Should Critical Care Medicine be a Formal Part of the Undergraduate Curriculum?

Medical students were surveyed shortly after completing the third year of medical school. TIle survey was designed to identify those areas of critical care medicine students had been exposed to and expressed interest in learning more about. In addition, the surveys sought to discern the level of confidence students felt with respect to different critical illnesses and intensive care unit (lCU) therapeutic modalities.Finally, the students were asked their opinion regarding the possibility or need for critical care medicine as pan of their medical school curriculum.The three most common topics of interest among medical students who had recently ftnished their third year in medical school were shock, hemodynamic monitoring, and mechanical ventilation. Less than 30% of the students surveyed felt "better-than-average" confidence on anyone of a number of critical care topics and treatment modalities. Of the 80% of students (n = 70) who completed the survey, 91% (n = 64) felt that critical care medicine should be made a pan of the medical school curriculum,6% (n = 4) felt it should not, and 3% (n = 2) were undecided.TIle survey results and the finding that most of the relevant literature acknowledges the need for critical care medicine in medical school has led us to conclude that a national core clerkship or a didactic lecture series in critical care medicine should be carefully designed and implemented into the undergraduate curriculum

Trauma resource pit stop: increasing efficiency in the evaluation of lower severity trauma patients

Background Overtriage of trauma patients is unavoidable and requires effective use of hospital resources. A ‘pit stop’ (PS) was added to our lowest tier trauma resource (TR) triage protocol where the patient stops in the trauma bay for immediate evaluation by the emergency department (ED) physician and trauma nursing. We hypothesized this would allow for faster diagnostic testing and disposition while decreasing cost.Methods We performed a before/after retrospective comparison after PS implementation. Patients not meeting trauma activation (TA) criteria but requiring trauma center evaluation were assigned as a TR for an expedited PS evaluation. A board-certified ED physician and trauma/ED nurse performed an immediate assessment in the trauma bay followed by performance of diagnostic studies. Trauma surgeons were readily available in case of upgrade to TA. We compared patient demographics, Injury Severity Score, time to physician evaluation, time to CT scan, hospital length of stay, and in-hospital mortality. Comparisons were made using 95% CI for variance and SD and unpaired t-tests for two-tailed p values, with statistical difference, p<0.05.Results There were 994 TAs and 474 TRs in the first 9 months after implementation. TR’s preanalysis versus postanalysis of the TR group shows similar mean door to physician evaluation times (6.9 vs. 8.6 minutes, p=0.1084). Mean door to CT time significantly decreased (67.7 vs. 50 minutes, p<0.001). 346 (73%) TR patients were discharged from ED; 2 (0.4%) were upgraded on arrival. When admitted, TR patients were older (61.4 vs. 47.2 years, p<0.0001) and more often involved in a same-level fall (59.5% vs. 20.1%, p<0.0001). Undertriage was calculated using the Cribari matrix at 3.2%.Discussion PS implementation allowed for faster door to CT time for trauma patients not meeting activation criteria without mobilizing trauma team resources. This approach is safe, feasible, and simultaneously decreases hospital cost while improving allocation of trauma team resources.Level of evidence Level II, economic/decision therapeutic/care management study

Non-Surgical Management and Analgesia Strategies for Older Adults with Multiple Rib Fractures: a Systematic Review, Meta-Analysis, and Practice Management Guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Chest wall injury in older adults is a significant cause of morbidity and mortality. Optimal nonsurgical management strategies for these patients have not been fully defined regarding level of care, incentive spirometry, noninvasive positive pressure ventilation, and the use of ketamine, epidural and other locoregional approaches to analgesia. METHODS: Relevant questions regarding older patients with significant chest wall injury with patient Population(s), Intervention(s), Comparison(s), and appropriate selected Outcomes (PICO) were chosen. These focused on ICU admission, incentive spirometry, noninvasive positive pressure ventilation, and analgesia including ketamine, epidural analgesia, and locoregional nerve blocks. A systematic literature search and review was conducted, and our data were analyzed qualitatively and quantitatively and the quality of evidence assessed per the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. No funding was utilized. RESULTS: Our literature review (PROSPERO 2020-CRD42020201241,MEDLINE,EMBASE, Cochrane,Web of Science,1/15/2020) resulted in 151 studies. ICU admission was qualitatively not superior for any defined cohort other than by clinical assessment. Poor incentive spirometry performance was associated with prolonged hospital length of stay, pulmonary complications, and unplanned ICU admission. Noninvasive positive pressure ventilation was associated with 85% reduction in odds of pneumonia (p \u3c 0.0001) and 81% reduction in odds of mortality (p = 0.03) in suitable patients without risk of airway loss. Ketamine use demonstrated no significant reduction in pain score but a trend toward reduced opioid use. Epidural and other locoregional analgesia techniques did not affect pneumonia, length of mechanical ventilation, hospital length of stay or mortality. CONCLUSION: We do not recommend for or against routine ICU admission. We recommend use of incentive spirometry to inform ICU status and conditionally recommend use of noninvasive positive pressure ventilation in patients without risk of airway loss. We offer no recommendation for or against ketamine, epidural or other locoregional analgesia. LEVEL OF EVIDENCE: Guideline; systematic review/meta-analysis, level IV