIGR/post-TIGR data related to participant screening, recruitment, consent, and research processes were compared. Research productivity was measured through abstracts, publications, and investigator-initiated projects. RESULTS: Research products increased from 12 to 42 (approximately 400%). Research proposals for federal funding increased from 0 to 3, with success rate of 66%. Participant screenings for the NIH-funded study increased from 40 to 313. Consents increased from 14 to 70. Laboratory service fees were reduced from $300 per participant to $5 per participant. CONCLUSION: Adding diversity to our scientific team via TIGR was exponentially successful in (1) improving research productivity, (2) reducing research costs, and (3) increasing research products and mentoring activities that the team before TIGR had not entertained. The team is now well positioned to apply for more federally funded projects, and more trauma clinicians are considering research careers than before.

Mesenteric cavernous hemangioma involving small bowel and appendix: a rare presentation of a vascular tumor.

We report on a case of cavernous hemangioma of the small bowel mesentery. Fewer than five cases of large mesenteric cavernous hemangioma have been reported in the English literature. Cavernous hemangioma of the small bowel mesentery is extremely rare. A 32-year-old black male presented with 1 week of abdominal pain, nausea, vomiting, and anorexia. He had recently undergone computed tomographic guided biopsy of a pelvic mass at another facility. Repeat CT guided biopsy was nondiagnostic, mesenteric angiography was inconclusive, and magnetic resonance imaging was performed as well. Complete workup was performed to localize primary source of abdominal mass and eventual open biopsy was planned resulting in en bloc resection of the mass, which had invaded the terminal ileum and appendix. Final pathologic diagnosis was cavernous mesenteric hemangioma. The patient experienced a prolonged postoperative ileus and was eventually discharged in stable condition, tolerating a regular diet with adequate bowel and urinary function. Diagnosis of cavernous mesenteric hemangioma is difficult and multiple imaging modalities can prove inconclusive. Adequate biopsy can be difficult to obtain even in patients with small body habitus. Standard of care is resection of entire mass en bloc.