Showing papers by "LAC+USC Medical Center published in 2018"

Prospective Observational Study on acute Appendicitis Worldwide (POSAW).

Abstract: Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments. This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016–September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study. A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%. The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

The Age of Undertriage: Current Trauma Triage Criteria Underestimate The Role of Age and Comorbidities in Early Mortality.

Abstract: Background National guidelines recommend that prehospital and emergency department (ED) criteria identify patients who might benefit from trauma center triage and highest-level trauma team activation. However, some patients who are seemingly “stable” in the field and do not meet the standard criteria for trauma activation still die. Objectives The purpose of this study was to identify these at-risk patients to potentially improve triage algorithms. Methods Patients enrolled in the National Trauma Data Bank (2007–2012) were included. All adult blunt trauma patients that were stable in the field and upon arrival to the ED (defined as a Glasgow Coma Scale score of 13–15, a heart rate ≤120 beats/min, systolic blood pressure ≥90 mm Hg, and diastolic blood pressure ≤200 mm Hg) and did not meet the standard criteria for the highest-level trauma team activation as defined by the American College of Surgeons were included. Demographic, clinical, and injury data including comorbidities, ED vitals, and outcome were collected. Regression models were used to identify independent risk factors for mortality. Results A total of 1,003,350 patients were stable in both the field and ED. Of these 11,010 (1.1%) died, including 1785 (0.2%) who died within 24 hours of hospital admission. The mortality in patients ≥60 years of age was 2.6%, and in patients ≥60 years of age with either a cerebrovascular accident (CVA) or congestive heart failure (CHF) was 5.4%. Age ≥60 years was a significant independent predictor of early mortality (odds ratio [OR] 4.53, p Conclusions Despite apparent evidence of both prehospital stability and stability upon arrival to the ED, patients ≥60 years of age and with a history of CHF or CVA have a significantly increased risk of early mortality after blunt trauma. These patients are at risk for subsequent clinical deterioration and should be considered for early transfer to a trauma center with highest-level activation.

An AAST-MITC analysis of pancreatic trauma: Staple or sew? Resect or drain?

Abstract: Introduction Pancreatic trauma results in high morbidity and mortality, in part caused by the delay in diagnosis and subsequent organ dysfunction. Optimal operative management strategies remain unclear. We therefore sought to determine CT accuracy in diagnosing pancreatic injury and the morbidity and mortality associated with varying operative strategies. Methods We created a multicenter, pancreatic trauma registry from 18 Level 1 and 2 trauma centers. Adult, blunt or penetrating injured patients from 2005 to 2012 were analyzed. Sensitivity and specificity of CT scan identification of main pancreatic duct injury was calculated against operative findings. Independent predictors for mortality, adult respiratory distress syndrome (ARDS), and pancreatic fistula and/or pseudocyst were identified through multivariate regression analysis. The association between outcomes and operative management was measured. Results We identified 704 pancreatic injury patients of whom 584 (83%) underwent a pancreas-related procedure. CT grade modestly correlated with OR grade (r 0.39) missing 10 ductal injuries (9 grade III, 1 grade IV) providing 78.7% sensitivity and 61.6% specificity. Independent predictors of mortality were age, Injury Severity Score (ISS), lactate, and number of packed red blood cells transfused. Independent predictors of ARDS were ISS, Glasgow Coma Scale score, and pancreatic fistula (OR 5.2, 2.6-10.1). Among grade III injuries (n = 158, 22.4%), the risk of pancreatic fistula/pseudocyst was reduced when the end of the pancreas was stapled (OR 0.21, 95% CI 0.05-0.9) compared with sewn and was not affected by duct stitch placement. Drainage alone in grades IV (n = 25) and V (n = 24) injuries carried increased risk of pancreatic fistula/pseudocyst (OR 8.3, 95% CI 2.2-32.9). Conclusion CT is insufficiently sensitive to reliably identify pancreatic duct injury. Patients with grade III injuries should have their resection site stapled instead of sewn and a duct stitch is unnecessary. Further study is needed to determine if drainage alone should be employed in grades IV and V injuries. Level of evidence Epidemiologic/Diagnostic study, level III.

Whole Brain Magnetic Resonance Spectroscopic Determinants of Functional Outcomes in Pediatric Moderate/Severe Traumatic Brain Injury

Abstract: Diffuse axonal injury contributes to the long-term functional morbidity observed after pediatric moderate/severe traumatic brain injury (msTBI). Whole-brain proton magnetic resonance echo-planar spectroscopic imaging was used to measure the neurometabolite levels in the brain to delineate the course of disruption/repair during the first year post-msTBI. The association between metabolite biomarkers and functional measures (cognitive functioning and corpus callosum [CC] function assessed by interhemispheric transfer time [IHTT] using an event related potential paradigm) was also explored. Pediatric patients with msTBI underwent assessments at two times (post-acutely at a mean of three months post-injury, n = 31, and chronically at a mean of 16 months post-injury, n = 24). Healthy controls also underwent two evaluations, approximately 12 months apart. Post-acutely, in patients with msTBI, there were elevations in choline (Cho; marker for inflammation and/or altered membrane metabolism) in all four brain lobes and the CC and decreases in N-acetylaspartate (NAA; marker for neuronal and axonal integrity) in the CC compared with controls, all of which normalized by the chronic time point. Subgroups of TBI showed variable patterns chronically. Patients with slow IHTT had lower lobar Cho chronically than those with normal IHTT; they also did not show normalization in CC NAA whereas those with normal IHTT showed significantly higher levels of CC NAA relative to controls. In the normal IHTT group only, chronic CC Cho and NAA together explained 70% of the variance in long-term cognitive functioning. MR based whole brain metabolic evaluations show different patterns of neurochemistry after msTBI in two subgroups with different outcomes. There is a dynamic relationship between prolonged inflammatory responses to brain damage, reparative processes/remyelination, and subsequent neurobehavioral outcomes. Multimodal studies allow us to test hypotheses about degenerative and reparative processes in patient groups that have divergent functional outcome, with the ultimate goal of developing targeted therapeutic agents.

Magnetic Resonance Spectroscopy of Fiber Tracts in Children with Traumatic Brain Injury: a combined MRS - diffusion MRI Study

Abstract: Traumatic brain injury can cause extensive damage to the white matter (WM) of the brain. These disruptions can be especially damaging in children, whose brains are still maturing. Diffusion magnetic resonance imaging (dMRI) is the most commonly used method to assess WM organization, but it has limited resolution to differentiate causes of WM disruption. Magnetic resonance spectroscopy (MRS) yields spectra showing the levels of neurometabolites that can indicate neuronal/axonal health, inflammation, membrane proliferation/turnover, and other cellular processes that are on-going post-injury. Previous analyses on this dataset revealed a significant division within the msTBI patient group, based on interhemispheric transfer time (IHTT); one subgroup of patients (TBI-normal) showed evidence of recovery over time, while the other showed continuing degeneration (TBI-slow). We combined dMRI with MRS to better understand WM disruptions in children with moderate-severe traumatic brain injury (msTBI). Tracts with poorer WM organization, as shown by lower FA and higher MD and RD, also showed lower N-acetylaspartate (NAA), a marker of neuronal and axonal health and myelination. We did not find lower NAA in tracts with normal WM organization. Choline, a marker of inflammation, membrane turnover, or gliosis, did not show such associations. We further show that multi-modal imaging can improve outcome prediction over a single modality, as well as over earlier cognitive function measures. Our results suggest that demyelination plays an important role in WM disruption post-injury in a subgroup of msTBI children and indicate the utility of multi-modal imaging.

Report and Recommendations of the Association of Pathology Chairs’ Autopsy Working Group:

Abstract: Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training.A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident.Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision.Technical standardization of autopsy performance and reporting must be improved.The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.

Extracorporeal membrane oxygenation in trauma: A single institution experience and review of the literature:

Abstract: Introduction:Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article ide...

Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial

Abstract: Previous studies have shown that lifestyle modification can successfully prevent or delay development of type 2 diabetes. This trial aimed to test if an underserved, low-income population would engage in a digital diabetes prevention program and successfully achieve lifestyle changes to reduce their risk of type 2 diabetes. Participants were recruited from three health care facilities serving low-income populations. The inclusion criteria were: a recent blood test indicating prediabetes, body mass index (BMI) > 24 kg/m 2 , age 18–75 years, not pregnant, not insured, Medicaid insured or Medicaid-eligible, internet or smartphone access, and comfort reading and writing in English or Spanish. A total of 230 participants were enrolled and started the intervention. Participants' average age was 48 years, average BMI = 34.8, average initial HbA1c = 5.8, 81% were female, and 45% were Spanish speaking. Eighty percent had Medicaid insurance, 18% were uninsured, and 2% were insured by a medical safety net plan. Participants completed a health assessment including measured anthropometrics, HbA1c test, and self-report questionnaires at baseline, 6 and 12 months. The 52-week digital diabetes prevention program included weekly educational curriculum, human health coaching, connected tracking tools, and peer support from a virtual group. Qualitative data on implementation was collected with semi-structured interviews with key informants to understand the barriers, keys to success, and best practices in the adoption of the program within the clinical setting. This paper describes the study design and methodology of a digital diabetes prevention program and early lessons learned related to recruitment, enrollment, and data collection.

Supermassive Transfusion: A 15-Year Single Center Experience and Outcomes.

Abstract: The objective of this study was to determine the survival outcome associated with large-volume blood transfusion after trauma. This was a retrospective study at a Level I trauma center from January 2000 to December 2014 that included trauma patients who received ≥25 units packed red blood cell (pRBC) within the first 24 hours of hospital admission. Univariate and multivariable logistic regressions identified risk factors for mortality. Receiver operating characteristic curve analysis evaluated the ability of pRBC volume to predict mortality. Among 74,065 adults (≥18 years old), 178 patients (0.24%) received ≥25 units of pRBC in the first 24 hours, of which 142 (79.8%) received 25 to 49 units, 28 (15.7%) received 50 to 74 units, and 8 (4.5%) received ≥75 units. Overall, 92.2 per cent were male, mean age 33.9 (±14.0), mean Injury Severity Score 28.9 (±14.3), and median Glasgow Coma Scale score 12 (3-15). The overall mortality was 65.2 per cent and 64.1 per cent for those receiving 25 to 49 units, 64.3 per cent for 50 to 74 units, and 87.5 per cent for ≥75 units. In univariate analysis, female gender was associated with lower mortality [odds ratio (OR) 0.24, P = 0.025]. Decreasing Glasgow Coma Scale (OR 0.82, P < 0.001), increasing Injury Severity Score (OR 1.07, P < 0.001), and thoracotomy (OR 3.91, P < 0.001) were associated with higher mortality. There was no transfusion cutoff that was significantly associated with higher mortality.

Hip dislocations and concurrent injuries in motor vehicle collisions.

Abstract: Introduction Motor Vehicle Collisions (MVC) can cause high energy hip dislocations associated with serious injury profiles impacting triage. Changes in safety and regulation of restraint devices have likely lowered serious injuries from what was previously reported in the 1990s. This study aims to describe modern-day injury profile of patients with traumatic hip dislocations, with special attention to aortic injury. Methods Retrospective review of a prospectively maintained trauma database at an urban level 1 trauma center was conducted. Patients with hip dislocation following MVC between January 2005 and December 2015 were grouped based on seatbelt use and airbag deployment. Patients with unknown restraint use were excluded. Multiple logistic regression was used to identify risk of injury profile between groups. Results Of 204 patients with hip dislocation after MVC, nearly 57% were unrestrained. Seatbelt alone was used in 36 (17.7%), airbag deployed in 14 (6.9%), and 38 (18.6%) with both. Gender and number of injuries were similar between groups. The most common concomitant injury was acetabular fracture (53.92%) and the abdominopelvic region was the most injured. Use of a seatbelt with airbag deployment was protective of concomitant pelvic ring injury (OR = 0.22). Airbag deployment was significantly protective of lumbar fracture (OR = 0.15) while increasing the likelihood of radial and ulnar fracture or dislocation (OR = 3.27), acetabular fracture (OR = 5.19), and abdominopelvic injury (OR = 5.07). The no restraint group had one patient (0.80%) with an intimal tear of the thoracic aorta identified on CT chest that was successfully medically managed. Discussion and conclusion Hip dislocations are high energy injuries with severe associated injuries despite upgrades in restraint devices. These patients require careful examination and heightened awareness when evaluating for concomitant injuries.

Localized Nasopharyngeal Amyloidosis: A Clinicopathologic Series of 7 Cases with a Literature Review

Abstract: Localized nasopharyngeal amyloidosis is an extremely rare entity with only 25 cases described in the English and German literature. We present a case series of seven patients with localized nasopharyngeal amyloidosis and combine the findings with a thorough review the literature.

Association of admission vs. nadir serum albumin concentration with short-term treatment outcomes in patients with acute heart failure.

Abstract: Objectives Hypoalbuminemia occurs in 25% to 76% of patients hospitalized for acute heart failure (HF) and is associated with increased mortality. Hypoalbuminemia may predispose patients to intravascular volume depletion, hypotension, and acute worsening of renal function; however, its association with treatment outcomes during hospitalization is unknown. Methods This retrospective cohort study involved 414 adult patients hospitalized for HF requiring intravenous diuretics. Temporal changes in serum albumin and the association of hypoalbuminemia with urine output, renal function changes, blood pressure, use of intravenous vasoactive drugs, and short-term outcomes were assessed. Results Serum albumin decreased in most patients (72%) during hospitalization. Hypoalbuminemia was present in 29% and 50% of patients based on the mean admission and nadir serum albumin level, respectively. Hypoalbuminemia as assessed by the nadir albumin level was associated with an increased risk of acute worsening of renal function. A nadir albumin level of <3.0 g/dL remained significantly associated in the multivariate analyses. Conclusions Serum albumin commonly decreases during hospitalization for acute HF. Hypoalbuminemia assessed using the nadir level during hospitalization, not the admission level, was associated with an increased risk of acute worsening of renal function. The timing of serum albumin measurement may influence its utility as a biomarker.

Balanced blood product transfusion during liver transplantation.

Abstract: INTRODUCTION This study was conducted to determine whether an intra-operative ratio of at least 1:1:2 of fresh frozen plasma (FFP):platelets (PLTs):packed red blood cells (pRBCs) improves outcomes in orthotopic liver transplantation (OLT). METHODS A single-center, retrospective study of deceased donor OLT recipients (MELD ≥15) requiring intra-operative pRBC transfusion (years 2013-2016). Patients were grouped into those receiving an intra-operative ratio of ≥1:1:2 of FFP:PLTs:pRBCs vs ratios .05). Patients in the ≥1:1:2 group had lower pRBC and intra-operative blood product requirements (11 ± 0.5 vs 19 ± 1.4 units, P < .001, and 33 ± 1.3 vs 43 ± 3.3 units, P = .006, respectively), improved 1-month mortality (0 vs 8%, P = .002), improved 1-year survival (P = .004), less intra-operative cardiac arrest (3% vs 10%, P = .03), and shorter operating room time (389 ± 7.2 vs 431 ± 17.2 minutes, P = .03). After multivariate adjustment for baseline and intra-operative variables, balanced blood product transfusion (BBPT) was significantly associated with less intra-operative pRBC transfusion (95% confidence interval: 0.60-0.72). CONCLUSION Balanced blood product transfusion is associated with reduced transfusion requirements in OLT.

Internal Iliac Artery Embolization versus Silastic Loop Ligation for Control of Traumatic Pelvic Hemorrhage.

Abstract: Angioembolization versus open control of traumatic pelvic hemorrhage is debated. We sought to compare outcomes between angioembolization and open internal iliac artery occlusion. A 14-year retrospective review (2004-2017) was performed at our academic Level I trauma center. All pelvic hemorrhage patients who underwent internal iliac artery angioembolization or silastic loop ligation via laparotomy were compared for outcomes. Patient demographics included vital signs, mechanism, and injury severity score (ISS). Outcomes included mortality (%), operating room visits, reoperation for hemorrhage (%), transfusion burden (units), and infection (%). A total of 163 trauma patients matched for age, ISS, mechanism, and cavitary involvement were included for analysis. Compared with silastic loop ligation (n = 51, mean ISS = 32 ± 14), patients who underwent angioembolization (n = 112, mean ISS = 30 ± 8.9) demonstrated decreased mortality (23% vs 57%, P < 0.01), made fewer operating room trips (mean = 2.2 vs 3.6 trips, P < 0.01), made fewer trips for pelvic (2.8 vs 11%, P = 0.05) and nonpelvic-related bleeding (3.6 vs 22%, P < 0.01), used fewer blood products [packed red blood cells, fresh-frozen plasma, platelets, and cryoprecipitate] (P < 0.01 for all), and indicated a trend toward fewer infections (5.7% vs 14%, P = 0.07). Internal iliac artery angioembolization demonstrates lower mortality, lower reoperation rates, decreased transfusion burden, and a trend toward fewer infections compared with silastic loop ligation.

Acute renal replacement therapy in patients with major extremity injuries.

Abstract: INTRODUCTION This narrative review will describe treatment options for patients in the ICU with major extremity injury requiring extracorporeal myoglobin removal and contemporaneous support for systemic complications, such as sepsis, systemic inflammation and coagulation disorders EVIDENCE ACQUISITION Peer-reviewed manuscripts indexed in PubMed A systematic search for articles describing treatment options for patients in the ICU with major extremity injury were included in the analysis Our group determined by consensus which resources would best inform this review EVIDENCE SYNTHESIS Acute renal replacement therapy (ARRT) for renal support may be needed for patients with major extremity trauma developing AKI Contemporary advances allow the physician to perform a tailored treatment that closely match patient's needs Techniques and equipment for ARRT can be modulated according to the patient's pathophysiological derangements, maximizing the therapeutic effects and minimizing adverse events CONCLUSIONS Most of the clinical reviews available in the literature on this topic limit their focus to the extracorporeal removal of myoglobin

For People Dying to Talk, It Finally Pays to Listen with Reimbursable Advance Care Planning.

Abstract: Whether at the beginning, middle, or end of life, health care delivery choices abound. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure. Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning (ACP) conversations. This article will explore the inherent challenges of and opportunities for developing formalized outcomes, methods of measurement, and training to ensure excellence in the performance of ACP conversation procedures. Whether at the beginning, middle, or end of life, health care delivery choices abound. Yet only recently have conversations specifically regarding preferences for care at the end of life become a reimbursable intervention, deemed equivalent in importance to a medical procedure. Quite distinct from other procedures, in which expectations for outcomes are explicit and measurable, outcomes have been left intentionally vague for advanced care planning (ACP) conversations. This article will explore the inherent challenges of and opportunities for developing formalized outcomes, methods of measurement, and training to ensure excellence in the performance of ACP conversation procedures.

Air Contamination in the Hospital Environment

Abstract: In this chapter, we summarize the data related to air contamination of various hospital pathogens outside the operating room. However, at this time, it is unclear if air plays an active role in horizontal transmission of organisms or becomes contaminated only transiently. Additionally, findings might change from one hospital to another depending on room layout, temperature, humidity, and air exchanges.

Early FAST Examinations during Resuscitation May Compromise Trauma Outcomes.

Abstract: Focused assessment with Sonography for trauma (FAST) examination is essential to trauma triage. We sought to determine whether FASTs completed early in sequencing portend worse outcomes. A two-year review (2014-2015) of all trauma activations at our Level I trauma center was performed. Patients were matched at baseline and FAST times were compared. Outcomes included resuscitation time (RESUS-h), ventilation days (d), hospital length of stay (HLOS-d), ICU length of stay (LOS-d), survival (%), nosocomial infection rate (%), and venous thromboembolism complication rate (%). ED interventions included transfusions, crystalloid, antibiotics, central line placement, intubation, thoracostomy, thoracotomy, pelvic X-ray, and binder. One thousand, three hundred and twelve patients were included for analysis (mean age = 38 ± 19 years, mean Injury Severity Score = 12 ± 11, 21% penetrating). Compared with FASTs completed after the primary survey, early FASTs led to significantly more ventilation days (P < 0.01), longer ICU length of stay (P < 0.01), and a greater incidence of nosocomial infections (P = 0.03). In the ED, early FASTs led to significantly more intubations (P < 0.01) and transfusions (P < 0.01) compared with late FASTs. FASTs completed before primary survey portend worse outcomes, with more ED interventions and equivocal results. FAST as a true adjunct to primary survey is recommended.

Sodium and Potassium Abnormalities

Abstract: Managing electrolyte abnormalities effectively requires that the critical care surgeon understands the organization and equilibrium of intracellular and extracellular (including the interstitial and intravascular) fluid compartments. Fluid shifts and subsequent electrolyte derangements are common in the surgical patient in the postoperative period as well as in the trauma patient. Sodium is the predominant cation in the extracellular compartment, while potassium dominates the intracellular space. Derangements in sodium homeostasis (hypo- or hypernatremia) are largely related to volume status (hypo-, eu-, or hypervolemia) and as such can be treated with some measure of fluid restriction and diuretics or volume administration. As the major intracellular cation, potassium plays integral roles in nerve conduction, ATPase transmembrane pumps, and cardiac myocyte excitability. Seemingly minor changes in potassium levels (hyper- or hypokalemia) can have significant physiologic consequences. Accordingly, there are a multitude of options with which to replete potassium or shift its location either intracellular (insulin or albuterol) or out of the body (diuretics or dialysis).

Damage Control Surgery

Abstract: Damage control is a combination of surgical techniques and damage control resuscitation. It can be performed in injuries involving the abdomen, chest, neck, vessels, bones, and soft tissues. It should be considered in patients with persistent bleeding and limited physiological reserve, in austere environments with limited resources, and in bleeding from anatomically difficult areas. It is a three-stage approach and involves temporary control of bleeding by packing, vascular shunting, or ligation and control of intestinal spillage in the operating room (first stage), physiological stabilization in the intensive care unit (second stage), and semi-elective definitive repair of all injuries in the operating room (third stage).

Defining the "Problem Resident" and the Implications of the Unfixable Problem: The Rationale for a "Front-door" Solution.

Abstract: Author(s): Taira, Taku; Santen, Sally A.; Roberts, Nicole K. | Abstract: Introduction: Problem residents are common in graduate medical education, yet little is known about their characteristics, deficits, and the consequences for emergency medicine (EM) residencies. The American Board of Internal Medicine (ABIM) defines a problem resident as “a trainee who demonstrates a significant enough problem that requires intervention by someone of authority, usually the program director [PD] or chief resident.” Although this is a comprehensive definition, it lacks specificity. Our study seeks to add granularity and nuance to the definition of “problem resident,” which can be used to guide the recruitment, selection, and training of residents. Methods: We conducted semi-structured interviews with a convenience sample of EM PDs between 2011 and 2012. We performed qualitative analysis of the resulting transcripts with our thematic analysis based on the principles of grounded theory. We reached thematic sufficiency after 17 interviews. Interviews were coded as a team through consensus. Results: The analysis identified diversity in the type, severity, fixability, and attribution of problems among problem residents. PDs applied a variety of thresholds to define a problem resident with many directly rejecting the ABIM definition. There was consistency in defining academic problems and some medical problems as “fixable.” In contrast, personality problems were consistently defined as “non-fixable.” Despite the diversity of the definition, there was consensus that residents who caused “turbulence” were problem residents. Conclusion: The ABIM definition of the problem resident captures trainees who many PDs do not consider problem residents. We propose that an alternative definition of the problem resident would be “a resident with a negative sphere of influence beyond their personal struggle.” This combination acknowledges the identified themes of turbulence and the diversity of threshold. Further, the combination of PDs’ unwillingness to terminate trainees and the presence of non-fixable problems implies the need for a “front-door” solution that emphasizes personality issues at the potential expense of academic potential. This “front-door” solution depends on the commitment of all stakeholders including medical schools, the Association of American Medical Colleges, and PDs.

An 18-Year-old Prisoner with Abdominal Pain.

Abstract: CASE PRESENTATION (Anna Darby, MD, MPH) An 18-year-old male presented to the emergency department (ED) with a complaint of severe abdominal pain for three days along with painful urination, vomiting, diarrhea and subjective fever and chills. The patient reported brief, severe, colicky episodes of mid and left upper quadrant (LUQ) abdominal pain that radiated to his testicles. He vomited several times because of the pain, which he stated began suddenly while he was lying down. Notably, the patient had recently got over a diarrheal illness a few days prior, followed by constipation, and had recurrence of one loose stool on the day of presentation. He denied any flank pain or back pain, and had never experienced anything like this current illness before. The patient had no prior medical or surgical history, and had no known family history. His family lived in Honduras, but the patient was currently incarcerated. He was previously a one-pack-per-day smoker, drank alcohol one to two times per month, but denied drug use. Review of systems was negative for weight loss, headaches, chest pain, shortness of breath, melena, hematemesis, rashes, or joint swelling. The vital signs were as follows: temperature 37.0°C orally, pulse 103 beats per minute, respiratory rate 11 breaths per minute (bpm), blood pressure 122/67 mmHg, and oxygen saturation 100% on room air. Physical examination revealed an alert young man intermittently doubled over in pain with spontaneous resolution. The heart was tachycardic and regular without murmurs, rubs or gallops. The lungs were clear bilaterally with normal work of breathing and no wheezes, rhonchi or rales. His abdomen was soft and non-distended with normoactive bowel sounds, but he demonstrated diffuse tenderness and guarding to palpation. He had no midline or costovertebral angle tenderness, and no ecchymoses were present on inspection of his back. His skin was warm, dry and without any obvious rashes. His neurological examination was grossly intact throughout. The patient was uncircumcised, and his right testicle was lying higher than his left, but neither was tender or swollen. No masses or inguinal hernias were appreciated in the groin. University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland Los Angeles County + USC Medical Center, Department of Emergency Medicine, Los Angeles, California *

Genitourinary and Splenic Hemorrhage: We’re Important Organs Too!

Abstract: Trauma to the genitourinary tract can affect the kidneys, ureters, bladder, and urethra. Of those, the kidneys are the most commonly injured organs with potential for significant blood loss. Considering this book’s focus on hemorrhage control, this chapter will therefore only discuss the management of kidney lacerations. In contrast to other solid organs, nonoperative management of high-grade renal lacerations is frequently successful and generally preferred. Isolated renal injuries causing hemodynamic instability are exceedingly rare, and a high index of suspicion should be maintained for the presence of associated injuries, particularly in blunt abdominal trauma. More often, kidney injuries are identified on abdominal computed tomography scan and can be managed nonoperatively with close monitoring and serial hemoglobin measurements. Intraoperatively, high-grade renal lacerations can present as zone II retroperitoneal hematoma and should only be explored in select circumstances.