Large cholelithiasis with cholecystoduodenal fistula.

Cholelithiasis is a common gastrointestinal pathology that can lead to rare complications including cholecystoduodenal fistulas and GI hemorrhage. Diagnosing cholelithiasis and cholecystoduodenal fistulas in the emergency department (ED) using computed tomography (CT) imaging despite nonspecific and variable symptoms is critical in determining management strategies for medically complex patients. An 87-year-old medically complex female presented to the ED in hemorrhagic shock after several episodes of hematemesis, hematochezia, and other nonspecific gastrointestinal symptoms. A CT of the abdomen/pelvis was performed revealing cholecystitis with a large 6-cm stone; additionally, a biliary enteric fistula was noted with blood products in the gallbladder. This case highlights the importance of CT imaging in the setting of gastrointestinal bleeding with cholelithiasis and biliary enteric fistula diagnosis, and discusses potential management strategies of these diagnoses in medically complex patients

Residency Reform: Anticipated Effects of ACGME Guidelines on General Surgery and Internal Medicine Residency Programs.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) has recently amended guidelines for resident work environment. This study was conducted to evaluate opinions of program directors regarding the impact of the changes on residents and residency programs. METHODS: General surgery and internal medicine program directors were sent a 19-question survey. Questions were asked regarding anticipated effects on patient safety, resident well-being, education, medical errors, implementation costs, and methods needed for compliance. Data were analyzed using the chi-square test, the Mann-Whitney method, and the independent samples t-test where appropriate. RESULTS: Responses were received from 153 surgery program directors and 126 medicine program directors. Differences noted were hours worked (surgery 84.2 hours vs medicine 68.7 hours, p \u3c 0.0005), current compliance (49% vs 73%, p \u3c 0.0005), and allowance of internal (13% vs 54%, p \u3c 0.0005) and external (24% vs 58%, p \u3c 0.0005) moonlighting. CONCLUSIONS: Program directors anticipate improved resident safety and well-being. However, education, continuity of care, and board certification success are not expected to improve. Increased cost to institutions is anticipated. Surgery program directors feel medical errors will not decrease; medicine program directors are neutral. To facilitate compliance, surgery program directors anticipate employing physicians\u27 assistants and technology, whereas medicine program directors may implement night float. Neither surgery nor medicine program directors expects increased quantity or quality of applicants. Program directors agree resident work hour reform is essential; however, varied methodology and outcomes are expected

Use of Admission Glasgow Coma Score, Pupil Size, and Pupil Reactivity to Determine Outcome for Trauma Patients.

BACKGROUND: Determination of nonsurvival in trauma patients is difficult because valid prognostic indicators are lacking. It was hypothesized that patients presenting with a Glasgow Coma Score (GCS) of 3 as well as fixed and dilated (FD) pupils do not have a reasonable chance of survival. METHODS: From 1999 through 2001, adult trauma patients (age, \u3e14 years) admitted with a GCS of 3 were reviewed. Patients receiving paralytic agents before initial assessment were excluded from analysis. Fixed and dilated pupils were defined as being 4 mm or more in diameter bilaterally and nonreactive to light. In this study, the FD patients were evaluated for survival, resuscitative measures, surgical procedures, length of hospital stay, and organ donation. The non-FD patients were evaluated for survival and length of hospital stay. RESULTS: Of the 137 patients evaluated with a GCS of 3, 104 had FD pupils and 33 did not. In the FD group, there were no survivors. On arrival, 28 (37.3%) of the patients were declared dead, and no further interventions were undertaken. Of the 76 patients (62.7%) who underwent further resuscitation, which included 53 surgical procedures, 30 died in the resuscitation bay, 39 within 24 hours, 4 within 48 hours, 2 within 72 hours, and 1 on day 6. There were 18 (23.7%) organ donors. Of the 33 patients without FD pupils, 11 (33%) survived to discharge (mean hospital stay, 21.4 days). Of the 22 nonsurvivors (67%), 10 died in the resuscitation bay, 8 within 24 hours, 1 within 48 hours, 1 on day 4, and 2 on day 6. CONCLUSIONS: Patients presenting with a GCS of 3 and FD pupils have no reasonable chance for survival. A significant percentage of these patients can be salvaged for organ donation. This information should be used in deciding to pursue aggressive resuscitation efforts and in discussing prognosis with family. Patients with a GCS of 3 who are not FD should be aggressively resuscitated because many of these patients survive to discharge