Prehospital care and interfacility transfer of trauma patients before reaching the emergency of a level-1 trauma care center

Background

Management of trauma patients includes prevention, prehospital care, appropriate resuscitation at a hospital, definitive treatment, and rehabilitation. Timely and adequate care for a trauma patient is paramount, which can dramatically impact survival. This study was planned to assess the proportion of patients who failed to receive adequate prehospital care before reaching our institute.

Materials and Methods

A retrospective study was conducted in the trauma and emergency department of a level-1 trauma center in eastern India from February to April 2022. The demographic profile, vital parameters, injury, mode of transport, travel duration, referring hospital, and any interventions as per airway/breathing/circulation/hypothermia were collected.

Results

The records of a hundred-two patients who were brought to the trauma and emergency department in the study period were reviewed. Road traffic accident involving two wheelers was the leading cause of injury. Eighty-three percent of the patients were referred from other health centers, of which 49 were referred from district headquarters hospitals. Only three patients out of 14 had been provided with an oropharyngeal airway for whom endotracheal intubation was indicated. Only one among the 41 patients needing Philadelphia collar actually received. Sixteen patients were provided supplemental oxygen out of the 35 for whom it was indicated. Out of 68 patients in whom intravenous cannulation and fluid administration were indicated, only 35 patients had received it. Out of 31 patients with fractures, none were provided immobilization.

Conclusion

The care of the trauma patients with respect to airway, breathing, circulation, and fracture immobilization was found to be grossly inadequate, emphasizing the need of structured and protocol based prehospital trauma care.

Use of Technology to Improve the Adherence to Surgical Safety Checklists in the Operating Room

BACKGROUND

Although checklists can improve safety in the operating room (OR), compliance with their use is variable. Use of a forcing function, a principle of human factors engineering, has not been reported earlier as a method of increasing checklist use. The authors conducted this study to determine the feasibility and effects of introducing a forcing function on OR surgical safety checklist implementation and adherence.

METHODS

The authors developed and introduced the use of an electronic version of the surgical safety checklist on an Android application, provided on a personal device available in the OR. This application was linked by Bluetooth to electrocautery equipment, which could not be started before the electronic checklist was completed on the screen of the personal device. In the same OR, retrospective data from use of the traditional (paper-based) checklist were compared with data from the new electronic checklist for frequency of use, and completeness (percentage of all checklist items completed) at three stages of the surgical process-sign-in, time-out, and sign-out.

RESULTS

The frequency of use was 100.0% for the electronic checklist, compared with 97.9% for the traditional checklist. The frequency of completeness was 27.1% for the traditional vs. 100.0% for the electronic (p < 0.001).The manual checklist's sign-out component was completed only 37.0% of the time.

CONCLUSION

Although checklist use in some form was already high with the traditional checklist, completion rate was low and significantly increased with the use of the electronic checklist with a forcing function.

Feasibility and outcomes of Desarda vs Lichtenstein hernioplasty by local anesthesia for inguinal hernia: a noninferiority randomized clinical trial

INTRODUCTION

The Desarda autologous tissue repair is comparable to the Lichtenstein hernioplasty for inguinal hernia regarding recurrence, chronic groin pain, and return to work activities. This study was designed to establish the outcomes of Desarda's repair versus Lichtenstein's hernioplasty concerning post-operative recovery to normal gait and its feasibility under local anesthesia (LA).

MATERIALS AND METHODS

This study was a single-center, prospective, double-blinded, non-inferiority, randomized trial. Patients undergoing open hernia repair for primary inguinal hernia were included. Patients were randomly assigned and followed up for 2 years. The primary endpoint was the time to return to normal gait post-surgery with comfort (non-inferiority margin fixed as 0.5 days). The secondary outcomes studied were post-operative pain score, the time required to return to work (all previously performed activities), and surgical-site occurrences (SSO).

RESULTS

One hundred ten eligible patients were randomly assigned [56 patients (50.9%) in the Desarda group and 54 patients (49.1%) in the Lichtenstein group]. All the procedures were safely performed under LA. The median (interquartile range) time for resuming gait post-surgery with comfort was 5 days in the Desarda vs 4 days in Lichtenstein's arm (P = 0.16), thereby failing to demonstrate non-inferiority of Desarda against Lichtenstein hernioplasty. However, there were no significant differences in days to return to work, SSO, chronic groin pain, and recurrence within two years of surgery.

CONCLUSIONS AND RELEVANCE

This study could not demonstrate the non-inferiority of the Desarda repair versus Lichtenstein hernioplasty regarding the time taken to return to normal gait. Comparing the days to return to work, pain score, SSO, and chronic groin pain, including recurrence rate, Desarda repair faired equally with Lichtenstein hernioplasty, thereby highlighting its feasibility and efficacy under LA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03512366.

Impact of personal protective equipment on patient safety and health care workers

Background

The study aims to assess the effect of personal protective equipment (PPE) on the physical and psychological well-being of health care workers (HCWs) and its impact on patient safety.

Methods

After ethical approval, a 14-point questionnaire was circulated offline and online among the HCWs of ours institute, who were involved in performing invasive procedures while wearing a PPE. The responses were analysed using the SPSS software version 26.

Results

Of 198 responses, the mean duration of PPE use was 4.6 ± 1.52 h. Seventy percent of respondents suggested <4 h of continuous use of PPE. Seventy-seven percent found difficulties during the procedures while wearing PPE and agreed to errors while performing a procedure. Poor visibility (95.5%), fogging (84.9%), communication difficulty (75.3%), sweating (74.2%), posture-related discomfort (56.1%) and poor concentration (51%) were major causes. Anxiety (39.9%) and fear of spreading an infection to the family (42.9%) were major psychological effects. Eighty percent of HCWs raised concern over the quality of PPE, N95 mask and eye protector. The HCWs felt the need to improve the quality of PPEs, use extra padding around the ears, sealing the N95 mask with adhesive tape, besides using sign language for communication for more safety. Fifty percent graded the procedure-related difficulty level >6 on a Likert scale of 1-10.

Conclusion

PPE-related discomfort is common among the HCWs and could contribute to errors during an invasive procedure. Efforts to alleviate the physical and psychological well-being of the HCWs will be essential for reducing procedural error while wearing a PPE.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

A self-reported survey on the implementation of infection prevention and control elements in Indian hospitals, part of a HAI surveillance network: Results from 23 hospitals conducting a standardized IPC assessment

BACKGROUND

Healthcare-associated infections (HAIs) are one of the most common adverse events in patient care that account for substantial morbidity and mortality. We evaluate the existing Infection Prevention and Control (IPC) practices in hospitals participating in the nationally representative HAI Surveillance network.

METHODS

This cross-sectional survey was conducted in 23 hospitals across 22 states of India from October-2015 to September-2018 in the HAI surveillance network. The World Health Organization (WHO) IPC core components assessment tool for health-care facility level (IPCAT-H) was adapted from IPC assessment tool developed by US Centers for Disease Control and Prevention (US CDC) under the Epidemiology and Laboratory Capacity (ELC) Infection Control Assessment and Response (ICAR) Program. Mann-Whitney U test was used to calculate the significant difference between scores (P < .05).

RESULTS

Amongst the participating hospitals, 7 were private sectors and 16 were public health care facilities. Infection IPCAT-H average score per multimodal strategy was less than 50% for programmed IPC activities (45.7); implementation of health care workers (HCWs) immunization programme (43.5%); monitoring and evaluation component (38.30%).

CONCLUSIONS

There is potential for improvement in Human Resources, Surveillance of HAIs as well as Monitoring and Evaluation components.

Transmesenteric Internal Abdominal Hernia: Multi-detector row computed tomography findings

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Lithotomy versus Prone Position for Perianal Surgery: A Randomized Controlled Trial

Purpose

Studies objectively comparing lithotomy and prone positions regarding surgeon comfort, ergonomics, patient comfort, and position related complications are scarce.

Methods

The patients posted for surgery of either fistula in ano, hemorrhoids, or were included in this study. Subjective Mental Effort Questionnaire (SMEQ) and Local Experienced Discomfort (LED) scale were used to score the level of mental and physical stress among the operating surgeon, assistants, and the scrub nurse. Other parameters studied were the exposure of the operative site, patient comfort level, and position-related complications.

Results

Thirty patients were operated in each position. Mean ± standard deviation of jackknife prone vs. lithotomy surgeon SMEQ score (15.6 ± 10.4 vs. 107.0 ± 11.5, P < 0.05) and LED score (1.8 ± 1.5 vs. 6.7 ± 0.5, P < 0.05) were found to be statistically significant. Prone vs. lithotomy assistant SMEQ score (29.1 ± 13.1 vs. 100.6 ± 8.7, P < 0.05) and LED score (4.6 ± 1.1 vs. 7.4 ± 0.8, P < 0.05) were also found to be statistically significant. SMEQ (10.0 ± 0.0 vs. 20.6 ± 2.5, P < 0.05) and LED scores (1.1 ± 0.3 vs. 3.3 ± 0.5, P < 0.05) of scrub nurses and LED scores (2.5 ± 0.5 vs. 6.3 ± 0.7, P < 0.05) of patients were also statistically significant. Exposure of the operative site was significantly better in the prone position (5.0 vs. 2.1, P < 0.05).

Conclusion

Significantly better SMEQ, LED, and exposure score suggests the superiority of jackknife prone position over the lithotomy in terms of significantly less mental and physical stress to the operating surgeon, assistant, and scrub nurse; better ergonomics, and excellent exposure.

Squamous Metaplasia in a Borderline Phyllodes Tumor-an Undocumented Histological Finding in Male Breast: Report of a Case and Review of Literature

Phyllodes tumor is a paradigm of fibroepithelial neoplasm that accounts for <1% of the breast neoplastic lesions usually detected in females and uncommonly in the male breast. The World Health Organization classifies the tumor into benign, borderline, and malignant based on the predefined morphological criteria. Squamous differentiation in phyllodes tumor is epithelial metaplasia, which has been occasionally documented in English literature. We report the first undocumented case of a recurrent borderline phyllodes tumor with cystic squamous metaplastic change in a 32-year-old male patient. The histology was that of a fibroepithelial neoplasm with the typical leaf-like projections and cystic spaces lined by squamous epithelium containing keratin debris. The purpose of presenting this case is to elucidate the pathogenesis and discuss other malignant and benign breast lesions that may be included in the differential diagnosis when evaluating a breast lesion with squamous metaplasia, particularly in the context of fine-needle aspirates.

745 Risk Factors of Incident Renal Stones in Indian Population: A Hospital-Based Case-Control Study

Introduction

Nephrolithiasis is pathological calcification in the excretory passages of the body and is prevalent among 7.6% of Indians. We aimed to study the various risk factors associated with renal stones from India.

Method

It was a hospital-based case-control study conducted over 18 months in a tertiary hospital in Delhi. Cases were defined as patients with renal stones diagnosed on the basis of history and radiological examination. Controls were similar to cases in all respects except for the diagnosis and selected from the hospital. A total of 18 risk factors, including age, gender, heavy metals, stress, metabolic factors, alcohol intake, dietary habits, co-morbidities, etc. were assessed. Logistic regression analysis was performed to calculate the strength of the risk associations.

Results

In the analysis of 60 cases and controls, we found 6 times, 5.5 times, and 2.4 times increased odds of renal stones in patients with increased arsenic, cadmium, and lead concentrations in blood, respectively. Similarly, there are 3 times increased odds of renal stones in patients suffering from stress.

Conclusions

Exposure to smoke, occupation dust, and contaminated water may lead to an increased ingestion/inhalation of heavy metals like cadmium, arsenic, and predisposing people to an increased risk of renal stones.

Malignant Extra-Gastrointestinal Stromal Tumor of the Mesentery

Gastrointestinal stromal tumors (GISTs), the commonest mesenchymal tumors of gastrointestinal tract are often described to take origin from the interstitial cells of Cajal (ICC) or its precursor cells. Rarely these tumors do arise in structures other than the alimentary tract like omentum, mesentery, retroperitoneum, etc., of varying malignant potential and are known as extra-gastrointestinal stromal tumors (eGISTs).

This is a case report of a 70-year-old female with multicentric malignant eGISTs arising in the mesentery of ileum. On laparotomy, a large mass of 20 × 15 cm was found in the small bowel mesentery without involvement of the adjacent ileum, with multiple other small nodules resembling lymph nodes, present adjacent to it. Histopathological study of the excised lump, confirmed the mass to be malignant eGIST without involvement of the adjacent ileum, with cluster differentiation (CD)117 positive and of high-risk stratification. The mesenteric nodule was confirmed on histopathology to be malignant eGIST, similar to that of that of the primary, without any lymphoid tissue. Adjuvant imatinib mesylate treatment was started immediately postoperation with the patient doing well at 1 year of follow-up. We report this case, due to the rare occurrence of multifocal malignant eGISTS of small bowel mesentery, which is yet to be reported. The existing literature is unclear regarding the clinicopathology and management of multifocal malignant stromal tumors of the mesentery.

Cetrimide-chlorhexidine-induced multiorgan failure in surgery of pulmonary hydatid cyst

Savlon (0.5% cetrimide/0.05% chlorhexidine) is used as a scolicidal during surgery of hydatid cysts. It is considered a safe and effective agent. However, there are no recommendations for the appropriate concentration or dosage of these agents. Previously reported to cause severe metabolic acidosis, its effects on the pulmonary system have not been explored. We present a case of acute lung injury and respiratory distress along with acute cardiopulmonary distress, severe metabolic acidosis, and renal failure following its use during surgical removal of pulmonary hydatid cyst. The agent may act as a chemical sclerosant causing pulmonary parenchymal damage through bronchial openings present in the pericyst. Till safe dose limits are known, use of this agent should be limited, especially in large or multiple cyst surgery.

Is laparoscopic cholecystectomy effective in relieving dyspepsia in patients of cholelithiasis? A prospective study

BACKGROUND

Laparoscopic cholecystectomy (LC) is routinely done for symptomatic gallstone disease; however, its role in relieving dyspeptic symptoms in cholelithiasis is controversial.

AIM

The study was designed to assess the role of laparoscopic cholecystectomy in relieving dyspeptic symptoms in patients having cholelithiasis with only dyspeptic symptoms.

METHODS

Patients with cholelithiasis having only dyspeptic symptoms not attributable to other causes (like Helicobacter pylori) were subjected to laparoscopic cholecystectomy. Dyspepsia scores (Dyspepsia Severity Assessment Score-DSAS and Gastrointestinal Quality of Life Index- GIQLI) were measured before and after surgery and analyzed using Greenhouse-Geisser, McNemar’s and ANOVA tests.

RESULTS

27 patients (M:F=1:26, mean age=40.48±10.60 years) having dyspepsia with asymptomatic gallstones were included in the study. There was significant improvement in DSAS (20.11±4.36 vs 28.63±3.42; p<0.001) and GIQLI(106.11±5.77 vs 122.56±7.95; p<0.001) after 2 months of LC. All symptoms improved individually; relief in early satiety and vomiting was the maximum (outcome benefit ratios=0.954, p=0.007 and 0.937, p=0.005 respectively). Multiple gallstones caused more dyspepsia than single (p=0.005). There was no significant difference between H. pylori positive and negative groups in terms of improvement of DSAS and GIQLI scores after LC (p=0.897 and p=0.375 respectively; however dyspepsia was seen to improve significantly within both groups).

CONCLUSION

Dyspepsia may be a symptom of gallstone disease, and these patients can benefit from LC especially when early satiety and vomiting are the main symptoms. A larger sample size may offer more insight.

Port site infection in laparoscopic surgery: A review of its management

Laparoscopic surgery (LS), also termed minimal access surgery, has brought a paradigm shift in the approach to modern surgical care. Early postoperative recovery, less pain, improved aesthesis and early return to work have led to its popularity both amongst surgeons and patients. Its application has progressed from cholecystectomies and appendectomies to various other fields including gastrointestinal surgery, urology, gynecology and oncosurgery. However, LS has its own package of complications. Port site infection (PSI), although infrequent, is one of the bothersome complications which undermine the benefits of minimal invasive surgery. Not only does it add to the morbidity of the patient but also spoils the reputation of the surgeon. Despite the advances in the field of antimicrobial agents, sterilization techniques, surgical techniques, operating room ventilation, PSIs still prevail. The emergence of rapid growing atypical mycobacteria with multidrug resistance, which are the causative organism in most of the cases, has further compounded the problem. PSIs are preventable if appropriate measures are taken preoperatively, intraoperatively and postoperatively. PSIs can often be treated non-surgically, with early identification and appropriate management. Macrolides, quinolones and aminoglycosides antibiotics do show promising activity against the atypical mycobacteria. This review article highlights the clinical burden, presentations and management of PSIs in LS as shared by various authors in the literature. We have given emphasis to atypical mycobacteria, which are emerging as a common etiological agent for PSIs in LS. Although the existing literature lacks consensus regarding PSI management, the complication can be best avoided by strictly abiding by the commandments of sterilization techniques of the laparoscopic instruments with appropriate sterilizing agent.

Validation of the EuroQol Five-dimensions - Three-Level Quality of Life Instrument in a Classical Indian Language (Odia) and Its Use to Assess Quality of Life and Health Status of Cancer Patients in Eastern India

BACKGROUND AND OBJECTIVES

The EuroQol five-dimensions - 3-level (EQ5D) is a versatile quality of life (QOL) instrument with five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression) and a visual analog scale. It can be used to calculate quality-adjusted life years. We aimed to evaluate the validity, reliability, and responsiveness of an Odia version of EQ5D and to study the QOL of cancer patients in our part of the country as cancer treatment in India still focuses largely on longevity due to scarcity of resources.

MATERIALS AND METHODS

The EQ5D tool was translated into Odia language in collaboration with the EQ group. This tool and the World Health Organization-5 (WHO-5) questionnaires were administered to 155 surgical outpatients and 150 cancer patients in two hospitals of Eastern India. The convergent and discriminant validities (construct validity), concurrent validity, reliability (test-retest method of administering the tool to a part of the population after 7-14 days), and the internal consistency (Cronbach's alpha) were measured using preestablished hypotheses. The data from the cancer patients were analyzed separately.

RESULTS

The QOL worsened with age and was worse in cancer patients proved that the tool had good construct validity. The Anxiety Depression dimension had good correlation with all the dimensions WHO-5 (rho > 0.4) indicating a good concurrent validity. Internal consistency and reliability of the tool were good (Cronbach's alpha > 0.7). Cancer patients had a poor QOL (mean EQ5D index 0.37SD 0.4) with male patients, patients with Grade II cancer or referred for pain care services and those with living spouses reporting worse QOL.

CONCLUSIONS

The Odia version of the EQ5D has good reliability and validity for the measurement of health status in cancer and outpatient department patients. Cancer patients in this part of the country have a poor QOL and may need a closer look at pain management and improved societal support systems.