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Introduction In peacetime, it is challenging for Army Forward Resuscitative Surgical Teams (FRST) to maintain combat readiness as trauma represents Methods Over a 3-year period, all FRSTs were surveyed at one civilian center. Results Six hundred and thirteen FRST soldiers were provided surveys and 609 responded (99.3%), including 499 (81.9%) non-physicians and 110 (18.1%) physicians/physician assistants. The non-physician group included 69% male with an average age of 34 ± 11 years and consisted of 224 AR (45%) and 275 AD (55%). Rank ranged from Private to Colonel with officers accounting for 41%. For AD vs. AR, combat experience was similar: 50% vs. 52% had ≥1 combat deployment, 52% vs. 60% peri-deployment patient load was trauma-related, and 31% vs. 32% had ≥40 patient contacts during most recent deployment (all P > .15). However, medical experience differed for AD and AR: 18% vs. 29% had >15 years of experience in practice and 4% vs. 17% spent >50% of their time treating critically injured patients (all P Conclusions This is the first study of clinical practice patterns in AD vs. AR, non-physician members of Army FRSTs. In concordance with previous studies of military surgeons, FRST non-physicians seem to be lacking clinical experience as well. To maintain readiness and to provide optimal care for our injured warriors, the entire FRST, not just individuals, should embed within civilian centers.

A significant proportion of readmissions occurs at a different hospital than the index admission, and is thus missed by current quality metrics. No study has examined all-hospital adult 30-day readmission rates, including different hospitals, following burn injury across the United States. The purpose of this study was to evaluate nationwide readmission rates, potential risk factors, and ultimately the burden of burn injury readmission, including readmission to a different hospital. The 2010-2014 Nationwide Readmissions Database was queried for patients admitted for burn. Multivariate logistic regression identified risk factors and associated cost for 30-day readmission at index and different hospitals. There were 94,759 patients admitted during the study period, with 7.4% (n = 7000) readmitted and of those, 29.2% (n = 2047) readmitted to a different hospital. The most common reason for readmission was infection (29.4% [n = 1990]). Risk factors for unplanned 30-day readmission to any hospital included burn of lower limbs (odds ratio [OR] 1.29, [1.21-1.37], P < .01), third degree burns (OR 1.31, [1.22-1.41], P < .01), Charlson Comorbidity Index ≥2 (OR 1.48, [1.37-1.60], P < .01), depression (OR 1.30, [1.19-1.41], P < .01), and psychoses (OR 1.53, [1.40-1.67], P < .01). Risk factors unique to readmission to a different hospital included: length of stay greater than 7 days (OR 2.07, [1.78-2.40], P < 0.01), and initial admission to a metropolitan teaching hospital (OR 1.50, [1.26-1.78], P < .01). Previously unreported, one in three burn readmissions nationally occur at a different hospital, have unique risk factors, and are costlier. Current hospital benchmarking underestimates readmission by failing to capture this unique subpopulation.

Electrocutions during tree trimming or fruit harvesting are occasionally reported in the public media, but the actual incidence is unknown. Some fruit trees (eg, mango and avocado) can exceed 30 feet, with dense foliage concealing the fruit and overlying power lines so burns associated with harvesting these fruits are often exacerbated with falls. However, there are limited data on this subject. To fill this gap, we provide some of the first information on this unique injury pattern. All electrocutions from 2013 to 2018 were retrospectively reviewed at an ABA-verified burn center. Demographics, injury patterns, and complications were analyzed. Of 97 electrocutions, 22 (23%) were associated with fruit procurement. This population was aged 43 ± 14 years, 95% (n = 21) male, injury severity score of 15 ± 13, and total body surface area burned 4% [1%-9%]. Third-degree burns were present in 36% (n = 8). ICU admission was required in 59% (n = 13) and 39% of the survivors required operative interventions for the burn. Compartment syndrome occurred in 18% (n = 4) and 14% (n = 3) patients required amputations. Falls complicated the care in 50% (n = 11), with associated head, chest, and/or extremity trauma. Mortality was 32% (n = 7), with three patients presenting dead on arrival. All but 3 injuries occurred between June and December, coinciding with mango and avocado season. Electrocution during fruit picking is a seasonal injury often exacerbated by falls. Management is challenging, and favorable outcome depends on recognition of the complexity of the polytrauma.

Objectives Entrapment of trauma patients in motor vehicle and other accidents is common. Frequently, Emergency Medical Services (EMS) personnel and firefighters are able to free the patient and initiate rapid transport to trauma centers. In rare circumstances, severe torso and extremity injuries combined with major entrapment may require complex rescue operations. These trauma patients spend the “Golden Hour” at the scene under difficult conditions. The objective of this review is to evaluate the role of the trauma surgeon leading the care at the scene of critically injured and entrapped trauma patients with possible need for surgical interventions. Materials and methods A 10-year review of all trauma surgeon to scene activations between 2005 and 2014 at the Ryder Trauma Center, an urban ACS Level 1 trauma center, was performed. An analysis of the trauma registry, individual cases, and surgical interventions was conducted. Results The University of Miami/Jackson Memorial Hospital (UM/JMH) Ryder Trauma Center and Miami Dade Fire Rescue have an established program in place for trauma surgeon to scene activations. During the study period, the on-call trauma surgeon was activated six times and traveled to the scene by air rescue helicopter four times, by ground in 1 case and in 1 case the patient expired before takeoff. One patient required on-scene amputation of an entrapped non-salvageable upper extremity. Two patients required on-scene amputation of bilateral lower mangled, entrapped extremities. One patient required a localized limb preserving surgical procedure to free him from entrapment. The incidence was 0.016% of 36,872 trauma alert activated patients evaluated at Ryder Trauma Center during the study period. Hemorrhagic shock, associated injuries, and long scene times were present in all patients. The survival of treated patients was 80%. Conclusion The need for on-scene amputations of nonsalvable extremities in entrapped trauma patients is rare. Experienced trauma surgeons should evaluate these patients and decide which interventions are necessary. All efforts should be made to salvage the limb. However, if the entrapped extremity appears nonsalvageable and the patient is in profound life-threatening shock requiring rapid transport, field amputation may be required. Policies, safety training and gear, supply kits, and partnerships with EMS are needed. How to cite this article Pust GD, Grossman MM, Shatz DV, Habib F, Pizano L, Zakrison TL, Marttos A, Ruiz G, Ginzburg E, Namias N. The Rare Requirement of On-scene Extremity Amputations in the Entrapped Trauma Patient. Panam J Trauma Crit Care Emerg Surg 2016;5(2):93-100.

We aimed to determine the association between environmental exposure to carbapenem-resistant Acinetobacter baumannii and the subsequent risk of acquiring this organism. Patients exposed to a contaminated hospital environment had 2.77 times the risk of acquiring carbapenem-resistant A. baumannii than did unexposed patients (relative risk, 2.77 [95% confidence interval, 1.50–5.13]; P = .002).

Importance The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. Objective To determine whether favorable evaluations are associated with ABSITE performance. Design, Setting, and Participants Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. Exposures Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. Main Outcomes and Measures Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. Results The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile ( r 2 = 0.014; P = .15), percentage correct unadjusted for PGY level ( r 2 = 0.019; P = .09), or percentage correct adjusted for PGY level ( r 2 = 0.429; P = .91). Conclusions and Relevance Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.

Objective The objective of this study was to review the outcome of nonoperative treatment for penetrating internal jugular vein (IJ) injuries in a continuous series of prospectively identified, hemodynamically stable patients. Methods All penetrating neck injuries assessed from February 1, 2004, to August 31, 2004, were prospectively identified. Patients without an indication for urgent neck exploration underwent diagnostic assessment with multislice helical computed tomographic angiography with or without vascular ultrasonography. All IJ injuries with no other indication for surgical exploration were treated nonoperatively. All patients were discharged home and followed up for a minimum of 1 week to document outcomes. Results From 51 neck injuries penetrating the platysma, 7 required urgent neck exploration, during which 2 IJ injuries were ligated. Forty-four patients underwent multislice helical computed tomographic angiography. Eight IJ injuries (two gunshot wounds and six stab wounds) with no other indication for neck exploration were identified and managed nonoperatively. One external wound was in zone 1, five were in zone 2, one was in zone 3, and one traversed all three zones. The average length of stay was 4.5 days. At follow-up, ranging from 1 week to 5 months, all patients were asymptomatic, and no patient required delayed operation for IJ injury. Conclusions In hemodynamically stable patients with no other indication for exploration, the nonoperative management of penetrating jugular vein injuries should be considered as a safe alternative.

Introduction Ureteral trauma is rare, accounting for less than 1% of all urologic traumas. However, a missed ureteral injury can result in significant morbidity and mortality. The purpose of this article is to review the literature since 1961 with the primary objective to present the largest medical literature review, to date, regarding ureteral trauma. Several anatomic and physiologic considerations are paramount regarding ureteral injuries management. Literature review Eighty-one articles pertaining to traumatic ureteral injuries were reviewed. Data from these studies were compiled and analyzed. The majority of the study population was young males. The proximal ureter was the most frequently injured portion. Associated injuries were present in 90.4% of patients. Admission urinalysis demonstrated hematuria in only 44.4% patients. Intravenous ureterogram (IVU) failed to diagnose ureteral injuries either upon admission or in the operating room in 42.8% of cases. Ureteroureterostomy, with or without indwelling stent, was the surgical procedure of choice for both trauma surgeons and urologists (59%). Complications occurred in 36.2% of cases. The mortality rate was 17%. Conclusion The mechanism for ureteral injuries in adults is more commonly penetrating than blunt. The upper third of the ureter is more often injured than the middle and lower thirds. Associated injuries are frequently present. CT scan and retrograde pyelography accurately identify ureteral injuries when performed together. Ureteroureterostomy, with or without indwelling stent, is the surgical procedure of choice of both trauma surgeons and urologists alike. Delay in diagnosis is correlated with a poor prognosis.