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Background: The Society of Black Academic Surgeons (SBAS) sought to understand who constitutes its membership and obtain feedback to improve the organization., Methods: SBAS conducted a 25-question survey amongst members., Results: The response rate was 19 ​% (n ​= ​132/685) with an even gender breakdown (male n ​= ​64, female n ​= ​68). The majority identified as Black or African American (85 ​%), followed by White (12 ​%). Fifty-two percent identified as trainees, while the rest were practicing surgeons specializing in burn/trauma/critical care (19 ​%), oncology (19 ​%), and general surgery (13 ​%). Half joined SBAS within the last 3 years. Satisfaction was reported at a mean of 3.7/5. Lack of awareness (41 ​%), time (13 ​%), or interest (5 ​%) limited committee participation. Networking (83 ​%), mentorship/sponsorship/allyship (71 ​%), and leadership development (46 ​%) were most valued benefits with job boards, webinars, and grants least valuable., Conclusion: SBAS is a unique organization uniting both new and lifetime members and opportunities exist to enhance current membership and improve participation., Competing Interests: Declaration of competing interest Shay Behrens, Andre R. Campbell, Colin Martin, and Michael A. Edwards have no relevant financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: This study describes perceived knowledge gaps of third-year medical students after participating in a virtual surgical didactic rotation (EMLR) and shortened in-person surgery rotation during the COVID-19 Pandemic., Methods: Open-ended and Likert questions were administered at the end of the virtual rotation and inperson-surgical rotation to medical students. Three blinded coders identified themes by semantic analysis., Results: 82 students (51% of all MS3s) participated in the EMLR. Semantic analysis revealed gaps in perioperative management (Post-EMLR:18.4%, Post-Inpatient:26.5%), anatomy (Post-EMLR:8.2%, PostInpatient:26.5%). and surgical skills (Post-EMLR: 43.0%, Post-Inpatient: 44.1%). Students also described gaps related to OR etiquette (Post-EMLR: 12.2%, Post-Inpatient: 8.8%) and team dynamics/the hidden curriculum (Post- Inpatient:26.6%). There was a significant improvement in perceived confidence to perform inpatient tasks after completing the inpatient clinical experience (p ≤ 0.01)., Conclusion: Virtual interactive didactics for cognitive skills development cannot replace a full clinical surgical experience for third-year medical students. Future curricula should address perceived gaps., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The COVID-19 pandemic provided an opportunity for surgical residency programs to rethink their methods of evaluating and recruiting candidates. However, the past year has not been seamless, with a soaring number of applications, reports of programs and applicants having difficulty evaluating each other, and an increasingly uneven distribution of interviews among applicants. Consequently, many have called for national changes to the residency application process to address these longstanding concerns., Results: Here, we review the evolving literature and advocate for the permanent adoption of visiting rotations, virtual interviews with a universal release date and data-driven attendance limits, and opportunities for in-person applicant visits., Conclusions: We believe these changes leverage the strengths of each format, allow for satisfactory bidirectional evaluation, and promote principles of justice, equity, diversity, and inclusion., (Copyright © 2021. Published by Elsevier Inc.)

The hidden curriculum of unspoken professional expectations negatively impacts medical student interest in surgery. Medical student mentorship and early surgical exposure have been shown to demystify the hidden curriculum. Although residents and faculty play a vital role, near-peer mentorship may aid in uncovering the hidden curriculum and promoting medical student interest in surgery, especially for those learners who are underrepresented in medicine. We developed and implemented a formalized near-peer mentorship program composed of quarterly small group Surgical Peer Teacher led lessons and one-on-one Surgical Support Team mentorship meetings covering surgical curriculum topics for medical students at an academic medical school. This structured near-peer mentorship model provides a mechanism to demystify surgical culture, increase early access to surgical mentorship, and develop mentorship skills amongst students. This program aims to uncover the surgical hidden curriculum to improve surgical career support and interest among medical students with less exposure and access to physician role models. This longitudinal mentorship model is student-run and can be easily adapted to enhance existing support models at medical schools. Future studies will evaluate utilization, impact on surgical specialty interest, and efficacy in demystifying the surgical hidden curriculum., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: The impact of COVID-19 on surgical education has been profound, and clinical learning experiences transitioned to virtual formats. This study investigated the impact of virtual experiences created to facilitate learning during the pandemic for medical students., Methods: We performed a cohort study to determine the perceived clinical preparedness for medical students enrolled in the preclinical surgery pilot course, surgical Extended Mastery Learning Rotation (EMLR), and longitudinal surgical clerkship (LC). The preclinical surgery pilot course took place before COVID-19 disruptions, and the EMLR and LC experiences took place virtually. Specialty choice was examined in the EMLR and LC cohorts. Performance on the NBME surgical assessments was analyzed among students enrolled in the traditional clerkship and pandemic-disrupted courses and compared to national data using a two-sample t-test., Results: Compared to preclinical students, EMLR and LC students demonstrated improvements in their perceived surgical clerkship readiness. After the 3-week EMLR course, in the setting of completing only one-third of the clerkship year, students had an average NBME Surgical Self-Assessment Exam score of 72 (SD 12), comparable to the national average of 71 (SD 9) p = 0.33. The average shelf exam score for students (N = 24) enrolled in the traditional clerkship (block 1), prior to COVID-19, disruptions was 66 (SD 9) compared to an average score of 69 (SD 9) for the longitudinal clerkship students (N = 20) that took the shelf exam later in the year (p = 0.36). COVID-19 disruptions did not affect specialty choice. All LC students have decided on a specialty; 50% nonsurgical and 50% surgical. From the EMLR cohort, 36% and 38% plan to pursue surgical and nonsurgical specialties, respectively, with 26% still undecided., Conclusions: Courses were well-liked and will be implemented in future clerkships. Surgical educators demonstrated flexibility and creativity in the development of the EMLR. Despite COVID-19 disruptions, medical students made progress in their clinical skills and foundational science knowledge. COVID-19 disruptions did not appear to impact specialty choice., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the performance and perspectives of third-year medical students (MS3s) participating in near-peer learning (NPL) sessions during their core surgical clerkship following a 15-month preclerkship curriculum., Design: An evaluation study of 7 NPL sessions developed and implemented by fourth-year medical students (MS4s) held from March 2019 to February 2020. MS4s taught 1-2 sessions per rotation that included test taking strategies, illness script development, radiology review, case-based multiple-choice questions, and rapid review. Participants completed a questionnaire with 11 seven-point Likert and open-ended questions after each session. Analyses included quantitative comparison of shelf score averages between NPL participants and nonparticipants and qualitative content analysis for open-ended questions., Setting: Surgical clerkship at the University of California, San Francisco., Participants: Forty-eight (32%) MS3s participated, with an average attendance of 10 students per rotation. Thirty-three (69%) participants completed the questionnaire., Results: MS3s enjoyed the session (6.9 ± 0.4), improved their knowledge (6.8 ± 0.5), and felt more prepared for the surgery shelf examination (6.5 ± 0.6). MS4 leaders found that MS3s always wanted radiology review, and their interest in test taking strategies and illness script development declined across the clerkship year. Participants had lower shelf exam scores compared to nonparticipants (68.1 vs 71.4, respectively; p = 0.04, ES = 0.03). Shelf exam scores increased over time in both cohorts. Each group had 2 shelf exam failures. Qualitative analysis suggests that MS3s appreciated the NPL's tailored approach and exam demystification, with a desire for increased NPL integration into the clerkship., Conclusion: Students participating in NPL were satisfied with the sessions. Participants may have been students who struggled as indicated by shelf exam scores and appreciated the support. The shift in preferred topics across the blocks reflects the students' development during clerkships. Near-peer teachers should adjust sessions over time to fit students' evolving needs., Competing Interests: Declaration of Competing Interest Julie Ann Sosa, MD, MA, is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by GlaxoSmithKline, Novo Nordisk, Astra Zeneca, and Eli Lilly. She receives institutional research funding from Exelixis and Eli Lilly., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical intensive care units (SICU) require complex care from a multi-disciplinary team. Frequent changes in team members can lead to shifting expectations for junior general surgical trainees, which creates a challenging working and learning environment. We aim to identify expectations of junior surgery trainee's medical knowledge and technical/non-technical skills at the start of their SICU rotation. We hypothesize that expectations will not be consistent across SICU stakeholder groups., Methods: Twenty-eight individual semi-structured interviews were conducted with six SICU stakeholder groups at a medium-sized academic hospital. Expectations were identified from interview transcripts. Frequency counts were analyzed., Results: Forty-one expectations were identified. 4 expectations were identified by a majority of interviewees. Most expectations were identified by 7 or fewer interviewees. 23 (53%) expectations were shared by at least one stakeholder group. 2 (8%) expectations were shared by all groups., Conclusions: SICU stakeholder groups identified ten medical knowledge, ten technical skill, and three non-technical skill expectations. Yet, few expectations were shared among the groups. Thus, SICU stakeholder groups have disparate expectations for surgery trainees in our SICU., Competing Interests: Declaration of competing interest The authors have no personal or financial conflicts of interest., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose of Review: With the rising popularity of standing motorized scooters in major cities in the United States, many hospitals are experiencing a surge of traumatic injuries associated with this new mode of transportation. The impact and characteristics of injuries associated with standing motorized scooters are evolving, and safety regulations for the riders are poorly defined. There is a need for a review for healthcare providers and policy makers on this topic., Recent Findings: Since its market introduction of rentable standing motorized scooters in late 2017, there has been an exponential rise in emergency department visits and hospitalization due to scooter-related trauma in urban hospitals. There have been a number of independent hospital-based and national-level studies describing demographics and trends of injury patterns in the last 2 years., Summary: Patients presenting to the hospital with injuries tend to be young male between 20 and 40 years of age, presenting at night. Head and extremity injuries are common, and patients often do not comply with helmets and other protective gears. Intoxication is a major risk factor for injuries requiring hospital admission and surgical interventions. These findings increase awareness for (1) healthcare providers to recognize and triage high-energy injuries, and (2) policy makers to advocate universal helmet use, increase public safety education, and enforce road safety regulations to minimize the impact of these injuries., Competing Interests: Conflict of interestWoon Cho Kim and Andre Campbell declares that they have no conflict of interest., (© The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021.)

Background: Patients with penetrating trauma who cannot be stabilized undergo operative intervention without preoperative imaging. In such cases, postoperative imaging may reveal additional injuries not identified during the initial operative exploration. The purpose of this study is to explore the utility of postoperative CT imaging in the setting of penetrating trauma., Methods: This was a retrospective analysis of patients with penetrating trauma treated at an urban Level 1 trauma center between 2010 and 2015. Patients were included if they underwent an emergent laparotomy without preoperative imaging. Patients were excluded if they had prior imaging or concomitant blunt injury. For the purposes of this study, occult injury was defined as a CT scan finding not mentioned in the first operative report. Descriptive statistics were used to compare patient characteristics who had received imaging immediately postoperatively with those who had not., Results: During the 5-year study period, 328 patients who had a laparotomy for penetrating trauma over the study period, 225 patients met the inclusion criteria. Seventy-three (32%) patients underwent CT scanning immediately postoperatively with occult injuries identified in 38 (52%) patients. The most frequent occult injuries were orthopedic (20 of 43) and genitourinary (9 of 43). Importantly, 10 (26%) of the 38 patients required an intervention for these occult injuries. Those selected for immediate postoperative imaging were more likely to have sustained gunshot wounds and were significantly more severely injured (higher Injury Severity Score and longer length of hospital stay) when compared to patients who did not receive immediate imaging., Conclusion: We recommend the use of immediate postoperative CT after emergent laparotomy especially when there is a high index of suspicion for spine or genitourinary injuries and in patients who have sustained ballistic penetrating injuries., Level of Evidence: Therapeutic/care management, level IV; diagnostic tests or criteria, level IV.

Importance: To date, a substantial portion of multiple casualty incident literature has focused exclusively on prehospital and emergency department resources needed for optimal disaster response. Thus, inpatient resources required to care for individuals injured in multiple casualty events are not well described., Objective: To highlight the resources beyond initial emergency department triage needed for multiple casualty events, using one of the largest commercial aviation disasters in modern US history as a case study., Design, Setting, and Participants: Prospective case series of injured individuals treated at an urban level I trauma center following the crash of Asiana Airlines flight 214 on July 6, 2013. This analysis was conducted between June 1, 2014, and December 1, 2015., Exposure: Commercial jetliner crash., Main Outcomes and Measures: Medical records, imaging data, nursing overtime, blood bank records, and trauma registry data were analyzed. Disaster logs, patient injuries, and blood product data were prospectively collected during the incident., Results: Among 307 people aboard the flight, 192 were injured; 63 of the injured patients were initially evaluated at San Francisco General Hospital and Trauma Center (the highest number at any of the receiving medical facilities; age range, 4-74 years [23 were aged <17 years and 3 were aged >60 years]; median injury severity score of 19 admitted patients, 9 [range, 9-45]), including the highest number of critically injured patients (10 of 12). Despite the high impact of the crash, only 3 persons (<1%) died, including 1 in-hospital death. Among the 63 patients, 32 (50.8%) underwent a computed tomographic imaging study, with imaging of the abdomen and pelvis being the most common. Sixteen of the 32 patients undergoing computed tomography (50.0%) had a positive finding on at least 1 scan. Nineteen patients had major injuries and required admission, with 5 taken directly from the emergency department to the operating room. The most frequent injury was spinal fracture (13 patients). In the first 48 hours, 15 operations were performed and 117 total units of blood products were transfused. A total of 370 nursing overtime hours were required to treat the injured patients on the day of the event., Conclusions and Relevance: Proper disaster preparedness requires attention to hospital-level needs beyond initial emergency department triage. The Asiana Airlines flight 214 crash highlights the need to plan for high use of advanced imaging, blood products, operating room availability, nursing resources, and management of inpatient hospital beds.

Traditional recommendations suggest placement of a subclavian central venous catheter (CVC) ipsilateral to a known pneumothorax to minimize risk of bilateral pneumothorax. We present the case of a 65-year-old male with a right hemopneumothorax who was found to have intrathoracic placement of his right subclavian CVC at thoracotomy despite successful aspiration of blood and transduction of central venous pressure (CVP). We thus recommend extreme caution with the interpretation of CVC placement by blood aspiration and CVP measurement alone in patients with large volume ipsilateral hemothorax.

Background: Simulation can enhance learning effectiveness, efficiency, and patient safety and is engaging for learners., Methods: A survey was conducted of surgical clerkship directors nationally and medical students at 5 medical schools to rank and stratify simulation-based educational topics. Students applying to surgery were compared with others using Wilcoxon's rank-sum tests., Results: Seventy-three of 163 clerkship directors (45%) and 231 of 872 students (26.5%) completed the survey. Of students, 28.6% were applying for surgical residency training. Clerkship directors and students generally agreed on the importance and timing of specific educational topics. Clerkship directors tended to rank basic skills, such as examination skills, higher than medical students. Students ranked procedural skills, such as lumbar puncture, more highly than clerkship directors., Conclusions: Surgery clerkship directors and 4th-year medical students agree substantially about the content of a simulation-based curriculum, although 4th-year medical students recommended that some topics be taught earlier than the clerkship directors recommended. Students planning to apply to surgical residencies did not differ significantly in their scoring from students pursuing nonsurgical specialties., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To compare outcome parameters for good-risk patients with classic signs, symptoms, and laboratory and abdominal imaging features of cholecystolithiasis and choledocholithiasis randomized to either laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC+LCBDE) or endoscopic retrograde cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy (ERCP/S+LC)., Design: Our study was a prospective trial conducted following written informed consent, with randomization by the serially numbered, opaque envelope technique., Setting: Our institution is an academic teaching hospital and the central receiving and trauma center for the City and County of San Francisco, California., Patients: We randomized 122 patients (American Society of Anesthesiologists grade 1 or 2) meeting entry criteria. Ten of these patients, excluded from outcome analysis, were protocol violators having signed out of the hospital against medical advice before 1 or both procedures were completed., Interventions: Treatment was preoperative ERCP/S followed by LC, or LC+LCBDE., Main Outcome Measures: The primary outcome measure was efficacy of stone clearance from the common bile duct. Secondary end points were length of hospital stay, cost of index hospitalization, professional fees, hospital charges, morbidity and mortality, and patient acceptance and quality of life scores., Results: The baseline characteristics of the 2 randomized groups were similar. Efficacy of stone clearance was likewise equivalent for both groups. The time from first procedure to discharge was significantly shorter for LC+LCBDE (mean [SD], 55 [45] hours vs 98 [83] hours; P < .001). Hospital service and total charges for index hospitalization were likewise lower for LC+LCBDE, but the differences were not statistically significant. The professional fee charges for LC+LCBDE were significantly lower than those for ERCP/S+LC (median [SD], $4820 [1637] vs $6139 [1583]; P < .001). Patient acceptance and quality of life scores were equivalent for both groups., Conclusions: Both ERCP/S+LC and LC+LCBDE were highly effective in detecting and removing common bile duct stones and were equivalent in overall cost and patient acceptance. However, the overall duration of hospitalization was shorter and physician fees lower for LC+LCBDE., Trial Registration: clinicaltrials.gov Identifier: NCT00807729.

Background: The spontaneous breathing pattern and its relationship to compliance, resistance, and work of breathing (WOB) has not been examined in patients with acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Clinically, the ratio of respiratory frequency to tidal volume (f/VT) during spontaneous breathing may reflect adaptation to altered compliance, resistance, and increased WOB. We examined the relationship between f/VT, WOB, and respiratory system mechanics in patients with ARDS/ALI., Methods: Data from spontaneous breathing trials were collected from 33 patients (20 with ARDS, 13 with ALI) at various points in their disease course. WOB and respiratory system mechanics were measured with a pulmonary mechanics monitor that incorporates Campbell diagram software. Differences between the patients with ARDS and ALI were assessed with 2-sided unpaired t tests. Multivariate linear regression models were constructed to assess the relationship between f/VT and other pulmonary-related variables., Results: Patients with ARDS had significantly lower compliance than those with ALI (24 +/- 6 mL/cm H2O vs 40 +/- 13 mL/cm H2O, respectively, p < 0.001), but this did not translate into significant differences in either WOB (1.70 +/- 0.59 J/L vs 1.43 +/- 0.90 J/L, respectively, p = 0.30) or f/VT (137 +/- 82 vs 107 +/- 49, respectively, p = 0.23). Multivariate linear regression modeling revealed that peak negative esophageal pressure, central respiratory drive, duration of ARDS/ALI, minute ventilation deficit between mechanical ventilation and spontaneous breathing, and female gender were the strongest predictors of f/VT., Conclusion: The characteristic rapid shallow breathing pattern in patients with ARDS/ALI occurs in the context of markedly diminished compliance, elevated respiratory drive, and increased WOB. That f/VT had a strong, inverse relationship to peak negative esophageal pressure also may reflect the influence of muscle weakness.

Objective: To assess the effects of step-changes in tidal volume on work of breathing during lung-protective ventilation in patients with acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS)., Design: Prospective, nonconsecutive patients with ALI/ARDS., Setting: Adult surgical, trauma, and medical intensive care units at a major inner-city, university-affiliated hospital., Patients: Ten patients with ALI/ARDS managed clinically with lung-protective ventilation., Interventions: Five patients were ventilated at a progressively smaller tidal volume in 1 mL/kg steps between 8 and 5 mL/kg; five other patients were ventilated at a progressively larger tidal volume from 5 to 8 mL/kg. The volume mode was used with a flow rate of 75 L/min. Minute ventilation was maintained constant at each tidal volume setting. Afterward, patients were placed on continuous positive airway pressure for 1-2 mins to measure their spontaneous tidal volume., Measurements and Main Results: Work of breathing and other variables were measured with a pulmonary mechanics monitor (Bicore CP-100). Work of breathing progressively increased (0.86 +/- 0.32, 1.05 +/- 0.40, 1.22 +/- 0.36, and 1.57 +/- 0.43 J/L) at a tidal volume of 8, 7, 6, and 5 mL/kg, respectively. In nine of ten patients there was a strong negative correlation between work of breathing and the ventilator-to-patient tidal volume difference (R = -.75 to -.998)., Conclusions: : The ventilator-delivered tidal volume exerts an independent influence on work of breathing during lung-protective ventilation in patients with ALI/ARDS. Patient work of breathing is inversely related to the difference between the ventilator-delivered tidal volume and patient-generated tidal volume during a brief trial of unassisted breathing.

Background: Pressure-control ventilation (PCV) and pressure-regulated volume-control (PRVC) ventilation are used during lung-protective ventilation because the high, variable, peak inspiratory flow rate (V (I)) may reduce patient work of breathing (WOB) more than the fixed V (I) of volume-control ventilation (VCV). Patient-triggered breaths during PCV and PRVC may result in excessive tidal volume (V(T)) delivery unless the inspiratory pressure is reduced, which in turn may decrease the peak V (I). We tested whether PCV and PRVC reduce WOB better than VCV with a high, fixed peak V (I) (75 L/min) while also maintaining a low V(T) target., Methods: Fourteen nonconsecutive patients with acute lung injury or acute respiratory distress syndrome were studied prospectively, using a random presentation of ventilator modes in a crossover, repeated-measures design. A target V(T) of 6.4 + 0.5 mL/kg was set during VCV and PRVC. During PCV the inspiratory pressure was set to achieve the same V(T). WOB and other variables were measured with a pulmonary mechanics monitor (Bicore CP-100)., Results: There was a nonsignificant trend toward higher WOB (in J/L) during PCV (1.27 + 0.58 J/L) and PRVC (1.35 + 0.60 J/L), compared to VCV (1.09 + 0.59 J/L). While mean V(T) was not statistically different between modes, in 40% of patients, V(T) markedly exceeded the lung-protective ventilation target during PRVC and PCV., Conclusions: During lung-protective ventilation, PCV and PRVC offer no advantage in reducing WOB, compared to VCV with a high flow rate, and in some patients did not allow control of V(T) to be as precise.

Objective: To assess the impact of implementing a low tidal volume ventilation strategy on hospital mortality for patients with acute lung injury or acute respiratory distress syndrome., Design: Retrospective, uncontrolled study., Setting: Adult medical-surgical and trauma intensive care units at a major inner city, university-affiliated hospital., Patients: A total of 292 patients with acute lung injury or acute respiratory distress syndrome., Interventions: Between the years 2000 and 2003, 200 prospectively identified patients with acute lung injury/acute respiratory distress syndrome were managed by the ARDS Network low tidal volume protocol. A historical control group of 92 acute respiratory distress syndrome patients managed by routine practice from 1998 to 1999 was used for comparison., Measurements and Main Results: Patients managed with the ARDS Network protocol had a lower hospital mortality compared with historical controls (32% vs. 51%, respectively; p = .004). Multivariate logistic regression estimated an odds ratio of 0.32 (95% CI, 0.17-0.59; p = .0003) for mortality risk with use of the ARDS Network protocol. Protocol-managed patients had a lower tidal volume (6.2 +/- 1.1 vs. 9.8 +/- 1.5 mL/kg; p < .0001) and plateau pressure (27.5 +/- 6.4 vs. 33.8 +/- 8.9 cm H2O; p < .0001) than historical controls., Conclusion: Adoption of the ARDS Network protocol for routine ventilator management of acute lung injury/acute respiratory distress syndrome patients was associated with a lower mortality compared with recent historical controls.

Background: The international consensus definitions for acute respiratory distress syndrome (ARDS) have formed the basis for recruitment into randomized, controlled trials and, more recently, standardized the protocols for ventilatory treatment of acute lung injury. Although possibly appropriate for sepsis-induced ARDS, these criteria may not be appropriate for posttraumatic ARDS if the disease patterns are widely divergent. This study tests the hypothesis that standard ARDS criteria applied to the trauma population will capture widely disparate forms of acute lung injury and are too nonspecific to identify a population at risk for prolonged respiratory failure and associated complications., Methods: Patients with and Injury Severity Score > or = 16 ventilated for > 12 hours were prospectively enrolled. Clinical data, including elements of cardiovascular, renal, hepatic, hematologic, neurologic, and pulmonary function, were collected daily. Two hundred fifty-four patients were enrolled over a 36-month period, of whom 70 met the consensus definitions of ARDS. Patients from whom support was withdrawn within 48 hours were excluded. The remaining 61 patients were stratified into two groups on the basis of intubation (n = 12) days., Results: There was considerable disparity in severity and clinical course. A mild, limited form of ARDS was characterized by earlier onset (group 1, 2 days; group 2, 4 days; p = 0.002), fewer intubation days (7 days vs. 28 days; p < 0.001), and less severe derangements in lung mechanics. A significant difference between the two groups was also seen in systemic inflammatory response syndrome score, incidence of sepsis, and incidence of multiple organ failure., Conclusion: The criteria for ARDS, when applied to the trauma population, capture a widely disparate group and has poor specificity for identifying patients at risk. Recruitment of trauma patients for ARDS studies or preemptive ventilatory management based solely on these criteria may be ill-advised.

Context: Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal., Objective: To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause., Design, Setting, and Participants: Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals., Main Outcome Measures: Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors., Results: In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P =.001), more time was spent listening to invited speakers (43.1% vs 0%; P<.001), and less time was spent in audience discussion (15.2% vs 36.6%; P<.001). Fewer internal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; P<.001) or errors causing an adverse event (18 [18%] vs 98 [42%], respectively; P =.001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P =.02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; P<.001). In discussions of cases with errors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error., Conclusions: Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal medicine missed opportunities to model recognition of error and to use explicit language in error discussion by acknowledging their personal experiences with error.

Objective: The purpose of this study was to determine the incidence of acute lung injury (ALI) in trauma patients with severe traumatic brain injury (TBI), to evaluate the impact of ALI on mortality and neurologic outcome after severe traumatic brain injury (TBI), and to identify whether the development of ALI correlates with the severity of TBI., Methods: Clinical data were collected prospectively over a 4-year period in a Level I trauma center. Patients included in the study met the following criteria: mechanical ventilation > 24 hours, head Abbreviated Injury Scale score >or= 3, no other body region Abbreviated Injury Scale score >or= 3, and age between 18 and 54 years. ALI was defined using international consensus criteria. Glasgow Outcome Scale scores were assessed at 3 and 12 months. Bivariate comparisons were made between ALI and non-ALI groups. Multivariate analysis with stepwise logistical regression was used to assess independent factors on mortality. The patient's admission head computed tomographic (CT) scan was graded using the Marshall system, and the presence and size of specific intracranial abnormality was noted. Glasgow Coma Scale (GCS) score, Marshall CT scan score, and intracranial abnormality were correlated with the development of ALI., Results: One hundred thirty-seven patients with isolated head trauma were enrolled in the study over a 4-year period. Thirty-one percent of patients with severe TBI developed ALI. Head trauma patients with ALI had a significantly higher ISS, a greater number of days on the ventilator, and a worse neurologic outcome for those who survived their hospitalization. Mortality was 38% in the ALI group and 15% in the non-ALI group (p = 0.004). Only 3 of 16 (19%) of the deaths within the ALI group were directly related to ALI. By multivariate analysis, only the presence of ALI, older age, and lower initial GCS score were associated with higher mortality. There was no association between ISS, the presence of arterial hypotension (arterial systolic pressure < 90 mm Hg) at admission to the hospital, or the amount of blood transfused and mortality. No correlation was found between the severity of head injury (GCS score, Marshall score, or intracranial abnormality) and development of ALI., Conclusion: The development of ALI is a critical independent factor affecting mortality in patients suffering traumatic brain injury and is associated with a worse long-term neurologic outcome in survivors. The risk of developing ALI is not associated with specific anatomic lesions diagnosed by cranial CT scanning.

Background: Lung-protective ventilation (LPV) can result in a ventilator tidal volume (V(T)) below patient V(T) demand, which may elevate work of breathing (WOB). Increasing the ventilator inspiratory flow may not sufficiently reduce WOB, because the patient's flow-time requirements may exceed the ventilator's flow-time delivery pattern. We investigated (1) the effects of V(T) demand on WOB during LPV and (2) which ventilator pattern best reduced WOB while achieving LPV goals., Methods: A standard WOB lung model simulated assisted breathing. Using 3 ventilators (Hamilton Veolar, Hamilton Galileo, and Dräger Evita 2 dura), we tested volume-control ventilation with a constant flow pattern (VCV-CF), volume-control ventilation with a decelerating flow (VCV-DF), and pressure-control ventilation (PCV). Simulated V(T) demand was increased from 50-125% of the ventilator-delivered V(T) (400 mL) as ventilator inspiratory time (T(I)) was decreased (0.95, 0.80, 0.65, and 0.45 s) relative to simulated T(I) (0.8 s). WOB was measured with a pulmonary mechanics monitor., Results: During VCV-CF and VCV-DF, a V(T) demand of > or = 100% drastically increased WOB, attributable to imposed WOB from the inspiratory valve. Increasing inspiratory flow by using the decelerating flow pattern and/or decreasing T(I) reduced WOB, but generally not to normal levels. "Double-triggered" breaths, with excessive V(T) delivery, often occurred when ventilator T(I) was well below simulated T(I). PCV was most effective in reducing WOB, but V(T) delivery exceeded the LPV target unless T(I) was reduced., Conclusions: Given our dual goals of reducing both WOB and V(T) during LPV, VCV-DF with relatively brief T(I) appeared to be the best option, followed by PCV with a relatively brief T(I).