J Trauma
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The core of general surgery supports multiple disciplines, each of which entails similar operative care for different diseases. The purpose of this study was to compare variations of practice patterns of four general surgeons to define the general surgical core that each shared in common, and to determine the effect of subspecialization in surgical critical care on the scope of practice and efficiency of revenue production. ⋯ These data demonstrate that subspecialization in surgical critical care provides valid additional earning capacity to surgical practitioners. Reimbursement is at least as good as for traditional operative care, and fees generated can actually exceed revenue from operative care. With impending decreases in global reimbursement, and attempts to unbundle operative fees, this additional capability becomes an important consideration in potential career choice, as well as a major component in the fiscal stability of trauma programs.
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Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. ⋯ No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.
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The American College of Surgeons Committee on Trauma has suggested triage criteria for the immediate attendance of a trauma surgeon to an injured patient in the emergency department. This study validates the accuracy of these criteria in identifying high-risk trauma patients and assesses the impact of trauma surgeon response time. ⋯ Trauma patients meeting the triage criteria proposed by the American College of Surgeons Committee on Trauma have more severe injuries, a higher mortality rate, and longer hospital and ICU stays than control patients. SBP < 90 mm Hg, ETI, and GSW are predictive of urgent operating room use and ICU admission. A significantly higher mortality rate is associated with SBP < 90 mm Hg, ETI, and GCS score < 8. Incorporating these criteria into trauma center triage rules to identify high-risk injured patients is warranted. However, trauma surgeon response time < or = 15 minutes was not associated with improved patient outcome, and optimal response time remains uncertain.
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After trauma and hemorrhagic shock (T/HS), mesenteric lymph (ML) activates polymorphonuclear neutrophils (PMNs), injures endothelial cells (ECs), and predisposes to lung injury. The involved mediators, however, are unknown. We studied the ability of aqueous (AQ) and lipid (LIP) extracts of rat T/HS ML to activate PMNs and injure ECs. ⋯ T/HS mesenteric lymph contains multiple biologically active mediators. Both AQ and LIP extracts of T/HS lymph are toxic to human umbilical vein endothelial cells, with AQ more active than LIP. Only AQ T/HS lymph activates rat PMNs, although LIP rat lymph extract activates human PMNs. These findings demonstrate the complex nature of gut lymph-derived biologic factors as well as species-specific differences on PMN and EC physiology. Therapies directed at any one specific molecule or mediator are therefore unlikely to be successful.
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Fluid resuscitation administered before hemorrhage control for trauma victims sustaining penetrating abdominal injury is controversial. Our objective was to evaluate intra-abdominal blood loss and hemodynamic and metabolic effects of no fluid resuscitation, small-volume 7.5% sodium chloride/6% dextran-70 (HSD), or large-volume lactated Ringer's (LR) solution during intra-abdominal vascular injury and uncontrolled hemorrhage. ⋯ Fluid resuscitation with either large-volume LR solution or small-volume HSD, during uncontrolled hemorrhage from intra-abdominal vascular injury, produced hemodynamic and metabolic benefits, without additional blood loss, whereas no fluid resuscitation was associated with sustained low cardiac output and hypotension.