Search

Background: The Rural Trauma Team Development Course (RTTDC) is designed to help rural hospitals better organize and manage trauma patients with limited resources. Although RTTDC is well-established, limited literature exists regarding improvement in the overall objectives for which the course was designed. The aim of this study was to analyze the goals of RTTDC, hypothesizing improvements in course objectives after course completion., Methods: This was a prospective, observational study from 2015 through 2021. All hospitals completing the RTTDC led by our Level 1, academic trauma hospital were included. Our institutional database was queried for individual patient data. Cohorts were delineated before and after RTTDC was provided to the rural hospital. Basic demographics were obtained. Outcomes of interest included: Emergency Department (ED) dwell time, decision time to transfer, number of total images/computed tomography scans obtained, and mortality. Chi square and non-parametric median test were used. Significance was set at P < .05., Results: Sixteen rural hospitals were included with a total of 472 patients transferred (240 before and 232 after). Patient demographics were similar before and after RTTDC. ED dwell time was significantly reduced by 64 min ( P = .003) and decision to transfer time was cut by 62 min ( P = .004) after RTTDC. Mean total radiographic images and CT scans were significantly reduced ( P < .001 and P = .002, respectively) after RTTDC. Mortality was unaffected by RTTDC completion ( P = .941)., Conclusion: The RTTDC demonstrates decreased ED dwell time, decision time to transfer, and number of radiographic images obtained prior to transfer. More rural hospitals should be offered this course., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This research was presented via podium presentation during the 36th Annual Eastern Association for the Surgery of Trauma Annual Scientific Assembly, Lake Buena Vista, FL on January 17th-21st. Dr Zachary Bauman is a paid educational consultant for KLS-Martin, Zimmer-Biomet, Smith & Nephew, and Atricure.

Background: In adhesive small bowel obstructions (ASBOs), literature has shown that passage of a water-soluble contrast challenge at either 8 hours or 24 hours is predictive of successful non-operative management (NOM) for an ASBO, but the long-term outcomes between these two groups are unknown. We hypothesized that patients who require longer transit times to the colon have a higher one-year recidivism of ASBO., Methods: This was a 4-year review of patients with presumed ASBO undergoing successful NOM. Those requiring operation or those with an SBO due to something other than adhesions were excluded. Patients were divided into two groups (8 hour and 24 hour) based on when contrast reached their right colon. Patients were followed for one year to determine ASBO recurrence., Results: 137 patients underwent NOM; 112 in the 8-hour group and 25 in the 24-hour group. One-year recurrence rate was 21.4% in the 8-hour group and 40% in the 24-hour group ( P = 0.05). The median time to recurrence was 113 days in the 8-hour group and 13 days in the 24-hour group ( P = 0.02). Of those who recurred in the 24-hour group, 60% recurred within 30 days ( P = 0.01). On univariable analysis, first-time ASBO and 24-hour transit time were risk factors for recurrence., Conclusions: Adhesive small bowel obstruction patients undergoing NOM in the 24-hour group had a recurrence rate nearly twice that of patients in the 8-hour group and may benefit from an operative exploration during the index hospitalization at the 8-hour mark of a water-soluble contrast challenge, especially if experiencing a first-time ASBO., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Surgeons care deeply about their patients, their patient's surgical outcomes, and their fund of knowledge as it relates to disease, treatment options, and risk is remarkable. Unfortunately, surgical patients' values, hopes, fears, and unacceptable levels of suffering are rarely elicited and addressed while constructing surgical treatment plans, even when the stakes are high. How can surgeons bring all their experience, education, and expertise to bear in a patient-centered manner amidst uncertainty? Surgeons typically emulate mentors who either employed a solely informative, facilitative, or directive/paternalistic approach to decision-making. These 3 styles fail to simultaneously address: (1) what matters most to patients and (2) the surgeon's expertise. Since communication in each of these 3 approaches is unidirectional, and the decisional power locus is imbalanced, they are unshared, nonpartnering, and-perhaps surprisingly-not patient-centered. Patient-centered, collaborative shared decision-making (SDM) approaches align with palliative care principles and are rarely employed, taught, or modeled. Furthermore, nonpartnering approaches to surgical decision-making are often laden with unintended consequences, such as patient and family suffering and the suffering of surgeons. We present the high-risk case of an abdominal gunshot wound in a morbidly obese man, which was complicated by 3 enterocutaneous fistulae and a loss of abdominal wall integrity, where ongoing empathic, partnering SDM dialogue is enabling a patient-centered and value-concordant care plan. The authors invite you to virtually journey with us as this case unfolds, as the impending surgical decisions are substantial and weighty. Uncertainty and risks appear at every turn-providing additional challenges to overcome.