The American surgeon
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The American surgeon · Jun 2006
Care of critically ill surgical patients using the 80-hour Accreditation Council of Graduate Medical Education work-week guidelines: a survey of current strategies.
As a result of the recently mandated work-hour restrictions, it has become more difficult to provide 24-hour intensive care unit (ICU) in-house coverage by the general surgical residents. To assess the current state of providing appropriate continuous care to surgical critical care patients during the era of resident work-hour constraints, a national survey was conducted by the Association of Program Directors of Surgery. The results revealed that 37 per cent of programs surveyed have residents other than general surgery housestaff providing cross-coverage and writing orders for surgical ICU patients. ⋯ In addition, 24 per cent used a "night-float" system in an attempt to maintain continuous care, yet still adhere to the mandated guidelines. In conclusion, our survey found multiple strategies, including the use of physician extenders, a "night-float" system, and the use of nongeneral surgical residents in an attempt to provide continuous coverage for surgical ICU patients. The overall outcome of these new strategies still needs to be assessed before any beneficial results can be demonstrated.
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The American surgeon · Jun 2006
Recurrent asystole resulting from high cervical spinal cord injuries.
Cervical spinal cord injury is a highly morbid condition frequently associated with cardiovascular instability. This instability may include bradyarrhythmias, as well as hypotension, and usually resolves in a relatively short time. However, over a 3-year period (January 2003-December, 2005), 5 of 30 patients with complete cervical spinal cord injuries seen at our Level I trauma center required placement of permanent cardiac pacemakers for recurrent bradycardia/asystolic events. Strong consideration for pacemaker placement should be given for those spinal cord-injured patients with symptomatic bradyarrhythmic events still occurring 2 weeks after injury.
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The American surgeon · Jun 2006
Case ReportsIndependent lung ventilation in the management of traumatic bronchopleural fistula.
Independent lung ventilation (ILV) is a technique for managing patients with unilateral lung disease or injury who have failed conventional mechanical ventilation. A 20-year-old man sustained severe ballistic injuries to the chest and abdomen. Damage control laparotomy controlled the patient's initial hemorrhage, however, an evolving cavitary pulmonary lesion subsequently developed into a high-volume bronchopleural fistula. ⋯ Synchronous ILV was initiated using a double-lumen endotracheal tube and two ventilators titrated to optimize the patient's oxygenation and ventilation and minimize ventilator-induced lung injury. Intensive ILV over the next 17 days resulted in recruitment of the atelectatic right lung, resolution of the bronchopleural fistula, and significant improvement in oxygenation and pulmonary compliance. This appears to be the longest reported use of ILV for traumatic lung injury.
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Adrenal insufficiency during sepsis is well documented. The association between hemorrhagic shock and adrenal insufficiency is unclear and may be related to ischemia, necrosis, or resuscitation. This study was designed to determine the incidence of relative adrenal insufficiency in hemorrhagic shock. ⋯ Two of the 15 patients died. Relative adrenal insufficiency appears to be common in hemorrhagic shock. Future research is warranted to elucidate the pathophysiology, as well as to prospectively determine which patients may benefit from steroid replacement.
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The American surgeon · May 2006
Comparative StudyAcute appendicitis: is there a difference between children and adults?
Historically, the lack of classic symptoms and delay in presentation make diagnosing acute appendicitis more difficult in children, resulting in a higher perforation rate. Despite this, the morbidity of acute appendicitis is usually lower in children. We evaluated the current differences in clinical presentation, diagnostic clues, and the outcomes of acute appendicitis between the two age groups. ⋯ A history of migratory pain together with physical findings and leukocytosis remain accurate diagnostic clues for children and adults. Perforation rate and morbidity in children is similar to those in adults. The outcomes of acute appendicitis in children are not associated with a delay in presentation or delay in diagnosis.