We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment.

INTRODUCTION: Communication failures between multidisciplinary teams can impact efficiency, performance, and morale. Academic operating rooms (ORs) often have surgical, anesthesia, and nursing teams, each teaching multiple trainees. Incorrectly identifying name and "rank" (postgraduate year [PGY]) of resident trainees can disrupt performance evaluations and team morale and even potentially impair delivery of quality care when miscommunication errors proliferate. METHODS: Our OR-based survey asked 50 participants (18 surgeons, 14 anesthesiologists, and 18 nursing members), to recall basic identification data including provider names and PGY levels from their recent collaborating OR teams. Participants also weighed in on the importance of using accurate "names and ranks" for all OR participants. RESULTS: Each service reliably knew their own team members' names and rank. However, surgery and anesthesia teams displayed decreased knowledge about their lower level trainees, whereas nursing teams performed best, identifying all level nurses present. Deficits occurred whenever participants tried recalling basic identifying data about contributors from any other collaborating team. Typically, misidentified participants were lower level PGY residents working on other teams' services. All survey respondents desired improving systems to better remember "names and ranks" identifications among OR participants, citing both safety and team morale benefits. CONCLUSIONS: Many fail to know the names and ranks of contributors among members of different OR teams. Even our most reliable nursing team was inconsistent at identification information from collaborating practitioners. Despite universally acknowledged benefits, participants rarely learned basic background identification data beyond their own team. Those surveyed all desired improving identifications with suggestions including sterile name and rank tags and proper notification of entry and exit from the OR. Because successful collaborations require appropriate level task delegations, participants believed knowing a resident's name and rank is important not only for team bonding but also for safety. Academia furthermore demands fair performance evaluations, and displaying them clearly improves recall. Refining our own identified gaps in OR communications may demonstrate improved teamwork and safer task delegations and perhaps even stimulate other performance benefits for academic ORs.

Negative Pressure Wound Therapy with Instillation in a Chronic Non-Healing Right Hip Trochanteric Pressure Ulcer.

Complex pressure ulcer wound sites often present with a wide scope of barriers to healing ranging from high colonization of multi-drug-resistant pathogens to tortuous internal anatomy which make the wound recalcitrant to traditional wound care including standard negative pressure wound therapy (NPWT). Negative pressure wound therapy with instillation (NPWTi-d) provides an opportunity to manage and heal wounds with indications not met by standard NPWT such as cavitating wounds with complex undermining and tunneling. In this clinical case report, a patient who presented with a chronic, non-healing Stage IV pressure ulcer underwent a tensor fascia lata flap reconstruction that was complicated by a partial flap-tip nonadherence with associated partial dehiscence of the flap incision that proved unresolvable until application of adjunctive NPWTi-d which allowed the wound to experience a robust rate of granulation, contraction, and closure.

Lateral gastrocnemius myocutaneous flap transposition to the midlateral femur: extending the arc of rotation.

We report the successful use of an extended lateral gastrocnemius myocutaneous flap for coverage of the midlateral femur using successive delayed elevations. A 62-year-old man underwent wide resection of a liposarcoma of the right anterior thigh with free flap reconstruction and subsequent radiation therapy 10 years before. Four years later, the patient fractured his irradiated femur and was treated with a retrograde intramedullary nail, which subsequently became infected, causing osteomyelitis of the distal femur, septic arthritis of the knee joint, and nonunion of his pathologic fracture. Although advised by numerous surgeons to undergo above-knee amputation, we offered our motivated patient a multidisciplinary approach to clear his infection and pathology; implanted new orthopedic hardware; performed delayed flap reconstruction; and rehabilitated him back to painless, unassisted ambulation. The extended lateral gastrocnemius myocutaneous flap used provided perfused soft tissues and durable coverage for the patient's exposed orthopedic hardware of the midlateral femur, 14 cm above the joint line of the knee. By using this flap to cover a femur defect well above published heights, our patient avoided amputation after years of worsening incapacitation.

Management of vascular graft infections with soft tissue flap coverage: improving limb salvage rates--a veterans affairs experience.

Graft infections are one of the most challenging issues in surgery with an incidence of 0.7 to 7 per cent, with femoral site infections being the most common (13% incidence). The gold standard treatment has been graft removal, wide débridement, and extra-anatomical bypass. Routine excision of infected peripheral arterial grafts and vascular reconstruction with extraanatomic conduits are associated with mortality rates ranging from 10 to 30 per cent and amputation rates of up to 70 per cent. As a result of the high morbidity and mortality associated with this approach, selective graft preservation techniques have been developed. Newer treatment plans discuss preservation of the graft with débridement and coverage of the infected region. Better wound care, nutrition optimization, and robust flap coverage have led to significantly improved graft salvage, lower amputation rates, and improved outcomes. The objective of this study was to evaluate the Veterans Affairs (VA) experience with flap coverage for femoral vascular graft infections. A retrospective review was conducted of all VA data from 1997 to 2008 with inclusion criteria of patients with deep groin wound infections requiring flap coverage after femoral bypass surgery. Eleven such patients were identified with a mean age of 73 years and with multiple comorbidities (hypertension, malnutrition, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, chronic renal insufficiency). Patients presented with wound drainage, exposed graft, hematoma, perigraft fluid collection, and pseudoaneurysm. Treatment protocol included: 1) aggressive débridement of the wound bed; 2) early soft tissue (flap) coverage; 3) wound vacuum assisted closure device or frequent dressing changes; and 4) skin graft once the bed was prepared. Eighty-two per cent of wounds had positive cultures with equal numbers of patients with Staphylococcus epidermidis, Pseudomonas, Escherichia coli (22%), and higher methicillin-resistant Staphylococcus aureus (33%), whereas in the literature Staphylococcus is the most common (greater than 50%). Average hospital length of stay was 94 days with average follow up at 10 months. Fifty-five per cent graft salvage (one Dacron [50%], two polytetrafluoroethylene [33%], two saphenous vein graft [100%], one cryovein [100%]) was achieved with 91 per cent limb salvage. Complications included graft blowout (two) requiring partial flap loss (one), retroperitoneal hematoma (one), limb loss (one), sepsis (one), and death (one). Infected vascular grafts remain a challenging problem requiring multidisciplinary care. Careful débridement and aggressive wound care followed by selective flap coverage appears to decrease morbidity and increase graft and limb salvage.

Swimmer's nose deformity.

This is the first published report of the swimmer's nose deformity. This common athletic deformity has a characteristic, asymmetric dorsolateral nasal hump that progressively develops over years during a competitive swimming career and persists after cessation of the sport. The cause is thought to be bone and soft tissue remodeling in response to repetitive trauma chronically inflicted by a swimmer's goggles during the water reentry phase of breathing.

The Dixie Cup technique for salvaging limb length and preserving nerve continuity in the mangled lower extremity.

The mangled lower extremity posses a difficult problem for the reconstructive surgeon. We describe a novel technique for preserving limb length and maintaining nerve continuity in a severely injured lower extremity. This specific example of fixating the viable, sensate distal foot tissues onto the proximal tibia was vital in maintaining optimal limb length. This allowed for a more desirable level of amputation, preserved knee function, and provided well-vascularized, sensate soft tissue coverage.

Microvascular hepatic artery reconstruction in pediatric abdominal transplantation: pearls and pitfalls.

The "back-wall first" hepatic artery microanastomosis in pediatric liver transplantation saves lives and reduces morbidity. We describe our technique of hepatic artery reconstruction and offer a systematic and multi-team collaborative approach that optimizes surgical outcomes.