The American surgeon
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Hollow visceral injuries are far less common in blunt abdominal trauma than in penetrating abdominal trauma. From 1982 through 1993 we treated 50 patients with 57 major blunt injuries to the gut, defined as perforation, transection, or devascularization. Thirty-two patients (64%) were injured in motor vehicle collisions. ⋯ Injuries to the abdominal hollow viscera are unusual following blunt trauma, but are the result of very high energy truncal trauma, and are associated with multiple additional injuries. Most alert patients had physical findings suggestive of peritoneal irritation, but when diagnostic testing was necessary, peritoneal lavage was superior to computed tomography scanning (false negatives = 6.7% versus 36%, respectively; P < 0.05). A high index of suspicion is necessary to avoid diagnostic delays that can lead to severe complications and death.
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Surgical residency training should be changed to provide much needed surgical manpower to rural America. Small-town and rural surgery practices demand that surgeons see and treat their patients as people. If rural surgery could become a real option for young surgeons, it could bring about a change in the sometimes adversarial relationship between patients and their physicians.
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The American surgeon · Dec 1994
Case ReportsMissile embolization revisited: a rationale for selective management.
Embolization of missiles is an unusual presentation of penetrating trauma. Often the management of these injuries may be quite challenging, and selective management continues to be subject to controversy. ⋯ It also recommends operative intervention for symptomatic venous emboli to the heart and pulmonary circulation. Nonoperative management may be considered in patients with asymptomatic emboli to the right heart or the cerebral and pulmonary circulation.
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The American surgeon · Dec 1994
Case ReportsRapid right atrial cannulation for fluid infusion during resuscitative emergency department thoracotomy.
A simple rapid technique for cannulating the right atrium during a resuscitative Emergency Department thoracotomy (EDT) for exsanguinating trauma is described. Following the thoracotomy and pericardiotomy, an ordinary Foley urinary bladder balloon catheter is inserted into the right atrial appendage for rapid, large volume normothermic blood and fluid infusion. A method for simplifying this maneuver, as well as the potential complications of over-resuscitation with myocardial distention and fluid overload, myocardial cooling, air embolism, and tricuspid valve occlusion are discussed. We recognize that this technique is radical and applicable to only a limited subset of severely injured patients, for example, victims of non-cardiac penetrating trauma who arrive at the hospital moribund or who arrest in the emergency center.
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Cancelled elective surgical cases result in wasted operating room time and additional hospital expense. We prospectively reviewed 1063 scheduled cases that resulted in 184 (17%) cancellations. ⋯ Lack of medical clearance and outpatient "no shows" accounted for the majority of avoidable cancellations. Case cancellations can be decreased by improved preoperative patient evaluation, improved communication between physician and patient, and modified schedule design.