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Many trauma patients currently transferred from rural and community hospitals (RCH) to Level I trauma centers (LITC) for trauma surgery evaluation may instead be appropriate for immediate discharge or admission to the local facility after evaluation by a trauma and acute care surgery (TACS) surgeon. Unnecessary use of resources occurs with current practice. We aimed to demonstrate the feasibility and acceptance of a teletrauma surgery consultation service between LITC and RCH.LITC TACS surgeons provided telehealth consults on trauma patients from 3 local RCHs. After consultation, appropriate patients were transferred to LITC; selected patients remained at or were discharged from RCH. Participating TACS surgeons and RCH physicians were surveyed.A total of 28 patients met inclusion criteria during the 5-month pilot phase, with 7 excluded due to workflow issues. The mean ± SD age was 63 ± 17 years. Of 21 patients, 7 had intracranial hemorrhage; 12 had rib fractures. The mean ± SD Injury Severity Score was 8.1 ± 4.0). A total of 6 patients were discharged from RCH, 4 admitted to RCH hospitalist service, 2 transferred to a LITC emergency room, and 9 transferred to LITC as direct admission. There was one 30-day readmission and no missed injuries or complications, or deaths. RCH providers were highly satisfied with the teletrauma surgery consultation service, TACS surgeons, and equipment used. Mental demand and effort of consulting TACS surgeons decreased significantly as the consult number increased.Teletrauma surgery consultation involving 3 RCH within our system is feasible and acceptable. A total of 10 transfers and 19 emergency department visits were avoided. There was favorable acceptance by RCH providers and TACS surgeons.

INTRODUCTION: As NASA and private spaceflight companies push forward with plans for missions to cis-lunar and interplanetary space, the risk of surgical emergency increases. At latencies above 500 ms, telesurgery is not likely to be successful, so near-real-time telementoring is a more viable option. We examined the effect of a 700-ms time delay on the performance of first year surgical residents on a simulated task requiring significant feedback from a mentor in a pilot study.METHODS: A simulated surgical task requiring precision and accuracy with built-in error detection was used. Each resident underwent two trials, one with a mentor in the same room and one with the mentor using a teleconference with time delay. Outcomes measured included time to complete task, game pieces successfully removed, number of errors, and scores on the NASA Task Load Index by both mentor and operator. Data were analyzed using paired t-tests.RESULTS: The time delay group removed significantly fewer pieces successfully than the real time group (3.0 vs. 1.6, P = 0.02). There was no difference in the NASA Task Load Index (TLX) scores for the operators between the two groups, but the mentor reported significantly higher scores on Mental Demand (5.6 vs. 12.0, P = 0.04) and Effort (6.2 vs. 11.8, P = 0.05) during the time-delayed trials.DISCUSSION: A 750-ms time delay significantly degraded performance on the task. Though operator TLX scores were not affected, mentor TLX scores indicated significantly increased mental load. Telementoring is viable, but more onerous than in-person mentoring.Kamine TH, Smith BW, Fernandez GL. Impact of time delay on simulated operative video telementoring: a pilot study. Aerosp Med Hum Perform. 2022; 93(2):123–127.

Previous studies on helicopter emergency medical service (HEMS) pilots found a positive correlation among fatigue, nodding off in flight, and accidents. We sought to quantify the amount of sleepiness in HEMS pilots using the Epworth Sleepiness Scale (ESS).An anonymous survey was sent via the National EMS Pilots Association emergency medical services listserv including demographics, the ESS, and subjective effects of fatigue on flying. Statistical analyses were performed using the t-test and analysis of variance.Thirty-one surveys were returned. Twenty-one (65%) reported an ESS10, indicating excessive daytime sleepiness. Twelve (39%) reported nodding off in flight; 20 (65%) indicated that they should have refused to fly, but only 14 (45%) actually did. En route was the most likely phase of flight to be affected by fatigue (23 [74%]), whereas takeoff (2 [7%]) and landing (2 [7%]) were the least likely to be affected.Many HEMS pilots in this small study reported excessive daytime sleepiness. Most respondents indicated that they should have turned down a flight because of fatigue. More research is necessary to quantify the burden of fatigue among HEMS pilots.

Background Although physician health promotes retention to the profession and encourages higher-quality patient care, residents can face challenges seeking routine medical care. Erratic working hours, time constraints, easy access to informal health consultation, and a culture of self-reliance can deter help-seeking behavior. Despite national focus on physician burnout and efforts to promote wellness, little is known about the self-care habits of residents. The goal of this study was to evaluate the routine healthcare practices of resident physicians. Study Design A 44-question survey with questions on medical and psychiatric health was electronically distributed to 102 program directors in 20 New England teaching hospitals. Program directors were asked to forward the survey to current trainees. Results Two hundred and ninety-nine residents completed the survey. One-third of respondents reported not having a routine place for care (RPFC), and these residents had lower use of preventive health services. Thirty-eight percent of residents taking daily prescription medication did not have an RPFC. Compared with residents in family medicine, those in surgery, internal medicine, radiology, anesthesia, OB/GYN, and pediatrics were considerably more likely to lack an RPFC. Although two-thirds of respondents reported symptoms of depression, these residents were less likely to have been under the care of a mental health professional than those who did not report depression symptoms. Conclusions Despite a high prevalence of self-reported depression and prescription medication use, a significant proportion of surveyed resident physicians in New England do not seek mental health resources and lack consistent, routine healthcare. Resident health is vital to the mission of physician well-being and mitigating the escalating problem of burnout. Barriers to self-care and help-seeking behavior should be evaluated to promote sustainable behavior that will encourage a long professional career.

BACKGROUND: In helicopter critical care and emergency medical services (HEMS) transportation, organizations aim for efficiency of the dispatch process. Most HEMS organizations do not provide transport under instrument flight rules (IFR), due to equipment and training cost. Boston MedFlight (BMF) provides IFR HEMS transport. We set out to determine if response time of IFR transport was superior to ground transport.METHODS: A retrospective analysis of quality improvement data was performed. Data was collected by two observers sitting in the BMF control room in varying shifts. A process map of the dispatch process, from the dispatch call to the vehicle en route was developed. Critical points in the dispatch process were determined and a variety of time differences to determine the length of processes in the dispatch calculated. We compared median time differences between visual flight rules (VFR) flight and IFR flight, between IFR flight and ground transport, and between VFR and Ground for these points using a Mann-Whitney U-test.RESULTS: During the study collection period, 443 transports occurred, of which 109 transports happened while the observers were present: 37 ground, 57 VFR, and 15 IFR. Due to weather, six IFR transports were declined. The overall time from dispatch call to vehicle en route was significantly increased for IFR flights [median: 30 min:8 s (interquartile range 19:06–49:04)] over both VFR flights [11:36 (9:24–17:06); P vs. IFR: 0.001] and ground transports [9:39 (6:59–14.51); P vs. IFR: 0.001]. Most of this increase was accounted for by increases in the time from dispatch to crew acceptance, and from rotor start to vehicle en route.DISCUSSION: IFR conditions resulted in significantly increased dispatch times over both VFR flight and ground transport. The increase is likely a result of weather check, filing an IFR flight plan, and IFR release. Dispatch algorithms should be adjusted for this time delay of IFR transports.Kamine TH, Thomas L, Davis C, Cohen J. Critical care transport time differences between ground, helicopter VFR, and helicopter IFR transports. Aerosp Med Hum Perform. 2020; 91(2):98–101.

Author(s): Kamine, Tovy H.; Rembisz, Adam; Barron, Rebecca J.; Baldwin, Carey; Kromer, Mark | Abstract: Introduction: The COVID-19 pandemic has led to social distancing and decreased travel in the United States. The impact of these interventions on trauma and emergency general surgery patient volume has not yet been described.Methods: We compared trauma admissions and emergency general surgery (EGS) cases between February 1–April 14 from 2017-2020 in five two-week time periods. Data were compared across time periods with Poisson regression analysis.Results: There were significant decreases in overall trauma admissions (57.4% decrease, pl0.001); motor vehicle collisions (MVC) (80.5% decrease, pl0.001); and non-MVCs (45.1% decrease, pl0.001) from February–April 2020. We found no significant change in EGS cases (p = 0.70). Nor was there was a significant change in trauma cases in any other year 2017-2019.Conclusion: The COVID-19 pandemic’s burden of disease correlated with a significant decrease in trauma admissions, with MVCs experiencing a larger decrease than non-MVCs.

Objective Recent surgical education literature has focused on means of improving structured educational experience in residency, particularly in the context of limited working hours. In addition, prior studies have illustrated a void in training regarding leadership. Learning teams have been adopted in several medical schools with an aim to improve the educational experience. We instituted resident learning teams with a goal of improving resident education. Design In the 2015 to 2016 academic year, we implemented a team-based learning (TBL) system of 5 teams each led by 1 to 2 chief residents and containing an approximately equal number of residents from postgraduate year (PGY)1-4. The learning teams competed for points based on weekly quizzes, preparation of materials for resident teaching, and American Board of Surgery In-Training Exam (ABSITE) scores. After a full year of TBL, residents were surveyed on their view of the learning teams with respect to the educational experience in the residency with a series of Likert-type questions. Median ABSITE scores of categorical interns were compared between the 3 years after the implementation of the learning teams and the 4 years prior with a Mann-Whitney U test. Setting Beth Israel Deaconess Medical Center, Boston, MA; Tertiary Care Center. Participants All residents from 2011 to 2018. Results After TBL implementation, median ABSITE percentile scores of PGY2-5 residents increased (35-44, p = 0.04). PGY1 scores were not significantly changed. After TBL implementation, a majority of residents agreed or strongly agreed that they studied more consistently, felt more prepared for the ABSITE, were more prepared for resident school, learned more in resident school, and that the learning teams improved the educational experience of the residency. Conclusions Learning teams subjectively improved the educational experience in our residency and engaged residents in studying and participating. In addition, PGY2-5 ABSITE scores were significantly improved. Learning teams are a program that can be easily adopted by surgical residencies elsewhere.

Background On July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) eliminated 30-hour call in an attempt to improve resident wakefulness. We surveyed interns on the Newton Wellesley Hospital (NWH) surgery service before and after the transition from Q4 overnight call to a night float schedule. Methods For 15 weeks, interns completed weekly surveys including the Epworth Sleepiness Scale (ESS). The service changed to a night float schedule after 3 weeks (ie, first to 3–4 and then to 6 nights in a row). Results The average ESS score rose from 9.8 ± 5.2 to 14.9 ± 3.1 and 14.4 ± 4.5 ( P = .042) on the 3/4 and 6/1 schedules, respectively. Interns were more likely to be abnormally tired on either night float schedule (relative risk=2.86; 95% confidence interval, 1.17–6.97, P = .029). Conclusions The new ACGME work hours increased the ESS scores among interns at NWH and caused interns to be more tired than interns on the Q4 schedule. This is likely caused by the multiple nights of poor sleep without a post-call day to make up sleep.

Laparoscopy has emerged as an alternative to laparotomy in select trauma patients. In animal models, increasing abdominal pressure is associated with an increase in intrathoracic and intracranial pressures. We conducted a prospective trial of human subjects who underwent laparoscopic-assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures. Ten patients undergoing lap VPS were recruited. Abdominal insufflation was performed using CO2 to 0, 8, 10, 12 and 15 mmHg. ICP was measured through the ventricular catheter simultaneously with insufflation and with desufflation using a manometer. Peak inspiratory pressures (PIP) were measured through the endotracheal tube. Blood pressure was measured using a noninvasive blood pressure cuff. End-tidal CO2 (ETCO2) was measured for each set of abdominal pressure level. Pressure measurements from all points of insufflation were compared using a two-way ANOVA with a post hoc Bonferroni test. Mean changes in pressures were compared using t test. ICP and PIP increased significantly with increasing abdominal pressure (both p

Objective To determine how the new 2011 Accreditation Council for Graduate Medical Education work hours affected case volume across postgraduate year (PGY) levels of surgical trainees. Design Retrospective review of Accreditation Council for Graduate Medical Education case logs of surgical residents at Beth Israel Deaconess Medical Center from 2006 to 2013. Setting Tertiary care center. Participants All categorical surgical residents from 2006 to 2013. Results PGY-1 cases decreased from 139 (122.25-172.5) to 111.5 (102.25-117.5) (p = 0.003). PGY-2 case volume decreased as well from 162 (151.5-192) to 126 (95.5-173) (p = 0.011). Only 45% of PGY-2 residents performed more than 250 major cases after the work hours changed compared with 82% of residents before 2011. PGY-3 cases increased from 263 (215-309) to 309 (282-340) (p = 0.0038). Cases performed by PGY-4 and PGY-5 residents were not statistically different. Total cases performed by graduating chiefs, however, has increased from 987 (848.5-1050) to 1090 (1033-1145) (p = 0.0006). Conclusions Intern and PGY-2 case volume has declined at our institution as new work-hour regulations took effect in 2011. However, PGY-3 case volume increased significantly, and graduating chiefs are graduating with more cases. The work hours do not appear to have had the intended result of improving intern educational experience from a standpoint of case volume. Significant programmatic changes will likely be required to achieve the 250-case minimum by the end of PGY-2 year, as per 2014 American Board of Surgery requirements.

Background Laparoscopy has emerged as an alternative to laparotomy in select trauma patients. In animal models, increasing abdominal pressure is associated with an increase in intrathoracic and intracranial pressures. We conducted a prospective trial of human subjects who underwent laparoscopic-assisted ventriculoperitoneal shunt placement (lap VPS) with intraoperative measurement of intrathoracic, intracranial and cerebral perfusion pressures.

Importance Increased abdominal pressure may have a negative effect on intracranial pressure (ICP). Human data on the effects of laparoscopy on ICP are lacking. We retrospectively reviewed laparoscopic operations for ventriculoperitoneal shunt placement to determine the effect of insufflation on ICP. Observations Nine patients underwent insufflation with carbon dioxide (CO 2 ) at pressures ranging from 8 to 15 mm Hg and ICP measured through a ventricular catheter. We used a paired t test to compare ICP with insufflation and desufflation. Linear regression correlated insufflation pressure with ICP. The mean ICP increase with 15–mm Hg insufflation is 7.2 (95% CI, 5.4-9.1 [ P 2 O. The increase in ICP correlated with increasing insufflation pressure ( P = .04). Maximum ICP recorded was 25 cm H 2 O. Conclusions and Relevance Intracranial pressure significantly increases with abdominal insufflation and correlates with laparoscopic insufflation pressure. The maximum ICP measured was a potentially dangerous 25 cm H 2 O. Laparoscopy should be used cautiously in patients with a baseline elevated ICP or head trauma.

anorexia. In addition 11 patients reported GERD, 3 had recurrent episodes of acute pancreatitis and 7 cases presented symptoms of upper GI obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18° +/-1.8 and distance 4.6 +/2.1 mm. A duodenojejunostomy was performed in 7 patients, in the remainders the duodenojejunostomy was done after distal duodenum resection. There were no mortality, we observed 2 post operative complications: an abdominal bleeding and a mild acute pancreatitis. At mean follow period of 10 +/6.3 months, all patients are well and alive, 2 of them are still complaining mild epigastric pain. There is a significant improvement in patient weight (pre-operatory mean 50+/-1 kg, post-operatory mean 55+/-9 kg p= 0.003) and BMI (pre-operatory mean 18.1+/-3.4 kg, post-operatory mean 20.0+/-3.4 kg p= 0.004) and there is a significant decreased in need of PPI therapy (p=0.004). We didn't observed significant differences, in the outcome, between the two surgical procedures. Conclusions: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass.