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Adrenal incidentalomas are a known entity that have been increasing in commonality with the advent of improved diagnostic and imaging techniques. There are a vast variety of causative pathologies to which this diagnosis can be attributed. Some of these pathologies are more common than others, while many remain extremely rare. One of the distinct entities that is a unique cause of incidentalomas is the diagnosis presented herein: pheochromocytoma. Pheochromocytomas are often an exceptional subset of incidentalomas that can certainly play a major role in treatment and management plans. However, the exclusivity of a pheochromocytoma diagnosis alone is not where the uniqueness of this case rests. The uniqueness in this patient is paramount to report due to 2 additional significant factors. The first was that the patient was entirely asymptomatic aside from complaints related to scrotal swelling due to a varicocele, for which this presentation of pheochromocytoma has been scarcely reported in the literature. Second, the patient had a pathology proven diagnosis of pheochromocytoma, while lacking both symptoms and biochemical findings to support the diagnosis, making it truly a silent pheochromocytoma.

Animal attacks are a worrisome and dangerous entity that occur at high volumes and are evaluated frequently by ER physicians, primary care physicians, trauma teams, acute care surgeons, and plastic surgeons. The severity of animal attacks can range from a small insect sting to mauling by large animal, and even death. With animal attacks of high intensity, there is often significant scratching, tearing, shearing, with destruction of the skin, subcutaneous tissues, muscles, and bone. Serious attacks frequently lead to infection, sepsis, pain, loss of sensation or mobility, operative interventions, and amputations of affected limbs. We report herein the traumatic mauling of a woman by a reported unknown animal. Though the entity of animal attacks has been reported in the past, this case dictates presentation given the suspicious circumstances surrounding the attack, the involvement of her care requiring a multidisciplinary surgical approach via trauma surgery and plastic surgery, multiple extensive interventions, and the excellent take of the split thickness skin graft (STSG) after the use of a dermal regeneration template (DRT).

Traumatic brain injury (TBI) remains a major cause of death and disability each year in the United States. Implementation of preestablished evidence-based guidelines has been associated with a decrease in overall TBI mortality and disability. OBJECTIVES An electronic clinical monitoring tool was developed for monitoring compliance with evidence-based TBI treatment protocols to improve the overall care and outcomes in this patient population. METHODS This project was designed as a process improvement project. For the preimplementation cohort of TBI patients, aggregate compliance data (by patient) were obtained from the Brain Trauma Foundation Trial patient registry maintained at Conemaugh Memorial Medical Center for the time between 2011 and 2012. The postimplementation cohort includes all patients older than 18 years who have sustained a TBI requiring clinical monitoring devices. RESULTS There was a statistical significance between groups; the TBI-2017 group demonstrated better compliance with anticonvulsant use and cerebral perfusion pressure maintenance. In addition, overall compliance was better in the TBI-2017 cohort compared with the TBI-2012 cohort. CONCLUSIONS Traumatic brain injury-specific education and frequent assessments improved compliance between TBI-2012 and TBI-2017, resulting in a higher percentage in overall survivors in the latter group.

Medical implants and surgical site infections (SSIs) can be a burden on both patients and healthcare systems with a significant rise in morbidity, mortality and costs. Preoperatively, our practice of a chlorohexidine gluconate (CHG) washcloth bath or solution shower was supplemented with nasal painting using povidone-iodine skin and nasal antiseptic (PI-SNA). We sought to measure the effectiveness in reducing SSIs in patients undergoing repair of lower extremity fractures. A retrospective review of trauma patients undergoing orthopedic operations conducted at Conemaugh Memorial Medical Center from 10/1/2012 through 9/30/2016. The intervention period was 10/1/2014 to 9/30/2016 which included the addition of nasal painting with PI-SNA preoperatively. All patients were followed for 1 year prior to January 2013 and 30 or 90 days thereafter for the development of a SSI. The pre-intervention group consisted of 930 cases with a 1.1% infection rate (10 SSIs). The intervention group consisted of 962 cases with a 0.2% infection rate (2 SSIs). This observed difference was statistically significant (P = 0.020). This retrospective review of a methicillin-resistant Staphylococcus aureus decolonization protocol using CHG bath/shower and PI-SNA nasal painting revealed a significant decrease in the infection rate of patients undergoing lower extremity fracture repairs. We recommend its use without contraindications, but recognize that additional investigations are necessary.

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.

Background Owing to parallel advances in health care and an aging population, geriatric injury has become an increasing burden to trauma systems, suggesting that specific clinical pathways may improve the care of this cohort. We created a dedicated Geriatric Trauma Institute, with multidisciplinary support, as a part of our existing trauma program, theorizing that the Geriatric Trauma Institute would promote quality care, reduce the length of stay, and reduce hospital charges. Methods We performed a retrospective analysis of the prospective database of our level 1 trauma center. Patients aged 65 years or older were identified over 12 months, representing 5 months prior and also after the implementation of the new program. Results The mean length of stay was reduced for admissions to a nontrauma vs geriatric trauma service (5.64 vs 4.43 days; P = .03), generating a charge reduction of 21.4% in only the first 5 months after program implementation. Conclusions Our preliminary findings, which require longer-term analysis, suggest that a dedicated geriatric trauma multidisciplinary system promotes quality patient care, improves throughput, and results in significant cost savings via reduced length of stay and concomitant hospital charges.

The study explores how residents and faculty assess the ACGME's 16-h limit on intern shifts.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.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.The 16-h limit on intern shifts has remained a source of concern and an educational challenge for residents and 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.

With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP).As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB.Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity.Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality.Therapeutic study, level IV.

Background The US geriatric population is projected to steadily increase to approximately 20% by 2030, thereby significantly increasing the burden to trauma services. This study sought to transform the geriatric trauma care model into one more effective, efficient, financially sustainable, and capable of absorbing the anticipated increased demand. Study design The goals were to improve the geriatric trauma care process—for patient and hospital, detail its evolution, and provide a formative evaluation of the result. A multidisciplinary team, internal and external to the hospital, was assembled including clinical, administrative, and technical staff. Over 18 months, application of Lean Six Sigma tools/concepts produced a novel care model, the Geriatric Trauma Institute (GTI). Retrospectively, formative evaluation was accomplished by comparing pre-GTI data time-matched with that from the first 8 months post-GTI initiation. Results The GTI has achieved 100% involvement of institution orthopedists with 100% of geriatric trauma admissions being converted to the GTI. Eight months post-GTI, geriatric trauma service admissions increased 26.6%, while non-trauma admissions decreased 78.2%. Out-transfers declined by 28.2%. Patients dispositioned to home increased 26.1% alongside decreases to rehabilitation (47.2%), skilled nursing, and transitional care facilities. Conclusion Geriatric trauma institute success is evidenced by the quantifiable benefits to patient and hospital. During development, new work processes, tools, and staff training helped boost the utilization of the trauma service regarding geriatric trauma care via the novel multidisciplinary approach. The GTI has demonstrated sustained quality improvement in geriatric trauma care maintained through the trauma service performance improvement initiative. How to cite this article DeLa'O CM, Rodriguez A, Boer J, Simunich T, Dumire R. From Trauma Quality Improvement Project to the Geriatric Trauma Institute: Developing an Innovative Care Model for the Coming Storm. Panam J Trauma Crit Care Emerg Surg 2014;3(3):105-108.

Trauma is the leading cause of death in those age 1–45 and the 3rd leading cause of death overall in all groups in the United States and is associated with an annual cost of 671 billion dollars. Education remains one of our most valuable tools in combatting this public health epidemic called “Trauma” and must, therefore, be provided in an efficient manner not only for nursing personnel but for all healthcare providers involved in the care of trauma patients. An on-line educational platform was utilized to introduce updates and revisions to our institutional traumatic brain injury (TBI) guidelines and protocols to a multidisciplinary group of nurses and surgical residents. In addition, a hands-on module was also utilized to ensure accuracy and consistency across all disciplines. Utilizing the NetLearning® educational process, an active learning platform, resulted in an improvement in test scores which was sustained at the 6-month point for both nurses and resident physicians. There was a statistically significant improvement in the nurse and resident physician combined scores between the pre-test and immediate post-test mean scores (74%±9.35% pre vs. 88%±6.23% post, P

The majority of concussion research has focused on timely diagnosis and treatment, yet little has been reported on primary prevention. The goal of this study is to examine the use of core training as a preventative tool. We performed a non-randomized prospective study involving high school athletes. They participated in a 10-week training session with exercises focused on increasing core strength [mobility, agility, stability, strength and flexibility (MASSf)]. Logs were kept of all concussions diagnosed using ImPACT concussion testing. Statistical analysis was done using Chi-square to calculate expected/observed frequency and Chi-squared test statistic, χ 2 . Test significance was accepted at a P 2 =9.84, corresponds to a P value of 0.0017. The MASSf program was repeated in the 2015 season with 2 concussions in 121 participants. Our study showed a statistically significant decrease in concussion rates after participating in MASSf training. This program shows a promise as a primary prevention method to reduce sports related concussions.

Background Overnight radiology services (ORSs) provide computed tomography (CT) scan readings that are automatically reviewed by staff radiologists (SRs) and the trauma service. Discordant readings and their clinical significance were investigated. Methods ORS-read CT scans over 3 years were reviewed. A discordant reading was clinically significant if it resulted in a substantive change in patient care. All clinically significant findings were reviewed by a blinded radiologist. Results Five hundred thirty-four CT scans were identified: 191 (35.8%) head, 187 (35%) cervical, 66 (12.4%) chest, and 90 (16.9%) abdomen/pelvis scans. One hundred twenty-three scans (23%) were abnormal with a DR of 16%: 5 head, 2 cervical, 7 chest, and 6 abdomen/pelvis scans. Seven (6%) scans had clinically significant findings missed: 3 head and 4 abdomen/pelvis scans. ORSs missed 7, and SRs missed 3 clinically significant findings. A blinded radiologist confirmed the clinically significant findings. Conclusions The discordant rate of readings for abnormal CT scans was 16% with 37% considered to be clinically significant. ORSs missed 100%, and 29% of the clinically significant findings were identified after SR/trauma service rounds. SR/trauma service review of ORS readings is supported.

Background The current level of continuity of care for following up a single patient through preoperative evaluation, surgery, and postoperative care is unknown. Methods A survey of residents was performed, asking for their best guess regarding the number of patients seen for 6 common and 4 uncommon surgeries, and ranking barriers to continuity of care. The length of time to achieve single-patient continuity of care in 5 patients was derived as well as the creation of odds ratios for the barriers. Results A total of 274 residents (56 programs) completed surveys. Residency length was 7 years for common surgeries and 9 for complex surgeries. The 30-hour work restrictions, inability to attend clinic, and floor/ward duties were the barriers to continuity of care. These data were unaffected by type of program, the presence of a night float system, or residency year. Conclusions Achieving the level of continuity of care used in this article will require a radical change in the length or structure of general surgery residency programs.

Purpose: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). Methods: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). Results: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. Conclusion: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Background Teaching physicians and academic medical centers may find it more difficult to meet clinical productivity expectations and still contribute to scholarly activity in the present economic climate of health care. Methods A multiquestion survey was developed and distributed via the Association of Program Directors in Surgery list-serve. Results There were 80 respondents (31% response rate), 29 university program (UP), 43 independent program (IP), and 8 "other." Although most programs had designated teaching faculty (72% UP, 93% IP), the trend was not to compensate for scholarly activity whether voluntary (100% UP, 91% IP), employed (82% UP, 74% IP), or contracted (57% UP, 85% IP; P = not specified). Most (69% UP, 75% IP) programs had no incentives for scholarly activities, despite dissatisfaction with involvement of volunteer faculty (19% UP, 55% IP; P = .04). Most compensation plans (79% UP, 66% IP) were discretionary or atypical. Conclusions Most programs, UP and IP, did not compensate for scholarly activity for teaching faculty. There was a significant proportion that believed compensation would improve teaching efforts.

A persistent pulmonary air leak, whether as a result of pulmonary surgery or as a result of a traumatic or spontaneous pneumothorax, is a difficult and frustrating problem to manage. Several therapies have been employed, including thoracotomy and repair of the air leak, prolonged tube thoracostomy suction, and chemical pleurodesis. We report two cases in which patients with a prolonged air leak who were not candidates for thoracotomy had immediate successful treatment with an autologous "blood patch" pleurodesis. An autologous blood patch pleurodesis is, in our limited experience, a simple, painless, inexpensive, and effective treatment for patients with a persistent pulmonary air leak.