Understanding the Trauma/Acute Care Surgery Workforce.

As the roles of trauma/acute care surgeons continue to evolve, it is imperative that health-care systems adapt to meet workforce needs. Tailoring retention strategies that elicit workforce satisfaction ensure continued coverage that is mutually beneficial to surgeons and health-care systems. We sought to elicit factors related to career characteristics and expectations of the trauma/acute care surgery (ACS) workforce to assist with such future progress. In this study, 1552 Eastern Association for the Surgery of Trauma members were anonymously surveyed. Data collected included demographics, career expectations, and motivators of trauma/ACS. Four hundred eight (26%) Eastern Association for the Surgery of Trauma members responded. Respondents were 78 per cent male and had a median age of 47.3 years. Forty-six per cent of surgeons reported earning $351K-$475K and 23 per cent >$475K. At this point in their career, 49 per cent of surgeons felt quality of life was "most important", followed by 31 per cent career ambitions and 13 per cent salary. Prominent career satisfiers were patient care and teaching. Greatest detractors were burnout, bureaucracy, and work environment. Eighty per cent would change jobs in the final 10 years of practice, 31 per cent because of family/retirement, 29 per cent because of professional growth, 24 per cent because of workload, and 7 per cent because of salary. This study could be used to help develop trauma/ACS workforce strategies. This workforce remains mobile into late career; personal happiness and patient ownership overshadow financial rewards, and most prefer a total and shared patient care model compared with no patient ownership. Burnout, bureaucracy, and work environment are dominant detractors of job satisfaction among surveyed trauma/ACS surgeons.

A crew resource management program tailored to trauma resuscitation improves team behavior and communication.

BACKGROUND: Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. STUDY DESIGN: An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. RESULTS: The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). CONCLUSIONS: Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients.

A Second's Chance: Gang Violence Task Force prevention program.

We describe a gang violence intervention and define targets for prevention. At-risk youths were identified through courts, public schools, and law enforcement regarding gang-related activities. They participated in "A Second's Chance," a true-to-life mock emergency department resuscitation and death of a gang member provided over an 18-month period. A questionnaire was completed by each participant. Forty-nine youths identified as at risk for gang involvement participated (37 male and 12 female, P < 0.001). Average age was 14.5 years (range, 10 to 19 years); 32 were black, 9 Hispanic, 6 white, and 2 other (P < 0.05). Seventeen (35%) had prior arrests (P = 0.059), 13 (77%) of whom had multiple arrests (P < 0.05). Forty-one (84%) reported a family member jailed (P < 0.001). Forty-two (86%) witnessed neighborhood criminal drug activity (P < 0.001). Household leadership was predominately maternal (24 [49%], (P < 0.05). Forty-four (90%) participants provided positive meaningful responses to the intervention (P < 0.001). Gang violence prevention should be channeled through maternal family members. History of incarcerated relatives, acquaintances, and neighborhood exposure to drugs and crime may represent additional risk factors for gang-related involvement. Demonstrations of gang violence scenarios raise awareness to consequences of gang-related activities. Family and neighborhood characteristics should be included in development of intervention scenarios.

Non-operative management in penetrating abdominal trauma: is it feasible at a Level II trauma center?

BACKGROUND: The recent mandate for surgical exploration for all penetrating abdominal trauma has been questioned. High-volume centers report good outcomes for non-operative treatment in penetrating trauma for hemodynamically stable patients without peritonitis and with tangential wounds. The applicability of this strategy in smaller hospitals is unknown. STUDY OBJECTIVES: The purpose of this study was to evaluate non-operative management of penetrating abdominal trauma at a Level II trauma center. METHODS: We retrospectively reviewed all patients with penetrating abdominal trauma from 2006 through 2008. Demographic information, treatments, and outcomes were analyzed using descriptive statistics. RESULTS: Our sample consisted of 86 patients with penetrating abdominal trauma; 12 (14%) had documented peritoneal violation and were managed non-operatively. The average age was 30 years (range 21-39 years), with 50% African American, 33% Caucasian, and 17% Hispanic. Male patients accounted for 92%, and the average Injury Severity Score was 5.2 (range 1-13). Overall non-operative treatment failed in 3 patients (25%); one required drainage of a retrogastric abscess on hospital day 4, and another underwent gastric and diaphragm repair on hospital day 1. The third treatment failure did not require an operation but developed a biloma requiring percutaneous drainage. There were no other complications related to non-operative therapy and no mortalities. The average length of stay was 3.9 days; 83% of patients were discharged home. CONCLUSIONS: In hemodynamically stable patients without peritonitis and documented isolated injuries to solid organs, non-operative management of penetrating abdominal trauma seems safe; however, it can delay diagnosis of hollow viscus injuries. Until further data emerge, extreme caution should be used in employing non-operative management for penetrating abdominal injuries at small trauma centers.

Clinical practice guideline: red blood cell transfusion in adult trauma and critical care.

OBJECTIVE: To develop a clinical practice guideline for red blood cell transfusion in adult trauma and critical care. DESIGN: Meetings, teleconferences and electronic-based communication to achieve grading of the published evidence, discussion and consensus among the entire committee members. METHODS: This practice management guideline was developed by a joint taskforce of EAST (Eastern Association for Surgery of Trauma) and the American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM). We performed a comprehensive literature review of the topic and graded the evidence using scientific assessment methods employed by the Canadian and U.S. Preventive Task Force (Grading of Evidence, Class I, II, III; Grading of Recommendations, Level I, II, III). A list of guideline recommendations was compiled by the members of the guidelines committees for the two societies. Following an extensive review process by external reviewers, the final guideline manuscript was reviewed and approved by the EAST Board of Directors, the Board of Regents of the ACCM and the Council of SCCM. RESULTS: Key recommendations are listed by category, including (A) Indications for RBC transfusion in the general critically ill patient; (B) RBC transfusion in sepsis; (C) RBC transfusion in patients at risk for or with acute lung injury and acute respiratory distress syndrome; (D) RBC transfusion in patients with neurologic injury and diseases; (E) RBC transfusion risks; (F) Alternatives to RBC transfusion; and (G) Strategies to reduce RBC transfusion. CONCLUSIONS: Evidence-based recommendations regarding the use of RBC transfusion in adult trauma and critical care will provide important information to critical care practitioners.

Is helical computed tomography effective for diagnosis of blunt aortic injury?

Computed tomography has had a questionable role in diagnosing blunt aortic injury (BAI). The objective of this study was to determine the effectiveness of helical computed tomography of the thorax (HCTT) for detection of BAI. Trauma Registry data and medical records were reviewed for 2,854 patients admitted over a 32-month period. A total of 243 patients were identified at risk for BAI. Patients were evaluated for BAI because of chest radiograph, physical examination, or clinical suspicion. Eleven of 2,834 patients sustained BAI. Of 243 patients who sustained blunt torso trauma, 232 patients underwent HCTT. Eleven underwent aortography without HCTT. Sixteen patients had an abnormal HCTT, revealing 9 patients with BAI. No delayed BAI were encountered. HCTT effectively screens for BAI. Aortography can be more specifically applied as a diagnostic study when preceded by HCTT. HCTT should not be used as solitary study for BAI as some injuries identified by HCTT do not represent BAI.