Association of Women Surgeons' Comprehensive Initiative for Healthy Surgical Families During Residency and Fellowship Training

Importance

The lack of family-friendly policies continues to contribute to the underrepresentation and attrition of surgical trainees. Women in surgery face unique challenges in balancing surgical education with personal and family needs.

Observations

The Association of Women Surgeons is committed to supporting surgical families and developing equitable family-friendly guidelines. Herein we detail recommendations for adequate paid parental leave, access to childcare, breastfeeding support, and insurance coverage of fertility preservation and assisted reproductive technology.

Conclusions and Relevance

The specific recommendations outlined in this document form the basis of a comprehensive initiative for supporting surgical families.

Disparities affecting incarcerated burn-injured patients: Insight from the National Burn Repository

OBJECTIVE

Incarcerated patients are a vulnerable population and little is known regarding the epidemiology of burn injury and subsequent outcomes. This study utilizes a national database to assess disparities in care affecting this understudied population.

METHODS

The National Burn Repository was queried for adult patients discharged into custody. Patients discharged to jail were compared to those with other dispositions. Additional analysis of the incarcerated patients compared those injured while in custody to those injured prior to incarceration.

RESULTS

Between 2002-2011, 809 patients were discharged to jail with 283 (35.0%) sustaining these injuries while in custody. Patients were predominantly male (86.2%) and White (52.3%), with median age 35.7 years (IQR 27.7-45.9). Incarcerated patients had significantly higher rates of drug abuse and psychiatric illness. They had significantly smaller burns (2.0% vs. 3.8%, p < 0.001) and were less likely to undergo an operation but had comparable lengths of stay in the hospital.

CONCLUSIONS

Although incarcerated burn-injured patients sustain smaller injuries and receive fewer operations they remain hospitalized for similar durations as non-incarcerated patients. Enhanced understanding of burn etiologies and injury characteristics as well as improved insight into the impact of psychosocial factors such as substance abuse and prevalence of psychiatric disorders may help improve care.

589 Burn Center Trainees: Not Just for Surgery or Plastic Surgery Residents

Introduction

The Burn unit offers a unique training environment for residents. The Accreditation Council for Graduate Medical Education (ACGME) requires all General Surgery trainees to have knowledge of burn physiology and experience with initial burn management. However, there are no burn requirements for other ACGME-sponsored training programs except for Plastic Surgery. Since care of the burned patient spans multiple settings – the intensive care unit, operating room, wards, outpatient clinic, and the emergency department – having residents from varied specialties might benefit not only the trainee, but also the Burn Center.

Methods

A retrospective review of all residents rotated to the burn center of an American Burn Association verified unit was performed. Data from the 7/2018-6/2018 academic year were collected by analyzing resident rotational and call schedules of both intra institutional and inter-institutional residents. The specific time period was chosen to account for COVID affecting the number of residents more recently.

Results

A total of 48 residents rotated at the burn center during the studied academic year. Within the institution, there were 34 residents (71%): 12 general surgery interns (8 categorical, 4 preliminary), 2 plastic surgery interns, 10 emergency medicine (EM) residents, and 10 anesthesia residents. There were 14 residents (29%) from 3 outside institutions: 3 plastic surgery residents, 8 surgery interns from one program, and 3 surgery interns from another program. All surgical specialty trainees were interns, whereas other specialties, EM and anesthesia, were PGY2 trainees.

Conclusions

While most residents were from general surgery and plastic surgery programs (58%) due to ACGME requirement, a significant portion of the resident complement (42%) was from non-surgical specialties. EM residents gain competency in wound reading as well as burn critical care. Anesthesia residents learn surgical management of the burn patient and critical care procedures. Since the burn center is a tertiary referral center, having outside residents rotating in the burn unit might facilitate transfers and increase knowledge of proper resuscitation.

8 Less Is More: Reconsidering Hourly Urine Output Goals in Burn Resuscitation

Introduction

Significant morbidity and mortality is seen with high volume burn resuscitations. Surpassing the Ivy Index, defined as 250 milliliters/kilogram (ml/kg), has been correlated with increased incidence of complications such as abdominal compartment syndrome. Cognizance of factors contributing to over-resuscitation can help optimize fluid administration strategies to minimize associated morbidity.

Methods

A single-center Quality Improvement review was performed of all adult (age ≧ 18 years) burn-injured patients presenting to a major metropolitan burn center with burns ≧ 20% total body surface area (TBSA) between 12/2020-8/2021. Those not surviving the first 24 hours were excluded. Patient demographics and injury characteristics were collected, and resuscitation volumes and timing were recorded prospectively. Patients were categorized by whether their initial 24-hour intake exceeded their Ivy Index, and groups were compared to assess factors associated with over-resuscitation.

Results

During the study period 11 patients met inclusion criteria, and one early mortality was excluded. Patients were predominantly male (70.0%), with mean age 49.9±17.4 years. Burns were primarily due to flame injury, with mean TBSA 41.4±18.6%. Patients required resuscitation volumes of 5.9±1.7 ml/kg/TBSA%, with half surpassing their Ivy Index in the first 24 hours. These patients had larger burns (55.1±17.0% v. 27.7±5.1%) with a significantly higher third degree component (41.4±15.8% v. 15.4±15.2%, p = 0.029). None had diagnosed inhalation injury, and none required abdominal decompression for resuscitation-related compartment syndrome. Observed mortality rate was 30.0%. Patients resuscitating beyond their Ivy Index had significantly higher hourly urine output rates (0.96 v. 0.52 ml/kg, p = 0.024), and hourly urine output was significantly higher among non-survivors as compared to survivors (1.10 v. 0.60 ml/kg, p = 0.033).

Conclusions

Patients with severe burn injury are at high risk for over-resuscitation and associated complications. While traditional teaching instructs a goal of hourly urine output of 0.5-1.0 ml/kg, our study shows that patients resuscitated on the higher end of this range were significantly more likely to surpass their Ivy Index and less likely to survive.

Prevalence and risk factors for acute stress disorder and posttraumatic stress disorder after burn injury

BACKGROUND

Psychological consequences of burn injury can be profound. Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) are known sequelae, but routine identification is challenging. This study aims to identify patient characteristics associated with outpatient positive screens.

METHODS

The Primary Care Posttraumatic Stress Disorder questionnaire (PC-PTSD-4) was administered at initial outpatient Burn Center visits between 5/2018-12/2018. Demographics, injury mechanism, and total body surface area (TBSA) were recorded. Those with ≥3 affirmative answers were considered positive. Patients with positive and negative screens were compared.

RESULTS

Of 307 surveys collected, 292 (median TBSA 1.5 %, IQR 0.5-4.0 %) remained for analysis after exclusions. Of those, 24.0 % screened positive. Positive screens were associated with presence of a deep component of the injury, injury mechanism, upper extremity involvement, ICU admission, and prolonged hospital length of stay.

CONCLUSIONS

Numerous factors distinguish burn injury from other traumatic mechanisms and contribute to disproportionate rates of traumatic stress disorders. Optimization of burn-oriented ASD and PTSD screening protocols can enable earlier intervention.

Firefighter Postinjury Return to Work: A Balance of Dedication and Obligation

Firefighters are at significant risk for burn injuries. Most are minor and do not significantly affect ability to work in full capacity, but there exists risk for both short- and long-term incapacitation. Many push for earlier return to work than is medically advisable. An online cross-sectional survey was sent to a statewide Professional Firefighters' Union. Multiple-choice format was used to assess demographics, injury details, medical care received, and return to work, with free-text format for elaboration. The survey was sent to 30,000 firefighters, with 413 (1.4%) responses. After exclusions, 354 remained for analysis with 132 burn-injured. Burns were small and affected the head (45.5%) and upper extremities (43.2%). Reported gear use was 90.7%, and the majority were not treated at a Burn Center. While 12 (12.1%) returned prematurely, nearly half knew a colleague who they felt had returned too soon. Factors cited include firefighter culture, finances, pressure from peers and employers, dislike of light duty, and a driving desire to get back to work. While many cite love of the job and a culture of pride and camaraderie that is "in our DNA," firefighters' decisions to return to work after burn injury are equally driven external pressures and obligations. Additional education is needed, which may best be facilitated by treatment at a Burn Center. Improved understanding of factors driving firefighters' views on returning to duty after injury may help establish support systems and improve education regarding risks of premature return to work, particularly with regard to reinjury.

Burn Injuries in Patients with Paralysis: A National Perspective on Injury Patterns and Outcomes

The affect of paralysis-related comorbidities on outcomes in burn-injured patients has not been explored. We hypothesize that comorbid paralysis is associated with increased morbidity in this population. All burned patients with prior diagnoses of paralysis were identified from the National Burn Repository (Version 8.0). One-to-one matching of nonparalyzed burn-injured patients was performed, and nonparametric analysis was used to compare the groups. We identified 432 paralyzed patients, who were predominantly male (70.6%) and Caucasian (57.6%), with an average age of 40.8 ± 19.0 years. The identified level of disability was distinguished as paraplegia (59.5%), hemiplegia (16.9%), quadriplegia (13.9%), or other (9.8%). A majority of injuries occurred in the home (75.2%), primarily due to scalds (48.1%). More than half sustained small injuries with affected total body surface area <5%. Lower extremities were frequently injured (72.2%), with 41.0% affecting exclusively the lower extremities. While the paralysis population had significantly longer hospital lengths of stay, nonparalyzed patients had longer intensive care unit length of stay and ventilator days (P < .001). There was no statistically significant difference in mortality rate between paralyzed and nonparalyzed patients (4.4% vs 4.9%, P = .550). Patients with paralysis are susceptible to small scald injuries in the home. Comorbid paralysis places patients at risk for longer, more indolent hospital stays, when compared with matched nonparalyzed patients with more critical illness. Further investigation is needed regarding the pathophysiologic mechanisms predisposing paralyzed burn patients to increased morbidity.

Patient and social characteristics contributing to disparities in outcomes after burn injury: application of database research to minority health in the burn population

BACKGROUND

Although racial disparities have been well described in trauma and medical literature, less is known about disparities in the burn population, especially the Native American, Hispanic, Black, and Asian minority groups. This study seeks to identify at-risk populations for differences in patient and social characteristics that may link certain race groups to disparate burn outcomes.

METHODS

Data was reviewed from the National Burn Repository. Information regarding patient demographics, co-morbidities, complications, and clinical outcomes was recorded. Student's T-test, ANOVA, and binary logistic regression were used to assess relationships between patient factors and outcomes.

RESULTS

The Native American cohort had higher rates of alcoholism, drug abuse, and homelessness compared to all patients. Native Americans also had significantly longer hospital lengths of stay, and higher rates of respiratory failure, pneumonia, sepsis, and wound complications. The Black population demonstrated the highest percentage of injury at home, child abuse, and non-insurance. Mortality was highest in the Black population compared to all patients.

CONCLUSIONS

These findings suggest that outcome disparities exist in burn-injured patients in multiple minority groups.

Graft loss: Review of a single burn center's experience and proposal of a graft loss grading scale

BACKGROUND

There exists neither a consensus definition of burn "graft loss" nor a scale with which to grade severity. We introduced an institutional scale in 2014 for quality improvement.

MATERIALS AND METHODS

We reviewed all burned patients with graft loss on departmental Morbidity and Mortality reports between July 2014 and July 2016. Graft loss grades were assigned during the course of clinical care per institutional scale. Chronic nonhealing wounds and nonburn wounds were excluded. Data abstracted included demographics, medical history, injury details, surgical procedures, graft loss, and lengths of stay (LOS). Photos of affected areas were graded by two blinded surgeons, and a linear weighted κ was calculated to assess interrater agreement.

RESULTS

Graft loss was noted in 50 patients, with 43 remaining after exclusions. Mean age was 50.1 y. The majority were male (58.1%) and African American (41.9%). Smoking (30.2%) and diabetes (27.9%) were prevalent. Total body surface area involvement ranged from 0.5% to 51.0% (11.8 ± 12.3%). Grade I graft loss was documented on one patient (2.3%), Grade II in 15 (34.9%), Grade III in 12 (27.9%), and Grade IV in 15 (34.9%). Reoperation was performed in 20 (46.5%). Hospital LOS was longer than predicted in 38 patients (88.4%). Seven had significant morbidity, including two amputations. Moderate agreement was reached between blinded surgeons (κ = 0.44, P = 0.004).

CONCLUSIONS

Graft loss is a major source of morbidity in burn patients. In this cohort, reoperation was common and hospital LOS was extended. Use of a grading scale improves dialog among providers and enables improved understanding of risk factors.

Thoracoscopic placement of phrenic nerve pacers for diaphragm pacing in congenital central hypoventilation syndrome

PURPOSE

Congenital central hypoventilation syndrome (CCHS), or Ondine's curse, is a rare disorder affecting central respiratory drive. Patients with this disorder fail to ventilate adequately and require lifelong ventilatory support. Diaphragm pacing is a form of ventilatory support which can improve mobility and/or remove the tracheostomy from CCHS patients. Little is known about complications and long-term outcomes of this procedure.

METHODS

A single-center retrospective review was performed of CCHS patients undergoing placement of phrenic nerve electrodes for diaphragm pacing between 2000 and 2012. Data abstracted from the medical record included operation duration, ventilation method, number of trocars required, and postoperative and pacing outcomes.

RESULTS

Charts of eighteen patients were reviewed. Mean surgical time was 3.3±0.7 hours. In all cases except one, three trocars were utilized for each hemithorax, with no conversions to open procedures. Five patients (27.8%) experienced postoperative complications. The mean ICU stay was 4.3±0.5 days, and the mean hospital stay is 5.7±0.3days. Eleven patients (61.1%) achieved their daily goal pacing times within the follow-up period.

CONCLUSIONS

Thoracoscopic placement of phrenic nerve electrodes for diaphragmatic pacing is a safe and effective treatment modality for CCHS. Observed complications were temporary, and the majority of patients were able to achieve pacing goals.

Sigmoid perforation and bucket-handle tear of the mesocolon after bicycle handlebar injury: a case report and review of the literature

We describe an unusual case of sigmoid colon perforation secondary to a bicycle handlebar injury. Because the patient presented 2 days after the initial injury, we suspected that the colon perforation was not the immediate result of the bicycle accident but, rather, was secondary to devascularization. At operation, we found a bucket-handle tear of the colonic mesentery, which was the patient's primary injury and cause of the perforated colon.