Do Interns Learn On-The-Job How to Obtain Proper Informed Consent for Surgical Procedures?

OBJECTIVE: Obtaining surgical informed consent (SIC) is a critical skill most residents are expected to learn "on-the-job." This study sought to quantify the effect of 1 year of clinical experience on performance obtaining SIC in the absence of formal informed consent education. DESIGN: In this case-control cohort study, PGY1 and PGY2 surgical residents in an academic program were surveyed regarding their experiences and confidence in obtaining SIC; then assessed obtaining informed consent for a right hemicolectomy from a standardized patient. SETTING: Single academic general surgery residency program in Buffalo, NY. PARTICIPANTS: Ten PGY1 and eight PGY2 general surgery residents were included in the study, after excluding residents with additional years of training. RESULTS: PGY2 residents had significantly more experience obtaining SIC compared to PGY1 residents (median response: ">50" vs "between 6 and 15," p = 0.001), however there was no difference in self-reported confidence in ability obtaining SIC (mean 3.2/5 in PGY1 vs 3.4/5 in PGY2, p = 0.61), self-reported knowledge of SIC (mean 3.1/5 in PGY1 vs 3.6/5 in PGY2, p = 0.15), performance on a test regarding SIC (mean score 9.0/20, SD 3.9 for PGY1 vs mean score 9.6/20, SD 3.5, t = 0.387, p = 0.739) or performance during a standardized patient interview (mean 11.2/20, SD 2.78 for PGY1 vs mean 11.4/20, SD 1.51 for PGY2, p = 0.87). In the interviews all residents addressed general risks (bleeding/infection), however both groups performed worse in addressing procedure-specific risks including anastomotic leak as risk for hemicolectomy. CONCLUSIONS: A year of clinical training between PGY1 to PGY2 did not improve performance in obtaining surgical informed consent when lacking formal education, despite self-confidence in their ability. A curriculum covering the content, delivery and assessment of informed consent should be initiated for residents upon arrival to surgical training.

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures.

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

Challenging Dogma by Skipping the Emergency Department Thoracotomy: A Propensity Score Matched Analysis of the Trauma Quality Improvement Database.

INTRODUCTION: Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT. METHODS: We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure. RESULTS: There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001). CONCLUSIONS: There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.

Spontaneous Diffuse Pyoderma Gangrenosum after Polytrauma and Orthopedic Fixation: A Case Report with Brief Review of Literature.

Introduction: Pyoderma gangrenosum (PG) is a skin condition driven by neutrophil activation resulting in painful ulcers with undermining borders and surrounding erythema. This can be seen, although rarely, post-traumatically. It has been reported in the setting of orthopedic trauma with only 31 cases reported in English literature after orthopedic surgery. Case Report: A 20-year-old Caucasian female presented with multisystem trauma and multiple orthopedic injuries following motor vehicle collision. After fixation of orthopedic injuries, within 1 week post-operatively, the patient began to show signs of wound breakdown characterized by apparent purulence and skin necrosis at surgical sites and subsequently at additional non-surgical sites on bilateral lower extremities. After the failure of aggressive debridement and negative cultures, skin biopsy revealed post-traumatic PG. After diagnosis and treatment with corticosteroid therapy, the patient promptly recovered with the resolution of systemic and musculoskeletal manifestations. Conclusion: Post-traumatic PG should be considered a potential etiology in non-healing wounds with negative cultures. A low threshold for skin biopsy and interdisciplinary involvement should be maintained to expedite diagnosis and guide treatment.

Pediatric Posterior Sternoclavicular Dislocation Closed Reduction and Management.

SUMMARY: Posterior sternoclavicular joint (SCJ) dislocations are rare shoulder girdle injuries. Despite the paucity of cases, posterior SCJ dislocations pose an important threat to patient safety because of the proximity of the medial clavicle to the mediastinum, resulting in possible compression and/or injury to these structures. Current guidelines recommend attempting closed reduction in the acute setting followed by open reduction if closed reduction is unsuccessful. This video highlights a case of posterior SCJ dislocation in a pediatric patient who presented with dyspnea after a football injury.

Pediatric Olecranon Osteochondral Flap Fractures With Subtle Radiographic Abnormality.

Pediatric olecranon osteochondral flap fractures are shear injuries of the humeroulnar joint with elevation of an articular cartilaginous flap from the subchondral bone of the olecranon articular surface. All previously reported cases included an osteochondral flap containing the coronoid, with varying imaging and fixation methods used. We treated 2 pediatric patients with this injury. One of our patients had a large, displaced osteochondral fracture of the medial semilunar notch including the coronoid, in addition to avulsions of the medial flexor mass and distal ulnar collateral ligament. The other patient sustained a displaced, rotated osteochondral fracture including the coronoid with subsequent humeroulnar subluxation. Both fractures were anatomically reduced and fixed with absorbable suture, leading to excellent results at 1 year. A high degree of suspicion, thorough work-up, and anatomical reduction of all injured structures are paramount in treatment of this rare, difficult-to-diagnose injury.

The Impact of Pharmacy Student Participation in the White Coat Ceremony on Professionalization.

Objective. To assess the impact of participation in a formal white coat ceremony on Doctor of Pharmacy (PharmD) students' professionalization by analyzing students' reflective writing. Methods. First-year PharmD students participated in the college's white coat ceremony following orientation. During the Foundations of Pharmacy course in the first semester, students were instructed to reflect on and write about the impact the white coat ceremony had on them as a graded assignment. A grading rubric was developed to standardize assessment of the reflections and to differentiate critical reflection (which cites future behavioral change) from other forms of reflection that are less impactful, such as non-critical reflection, general understanding, and non-reflection. Thematic analysis was conducted and prevalent themes were identified. Each reflection was then reviewed to identify up to three themes. Results. Of the 225 students in the incoming class of 2020, 218 submitted valid reflection assignments. Of these, 92% met critical reflection criteria. Four percent offered "negative connotation," while 75% described an eye-opening experience or realization. Of 483 thematic classifications, six student professionalization themes were identified, as follows: personal achievement (26%), professionalism (21%), welcome to pharmacy (18%), patient care (16.8%), life-long learning (12.8%), and code of ethics (5.2%). Conclusion. For the majority of PharmD students, the white coat ceremony held during first-year orientation had a positive impact on their professionalization. All pharmacy schools should conduct a white coat ceremony that includes recitation of the Pledge of Professionalism as an impactful first step toward student professionalization.

Impact of Trauma Hospital Ransomware Attack on Surgical Residency Training.

BACKGROUND: A recent ransomware attack led to the shutdown of the electronic health information system (HIS) at our trauma center for 2 mo. We investigated its impact on residency training during the downtime. MATERIAL AND METHODS: General and orthopedic surgical residents who rotated at the hospital were invited to participate in a survey regarding their patient care and residency training experiences during the downtime. Attending surgeons from both the specialties were invited to participate in a semistructured interview regarding their attitude toward residency training during the downtime. RESULTS: Twenty-nine residents responded to the survey with a response rate of 78.4%. Residents acknowledged significant increases in face-to-face communication and decreases in use of online educational resources during the downtime (P < 0.01). Residents were significantly stressed by the dearth of online resources (P < 0.0001) and by paper-based orders and outpatient clinic (P < 0.05). A multivariate analysis demonstrated an inverse relationship between postgraduate year and stress from paper orders (P = 0.003). Attending surgeon's interviews revealed that they recognized residents' unpreparedness and strove harder to teach more effectively. CONCLUSIONS: Our study demonstrated that an unexpected shutdown of the hospital HIS imposed significant stress upon surgical residents providing trauma patient care and made attending surgeons take greater efforts to be more effective teachers. Residents who are digital natives lack adaptability to handle a paper-based workflow. With cyber security threats increasing in health care, preparedness should be included in the graduate medical education curriculum.

Variation in the Practice of Central Venous Catheter and Chest Tube Insertions among Surgery Residents.

OBJECTIVES: Central venous catheter (CVC) and chest tube (CT) insertions are common bedside procedures frequently performed by surgery residents. Despite published guidelines, variability in the practice exists. We sought to characterize the surgery residents' practice patterns surrounding these two bedside procedures. MATERIALS AND METHODS: Over the last 1½ months of the academic year in 2012 and 2013, surgery residents across the US were surveyed online. Participants reported levels of agreement for 15 questions in a 5-point Likert scale format. RESULTS: A total of 219 residents completed the survey. Majority of residents agreed that they received appropriate education and training. Over half of the respondents reported that they did not have attending staff physician's supervision during the procedures. Junior residents felt less confident in performing CVC or CT insertions. Those younger than 29 years old and of female sex were also less confident in performing CT insertion. Although almost all residents reported using maximal sterile barrier precautions, 7% reported not securing their gowns and another 7% reported inadequate draping of patients. About ⅓ reported no hand cleansing before the procedures. Those from community programs compared to university programs less frequently used antibiotics. Sixty-five percent of residents reported routine use of ultrasound for CVC insertion. CONCLUSION: Surgery residents do not strictly adhere to the guidelines for CVC and CT insertions, and there is substantial variation in the practice of the procedures, which may contribute to complications associated with these procedures. This survey opens new areas for in-service education, feedback, and practices for these procedures to reduce the risk of complications, especially the infectious one.

Process and Microstructure to Achieve Ultra-high Dielectric Constant in Ceramic-Polymer Composites.

Influences of process conditions on microstructure and dielectric properties of ceramic-polymer composites are systematically studied using CaCu3Ti4O12 (CCTO) as filler and P(VDF-TrFE) 55/45 mol.% copolymer as the matrix by combining solution-cast and hot-pressing processes. It is found that the dielectric constant of the composites can be significantly enhanced-up to about 10 times - by using proper processing conditions. The dielectric constant of the composites can reach more than 1,000 over a wide temperature range with a low loss (tan δ ~ 10-1). It is concluded that besides the dense structure of composites, the uniform distribution of the CCTO particles in the matrix plays a key role on the dielectric enhancement. Due to the influence of the CCTO on the microstructure of the polymer matrix, the composites exhibit a weaker temperature dependence of the dielectric constant than the polymer matrix. Based on the results, it is also found that the loss of the composites at low temperatures, including room temperature, is determined by the real dielectric relaxation processes including the relaxation process induced by the mixing.

"How dare you question what I use to treat this patient?": Student pharmacists' reflections on the challenges of communicating recommendations to physicians in interdisciplinary health care settings.

A growing number of pharmacists practice within interdisciplinary health care teams, leading pharmacy educators to place increased emphasis on the development of interprofessional collaboration skills. In the pharmacist-physician relationship, pharmacists' medication therapy recommendations (MTRs) are a recurrent and significant interprofessional activity, one that can be challenging for both seasoned and student pharmacists. Drawing on in-depth ethnographic interviews with pharmacy preceptors and advanced student pharmacists, we identify and describe an important distinction between pharmacist-initiated MTRs and physician-initiated MTRs as contexts for interprofessional collaboration. We describe and illustrate a range of social, professional, and communication challenges that students experience in each context, as well as some strategies they use to navigate these challenges. Using the theoretical framework of dialectic tensions, we argue that the pharmacist-physician relationship is characterized by a tension between assertiveness and deference. We also offer recommendations to pharmacy preceptors, who can use this article to enhance the experiential education of pharmacists.

Telemedicine security: a systematic review.

Telemedicine is a technology-based alternative to traditional health care delivery. However, poor security measures in telemedicine services can have an adverse impact on the quality of care provided, regardless of the chronic condition being studied. We undertook a systematic review of 58 journal articles pertaining to telemedicine security. These articles were selected based on a keyword search on 14 relevant journals. The articles were coded to evaluate the methodology and to identify the key areas of research in security that are being reviewed. Seventy-six percent of the articles defined the security problem they were addressing, and only 47% formulated a research question pertaining to security. Sixty-one percent proposed a solution, and 20% of these tested the security solutions that they proposed. Prior research indicates inadequate reporting of methodology in telemedicine research. We found that to be true for security research as well. We also identified other issues such as using outdated security standards.

Safety assessment of a home-based telecare system for adults with developmental disabilities in Indiana: a multi-stakeholder perspective.

We investigated the perceptions of people about the safety, security and privacy of a telecare monitoring system for adults with developmental disabilities living in residential settings. The telecare system was used by remote caregivers overnight, when staff were not present in the homes. We surveyed 127 people from different stakeholder groups in the state of Indiana. The people surveyed included those with knowledge or experience of telecare, and those without. The stakeholders were clients, their advocates, service provider administrators and independent case coordinators. The responses in each category for every group were positive except one: only 4 of the 11 telecare case coordinators agreed that the telecare system provided a secure environment. Overall, the telecare system was perceived to be as safe, secure and private as the conventional alternative of having staff in the home.

Clinical outcomes of patients with diabetes mellitus receiving medication management by pharmacists in an urban private physician practice.

PURPOSE: The clinical outcomes of patients with diabetes mellitus in an urban environment receiving pharmacist medication management in collaboration with private-practice physicians were assessed. METHODS: Patients older than 18 years with type 1 or 2 diabetes mellitus who were receiving oral and insulin therapy and who were referred to a pharmacy clinic within a private physician practice for medication management between March 1, 2002, and August 31, 2003, were eligible for study inclusion. Data were collected at three junctures: six months before the first visit with the pharmacist (preperiod measure), on the date of clinic entry (index measure), and six months after the first clinic visit (postperiod measure). Primary outcomes analyzed were glycosylated hemoglobin (HbA(1c)), weight, and blood pressure (goal, <130/80 mm Hg). Secondary outcomes analyzed were smoking cessation and initiation of aspirin, angiotensin-converting-enzyme inhibitor, or angiotensin receptor blocker therapy. RESULTS: A significant reduction in HbA(1c) from the index measure to the postperiod measure was observed (p < 0.001). No significant change was noted in weight or number of patients at goal blood pressure among the preperiod, index, and postperiod measures. No change was observed in the secondary outcomes during the study time intervals. CONCLUSION: Integrating a pharmacist into a private physician practice significantly improved patient glycemic control and maintained patients' weight and the number of patients at blood pressure goal. Clinic adherence with the American Diabetes Association recommendations was sustained.