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Crucial decision must be made quickly and efficiently: Which patients need immediate surgery? What imaging test is best for this patient? When should extra-abdominal cases be considered? Here's some expert guidance. [ABSTRACT FROM AUTHOR]

Background: Stops at nontrauma centers for severely injured patients are thought to increase deaths and costs, potentially because of unnecessary imaging and indecisive/delayed care of traumatic brain injuries (TBIs)., Methods: We studied 754 consecutive blunt trauma patients with an Injury Severity Score greater than 20 with an emphasis on 212 patients who received care at other sites en route to our level 1 trauma center., Results: Referred patients were older, more often women, and had more severe TBI (all P < .05). After correction for age, sex, and injury pattern, there was no difference in the type of TBI, Glasgow Coma Scale (GCS) upon arrival at the trauma center, or overall mortality between referred and directly admitted patients. GCS at the outside institution did not influence promptness of transfer., Conclusions: Interhospital transfer does not affect the outcome of blunt trauma patients. However, the unnecessarily prolonged stay of low GCS patients in hospitals lacking neurosurgical care is inappropriate., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective(s): The goals of this focused meeting were to verify and clarify the causes and extent of the general surgery (GS) workforce shortfalls. We also sought to define workable solutions within the existing framework of medical accreditation and certification., Background: Numerous peer-reviewed and lay reports describe a current and worsening availability of GS services, affecting rural areas as well as large cities, academia, and the military., Method: Primary recommendations were broadly agreed upon by attendee surgeons who were selected from numerous different professional scenarios and included 2 nonmedical observers., Recommendations: (1) enhance the number of GS trainees and the breadth of training, (2) incorporate more flexibility and breadth in residency, (3) minimally invasive surgery should largely return to GS, (4) broader use of community hospitals in these efforts, (5) publicize loan forgiveness and improved visa status for international medical graduates going into GS, and (6) select candidates with a bias toward a general surgical career., Conclusion: These methods are promising approaches to this serious deficiency but will require regular reporting and publicity for the recording of actual increases in GS output.

Background: Since the 2001 terrorist attacks on the United States, federal and state funding, primarily from the National Bioterrorism Hospital Preparedness Program, has resulted in a surge of hospital activity to prepare for future natural or human-caused catastrophes. Trauma centers were integrally involved in the response to the 2001 attacks as first receivers of patients, communication hubs, and as convergence sites for families, the worried well, volunteers, and donors. After the Madrid train station terrorist attack, Congress identified the need to study trauma center preparedness as an essential part of the nation's emergency management system., Methods: The NFTC received a one-year grant funded by the Centers for Disease Control and Prevention (CDC/NCIPC) to survey the capability and capacity of trauma centers to respond successfully to mass casualty incidents, particularly those brought about by acts of terrorism. This report summarizes responses to a US CDC/NCIPC-funded survey, R 49 CE000792-01, sent to all designated or verified Level I and II trauma centers in the US, to which 33% or 175 trauma centers replied., Results: The results are categorized by preparedness scoring, vulnerability, threats, and funding. Planning communication, surge capacity, diversion, sustainability, special populations, and finance represent additional categories examined in the survey., Conclusions: Trauma centers are a major resource in disaster management. One-hundred and seventy-five centers candidly reported their resources and vulnerabilities. This inventory should be expanded to all trauma centers and recommendations for change as discussed.

Long-term morbidity after severe chest wall injuries is common. We report our experience with acute chest wall injury repair, focusing on long-term outcomes and comparing our patients' health status with the general population. We performed a retrospective medical record review supplemented with a postal survey of long-term outcomes including the McGill Pain Questionnaire (MPQ) and RAND-36 Health Survey. RAND-36 outcomes were compared with reference values from the Medical Outcomes Study and from the general population. Forty-six patients underwent acute chest wall repair between September 1996 and September 2005. Indications included flail chest with failure to wean from the ventilator (18 patients), acute, intractable pain associated with severely displaced rib fractures (15 patients), acute chest wall defect/deformity (5 patients), acute pulmonary herniation (3 patients), and thoracotomy for other traumatic indications (5 patients). Three patients had a concomitant sternal fracture repair. Fifteen patients with a current mean age of 60.6 years (range 30-91) responded to our surveys a mean of 48.5 +/- 22.3 months (range 19-96) postinjury. Mean long-term MPQ Pain Rating Index was 6.7 +/- 2.1. RAND-36 indices indicated equivalent or better health status compared with references with the exception of role limitations due to physical problems when compared with the general population. The operative repair of severe chest wall injuries is associated with low long-term morbidity and pain, as well as health status nearly equivalent to the general population. Both the MPQ and the RAND-36 surveys were useful tools for determining chest wall pain and disability outcomes.

Over the course of history, while the underlying causes for wars have remained few, mechanisms of inflicting injury and our ability to treat the consequent wounds have dramatically changed. Success rates in treating war-related injuries have improved greatly, although the course of progress has not proceeded linearly. From Homer's Iliad to the Civil War to Vietnam, there have been significant improvements in mortality, despite a concurrent increase in the lethality of weapons. These improvements have occurred primarily as a result of progress in three key areas: management of wounds, treatment of shock, and systems of organization.

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Background: Tom Friedman, in his book,"The World is Flat," makes a very persuasive argument that our current economic policy transcends national boundaries. Friedman describes various processes that prove his point. These include workflow software, open sourcing, outsourcing, off-shoring, supply chaining, in-sourcing, and informing. The United States already outsources surgery. In this article, I give the retail surgical rates and discount rates of the US, and compare them to that of the same surgery in India, Thailand, and Singapore. Supply chaining is another example that applies to the field of medicine, particularly pharmaceuticals. Most pharmaceutical firms are located in developed countries, but 80% of the pharmaceuticals are manufactured in developing countries. A phenomenon that may be unique to the United States is that we off-shore some of our diagnostic capabilities, primarily during out nighttime hours. Under the rubric of "Nighthawk," X-rays, including CT scans, are digitized and sent to Australia, Spain, and other countries during our nighttime hours. A diagnosis is made and sent back to the referring hospital in the US, usually within 30 minutes. I think an argument can be made that almost all of the issues that Friedman talks about in his book, apply to the field of medicine. Trauma care is a microcosm of medicine and uses most of the resources shared by other specialties. The trauma patient has to be identified and ambulances called, usually by 911 or similar numeric systems in other countries. The patient is transported to an emergency room, and if the injury is severe, admitted for acute care, which often requires surgery, intensive care, and ward care. When possible, the patient is discharged home, but is often sent to a rehabilitation facility or a nursing home. To improve trauma care and outcome, surgeons have turned to the organization and system approach that has been so successful in military situations., Materials and Methods: An extensive review of the surgical and public health papers relating to trauma was carried out. This article is an inventory of how trauma systems are progressing in different countries and whether they are effective. Some of the pitfalls that globalization may bring are also discussed., Results and Conclusions: For the last 100 years, there has been gradual improvement in care of the civilian patients, as a system approach similar to the military care of injured patients has been introduced and matured. These systems include prehospital care, acute care, rehabilitation; ideally, using a public health approach, preventive components are also utilized. Research is another component that is key in improving patient outcomes.

The crisis in patient access to emergency surgical care as articulated by the Division of Advocacy and Health Policy of the American College of Surgeons is real. It is most likely that in the next 10 years this crisis will only get worse. At last count, there were 190 Level I trauma centers in the United States, of which, 48 have been verified by the American College of Surgeons. There are 263 Level II centers, of which, 51 have been verified. These centers provide approximately 50% of tertiary trauma care in the United States. The data is overwhelming that they do make a difference in outcome. Neurosurgical professional societies participated with the American College of Surgeons in developing the recent white paper from the Division of Advocacy and Health Policy. It is now time to solve the crisis, and neurosurgery should step up to the plate and provide coverage for Level I and Level II trauma centers at a reasonable cost. Furthermore, neurosurgery should be involved in continuing to help to solve the crisis that currently exists. If neurosurgery cannot or does not want to provide coverage, they should let other surgeons provide coverage.

In summary, the current U.S. health care system is broken. It is a high-cost, mediocre system. Access is a major problem. Pharmaceutical costs are out of control. Malpractice insurance costs are egregious, and there is no question that solutions will be difficult. In my opinion, leadership will not come from the Executive Branch of our government, and Congress is so partisan at the present time that the elected officials are simply impotent in dealing with health care and other problems. Until recently, organized medicine has not provided any solutions either. I believe the American College of Surgeons has been taking a leadership role. However, long-term solutions will require more than tweaking the current dysfunctional system.

Background: Our goal was to use a hospital population-based data set that was a sample of all injured patients admitted to a hospital in the United States to develop universal measures of outcome and processes of care., Methods: Patients with a primary discharge diagnosis of injury (ICD-9 800 to 959) in the HCUP/Nationwide Inpatient Sample for the years 1995 to 2000 were used to estimate the annual number of hospitalized injured patients. Using census data, we calculated age- and sex- adjusted average annual incidence rates for four census regions in the United States: Northeast, Midwest, South and West. Outcomes measured were annual rates per million populations of hospitalization rate, death rate, and potentially ineffective care (PIC) rate defined as >28 days of hospitalization ending in death. Length of stay (LOS) was calculated as total number of days annually hospitalized for injury for census regions per million populations., Results: Incidence rates per million populations and 95% confidence intervals for rate of hospitalizations for injury were: Northeast, 5596 (5338-5853); Midwest, 5516 (5316-5716); South, 5639 (5410-5869); West, 5307 (5071-5543). Incidence rates per million populations and 95% confidence intervals for rate of in-hospital deaths were: Northeast, 129 (119-139); Midwest, 131 (122-139); South, 141 (129-152); West, 114 (106-123). Incidence rates per million populations and 95% confidence intervals for rate of PIC were: Northeast, 11 (10-13); Midwest, 5 (4-5); South, 6 (5-7); West, 4 (3-4). Incidence rates per million populations and 95% confidence intervals for hospital days were: Northeast, 34 (32-36); Midwest, 30 (28-31); South, 30 (29-32); West, 26 (24-27)., Conclusion: Regional differences in outcomes and processes of care for hospitalized injured patients exist and may be influenced by hospital characteristics and region of the country. Research to identify the factors that cause these hospital and regional variations is needed. These observations suggest that to develop a uniform standard for quality of care, it will be essential to have valid and robust hospital population-based measures.

In the introduction, I posed several questions that were issues/controversies. The answers will probably be interpreted as equally controversial. I do not believe there is strong evidence that the incidence of liver injuries has increased. Diagnostic modalities have contributed to this seeming increase, as well as population increases and the concentration of severe liver injuries in trauma centers, now present in 35 states. I believe there are more blunt injuries now, relative to penetrating injuries. The peak of penetrating injuries occurred in the 1970s and 1980s and lasted almost 2 decades. I believe some authors are overly enthusiastic for nonoperative management. I am particularly critical of authors who do not include all components of the surgical armamentarium into their treatment of severe liver injuries. I also believe that the complications following nonoperative management are currently unacceptable, as documented in the references. I have shared with you the strategies for operative management, but there are equally good or better strategies in the surgical literature.

In summary, the incidence of BCI following blunt thoracic trauma patients has been reported between 20% and 76%, and no gold standard exists to diagnose BCI. Diagnostic tests should be limited to identify those patients who are at risk of developing cardiac complications as a result of BCI. Therapeutic interventions should be directed to treat the complications of BCI. Finally, the prognosis and outcome of BCI patients is encouraging

Background: In population-based studies, the quality of care delivered to injured patients is commonly judged by hospital survival rates. Evidence suggests injured patients surviving hospitalization remain at risk for death from their injuries after discharge. Patient characteristics associated with higher risk of late death are not completely defined., Methods: The National Death Index is a government-maintained database composed of death certificate records from all decedents in the United States. Patients in a trauma registry were cross-linked to decedents in National Death Index on the basis of Social Security number or other unique identifiers. Decedents' time from injury to death was calculated. Logistic regression models were fit to those who died at hospital discharge and those who died in the first year after injury., Results: Among 4293 hospitalized injured patients recorded in a trauma registry, 157 died during hospitalization. Among the 4136 discharged alive, 91 patients were linked to death certificate records filed in the 365 days after discharge. Patients over the age of 65 had a 15-fold greater odds of death than younger patients., Conclusion: Trauma registry data cross-linked to vital statistics records is practicable. Patients who die in the year after injury differ from the traditional population used to evaluate quality of trauma care, and new standards are needed that evaluate long-term survival.

Background: S-nitrosocysteine is a carrier form of nitric oxide that can be delivered intravenously. S-nitrosocysteine is rapidly metabolized by plasma (half-life = 2-3 seconds), forming nitric oxide and cysteine. With its short half-life and potent vasodilatory properties, S-nitrosocysteine may be useful as a pulmonary vasodilating agent in cases of postoperative and chronic pulmonary hypertension., Objective: Our objective was to determine the hemodynamic properties of S-nitrosocysteine on the pulmonary and systemic circulations to assess its potential utility as a pulmonary vasodilatory agent., Methods: Eleven adult swine were anesthetized. Thermodilution (Swan-Ganz; Baxter International, Inc, Deerfield, Ill) and arterial catheters were inserted. Flow probes were placed around the coronary, renal, superior mesenteric, and iliac arteries. Incremental infusion doses of S-nitrosocysteine (5-80 nmol. kg(-1). min(-1)) were delivered into the right atrium. Cardiac output, right and left heart pressures, heart rate, Pao(2), and iliac, renal, coronary, and mesenteric blood flow rates were recorded at baseline and at each infusion dose of S-nitrosocysteine., Results: Low-dose S-nitrosocysteine infusion decreased mean pulmonary artery pressure (15%, P =.013) without a significant reduction in mean systemic artery pressure. Higher dose infusions produced further dose-dependent declines in pulmonary vascular resistance and measurable reductions in systemic vascular resistance (P =.01). At an S-nitrosocysteine dosage of 40 nmol. kg(-1). min(-1), there was a significant reduction in renal (P <.001) and mesenteric (P =.003) blood flow but no change in iliac (P >.2) or coronary (P >.2) blood flow. Cardiac output remained constant up to infusion rates of 40 nmol. kg(-1). min(-1) (P >.2). Doses higher than 5 nmol. kg(-1). min(-1) resulted in a substantial dose-dependent reduction in Pao(2) (P <.001), suggesting dilation of atelectatic areas of the lung., Conclusion: S-nitrosocysteine is a potent vasodilatory agent capable of overcoming the hypoxic vasoconstrictive response of the lung. Our results suggest it may prove useful as a pulmonary vasodilatory agent at low doses. Higher dose infusions reduce mean systemic pressure and lead to compensatory reductions in renal and mesenteric blood flow without a decrease in cardiac output.

We report a case of operative stabilization of an incompetent upper chest wall 6 years following flail chest. The indications for stabilization were chronic pain and dyspnea associated with rib malunion and loss of hemithorax volume. At operation, multiple pseudoarthroses were encountered and partial resection of ribs three and four was required. Malleable plates were used to bridge the gaps created by the resection and were secured in place with sternal wire. The patient reported a dramatic relief of symptoms and, at 18 months postoperatively, continues to work full-time on his cattle ranch essentially pain-free.

Since World War II, multiple changes have occurred in medicine that are now affecting academic health centers and department of surgery chairpersons. None of these changes by themselves were intended to adversely affect department of surgery chairpersons, but the sum total effect constitutes a negative external force. In addition, there are internal forces in the schools of medicine and university hospitals that may negatively affect department of surgery chairperson in fulfilling the stated goals of excellent patient care, teaching, and research. Many of the problems brought about by these negative forces cannot be solved by a single department chairperson. However, individual department chairs can contribute to the solution by returning to the values taught to them by the role models of their surgical training.

Introduction: The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA., Methods: Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge., Results: The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant., Conclusion: The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Until recently the development of systems for trauma care in the United States has been inextricably linked to wars. During the Revolutionary War trauma care was based on European trauma principles particularly those espoused by the Hunter brothers. Surgical procedures were limited mostly to soft tissue injuries and amputations. The American Civil War was remarkable because of the contributions that were made to the development of systems for trauma care. The shear magnitude of casualties required extensive infrastructure to support the surgeons at the battlefield and to care for the wounded. For the first time in an armed conflict, anaesthetics were used on a routine basis. Despite these major contributions, hospital gangrene was a terrible problem and was the cause of many mortalities. World War I and World War II were noteworthy because of the contributions made by surgeons in the use of blood. One of the major lessons of World War II was the reemphasis of how frequently lessons have to be relearned regarding the treatment and care of wounds. Between the Korean Conflict and the Vietnam War the discovery was made of the tremendous fluid shifts into the cell after severe hemorrhagic shock. As a consequence, the treatment of patients with shock was altered during the Vietnam Conflict, which resulted in better outcomes and less renal failure. The first trauma centers for civilians were started in the United States in 1966. Since 1988 the number of states with mature trauma systems has expanded from two to 35. During the same period, many studies have documented the efficacy of trauma systems in reducing unnecessary mortality and disability.

Hypothesis: The management of geriatric injured patients admitted to a trauma center includes the selective decision to provide comfort care only, including withdrawal of therapy, and a choice to not use full application of standard therapies. The decision makers in this process include multiple individuals in addition to the patient., Design: Retrospective review of documentation by 2 blinded reviewers of the cohort of patients over a recent 5-year period (1993-1997)., Setting: Trauma service of a level I trauma center., Patients: A convenience sample of patients aged 65 years and older who died, and whose medical record was available for review., Main Outcome Measures: Patients were categorized as having withdrawal of therapy, and documentation in the medical record of who made the assessment decisions and recommendations, and to what extent the processes of care were documented., Results: Among 87 geriatric trauma patients who died, 47 had documentation interpreted as indicating a decision was made to withdraw therapy. In only a few circumstances was the patient capable of actively participating in these decisions. The other individuals involved in recommendations for withdrawal of therapy were, in order of prevalence, the treating trauma surgeon, family members (as proxy reporting the patient's preferences), or a second physician. Documentation regarding the end-of-life decisions was often fragmentary, and in some cases ambiguous. Copies of legal advance directives were rarely available in the medical record, and ethics committee participation was used only once., Conclusions: Withdrawal of therapy is a common event in the terminal care of geriatric injured patients. The process for reaching a decision regarding withdrawal of therapy is complex because in most circumstances patients' injuries preclude their full participation. Standards for documentation of essential information, including patients' preferences and decision-making ability, should be developed to improve the process and assist with recording these complicated decisions that often occur over several days of discussion.

The purpose of the present study was to determine whether human gastric mucous epithelial cells express a functional Ca2+-sensing receptor (CaR). Human gastric mucous epithelial cells were isolated from surgical tissues and cultured on glass coverslips, plastic dishes, or porous membrane filters. Cell growth was assessed by the MTT assay, CaR localization was detected by immunohistochemistry and confocal microscopy, CaR protein expression was assessed by Western immunoblotting, and intracellular Ca2+ concentration ([Ca2+]i) was determined by fura 2 spectrofluorometry. In paraffin sections of whole stomach, we found strong CaR immunohistochemical staining at the basolateral membrane, with weak CaR-staining at the apical membrane in mucous epithelial cells. Confocal microscopy of human gastric mucous epithelial cell cultures showed abundant CaR immunofluorescence at the basolateral membrane and little to no CaR immunoreactivity at the apical membrane. Western immunoblot detection of CaR protein in cell culture lysates showed two significant immunoreactive bands of 140 and 120 kDa. Addition of extracellular Ca2+ to preconfluent cultures of human gastric mucous epithelial cells produced a significant proliferative response. Changes in [Ca2+]i were also observed in response to graded doses of extracellular Ca2+ and Gd3+. The phospholipase C inhibitor U-73122 specifically inhibited Gd3+-induced changes in [Ca2+]i in the gastric mucous epithelial cell cultures. In conclusion, we have identified the localization of a functional CaR in human gastric mucous epithelial cells.