The TEAM (Trauma Evaluation and Management) course: medical student knowledge gains and retention in the USA versus Ghana.

IntroductionTrauma and injury are significant contributors to the global burden of disease, with 5 million deaths and 250 million disability-adjusted life years lost in 2015. This burden is disproportionally borne by low- and middle-income countries (LMICs). Solutions are complex, but one area for improvement is basic trauma education. The American College of Surgeons has developed the Trauma Evaluation and Management (TEAM) course as an introduction to trauma care for medical students. We hypothesized that the TEAM course would be an effective educational program in LMICs and result in increased knowledge gains and retention similar to students in high-income countries (HICs).MethodsThe TEAM course was taught and students evaluated at two sites, one LMIC (Ghana) and one HIC (USA), after obtaining approval from the HIC Institutional Review Board and medical schools at both sites. Participation was optional for all students and results were de-identified. The course was administered by a single educator for all sessions. Multiple-choice exams were given before and after the course, and again 6 months later.ResultsA total of 62 LMIC and 64 HIC students participated in the course and completed initial testing. Demographics for the two groups were similar, as was participant attrition over time. LMIC students started with a relative knowledge deficit, scoring lower on both pre-course and post-course tests than HIC students, but gained more knowledge during the initial teaching session. After 6 months, the LMIC students continued to improve, whereas the HIC students' knowledge had regressed. Most students recommended course expansion.ConclusionThe TEAM course is a useful tool to provide the basic principles of trauma care to students in LMICs, and should be expanded. Further study is needed to determine the impact of TEAM education on patient care in LMICs.Level of evidenceLevel III; Care Management

Assessment of Surgical Care Provided in National Health Services Hospitals in Mozambique: The Importance of Subnational Metrics in Global Surgery

IntroductionSurgery plays a critical role in sustainable healthcare systems. Validated metrics exist to guide implementation of surgical services, but low-income countries (LIC) struggle to report recommended metrics and this poses a critical barrier to addressing unmet need. We present a comprehensive national sample of surgical encounters from a LIC by assessing the National Health Services of Mozambique.Material and methodsA prospective cohort of all surgical encounters from Mozambique's National Health Service was gathered for all provinces between July and December 2015. Primary outcomes were timely access, provider densities for surgery, anesthesiology, and obstetrics (SAO) per 100,000 population, annualized surgical procedure volume per 100,000, and postoperative mortality (POMR). Secondary outcomes include operating room density and efficiency.ResultsFifty-four hospitals had surgical capacity in 11 provinces with 47,189 surgeries. 44.9% of Mozambique's population lives in Districts without access to surgical services. National SAO density was 1.2/100,000, ranging from 0.4/100,000 in Manica Province to 9.8/100,000 in Maputo City. Annualized national surgical case volume was 367 procedures/100,000 population, ranging from 180/100,000 in Zambezia Province to 1,897/100,000 in Maputo City. National POMR was 0.74% and ranged from 0.23% in Maputo Province to 1.78% in Niassa Province.DiscussionSurgical delivery in Mozambique falls short of international targets. Subnational deficiencies and variations between provinces pose targets for quality improvement in advancing national surgical plans. This serves as a template for LICs to follow in gathering surgical metrics for the WHO and the World Bank and offers short- and long-term targets for surgery as a component of health systems strengthening

Respect your elders- age disparities in intracranial pressure monitor use in traumatic brain injury

The Brain Trauma Foundation recommends intracranial pressure (ICP) monitor placement for patients with severe traumatic brain injury (TBI). Adherence with these guidelines in elderly patients is unknown. We hypothesized that disparities in ICP monitor placement would exist based on patient age

Respect your elders- age disparities in intracranial pressure monitor use in traumatic brain injury

The Brain Trauma Foundation recommends intracranial pressure (ICP) monitor placement for patients with severe traumatic brain injury (TBI). Adherence with these guidelines in elderly patients is unknown. We hypothesized that disparities in ICP monitor placement would exist based on patient age

Electronic health record machine learning model predicts trauma inpatient mortality in real time: A validation study

IntroductionPatient outcome prediction models are underused in clinical practice because of lack of integration with real-time patient data. The electronic health record (EHR) has the ability to use machine learning (ML) to develop predictive models. While an EHR ML model has been developed to predict clinical deterioration, it has yet to be validated for use in trauma. We hypothesized that the Epic Deterioration Index (EDI) would predict mortality and unplanned intensive care unit (ICU) admission in trauma patients.MethodsA retrospective analysis of a trauma registry was used to identify patients admitted to a level 1 trauma center for >24 hours from October 2019 to July 2020. We evaluated the performance of the EDI, which is constructed from 125 objective patient measures within the EHR, in predicting mortality and unplanned ICU admissions. We performed a 5 to 1 match on age because it is a major component of EDI, then examined the area under the receiver operating characteristic curve (AUROC), and benchmarked it against Injury Severity Score (ISS) and new injury severity score (NISS).ResultsThe study cohort consisted of 1,325 patients admitted with a mean age of 52.5 years and 91% following blunt injury. The in-hospital mortality rate was 2%, and unplanned ICU admission rate was 2.6%. In predicting mortality, the maximum EDI within 24 hours of admission had an AUROC of 0.98 compared with 0.89 of ISS and 0.91 of NISS. For unplanned ICU admission, the EDI slope within 24 hours of ICU admission had a modest performance with an AUROC of 0.66.ConclusionEpic Deterioration Index appears to perform strongly in predicting in-patient mortality similarly to ISS and NISS. In addition, it can be used to predict unplanned ICU admissions. This study helps validate the use of this real-time EHR ML-based tool, suggesting that EDI should be incorporated into the daily care of trauma patients.Level of evidencePrognostic, level III

Association of 30-ft US-Mexico Border Wall in San Diego With Increased Migrant Deaths, Trauma Center Admissions, and Injury Severity.

This observational study assesses the changes in morbidity and mortality of border wall injuries after construction of the 30-ft border wall in San Diego and Imperial Counties, California

Management of choledocholithiasis in the elderly: Same-admission cholecystectomy remains the standard of care.

BackgroundCurrent guidelines recommend that patients with choledocholithiasis undergo same-admission cholecystectomy. The compliance with this guideline is poor in elderly patients. We hypothesized that elderly patients treated with endoscopic retrograde cholangiopancreatography (ERCP) alone would have higher complication and readmission rates than the patients treated with cholecystectomy.MethodsThe Nationwide Readmissions Database was queried for all patients aged ≥65 years with admission for choledocholithiasis January to June 2016. The patients were divided based on index treatment received: (1) no intervention; (2) ERCP alone; or (3) cholecystectomy. Multivariate analyses identified predictors of cholecystectomy during index admission and of readmissions.ResultsA total of 16,121 patients with choledocholithiasis were admitted; 38.4% underwent cholecystectomy, 37.6% endoscopic retrograde cholangiopancreatography alone, and 24.0% no intervention. The patients not receiving a cholecystectomy were more likely to be older, female, have a higher Elixhauser score, do-not-resuscitate status, and at a teaching hospital (all P < .001). Emergency readmissions for recurrent biliary disease were lowest in patients undoing a cholecystectomy (2.2% vs 9.2% endoscopic retrograde cholangiopancreatography and 12.4% no intervention, P < .001), as were readmissions for complications (3.6% vs 5.5% and 7.8%, P < .001). Cholecystectomy reduced rates of readmissions for recurrent disease (odds ratio 0.168, P < .001), for complications (odds ratio 0.540, P < .001), and death during readmission (odds ratio 0.503, P = .007); endoscopic retrograde cholangiopancreatography alone reduced only rates of readmissions. Age was not a predictor of readmission or death.ConclusionIndex admission cholecystectomy is associated with a lower risk of readmission for biliary disease or complications, as well as death during readmission, in elderly patients. Age alone is not predictive of outcomes; surgical intervention should be guided by clinical condition, comorbidities, and patient preference

Ultrasound-guided percutaneous intercostal nerve cryoneurolysis for analgesia following traumatic rib fracture -a case series.

BackgruondRib fractures are a common injury in trauma patients and account for significant morbidity and mortality within this population. Local anesthetic-based nerve blocks have been demonstrated to provide significant pain relief and reduce complications. However, the analgesia provided by these blocks is limited to hours for single injection blocks or days for continuous infusions, while the duration of this pain often lasts weeks.CaseThis case series describes five patients with rib fractures whose pain was successfully treated with cryoneurolysis.ConclusionsUltrasound-guided percutaneous cryoneurolysis is a modality that has the potential to provide analgesia matching the duration of pain following rib fractures