20.06 #Ilooklikeasurgeon: 20-year Review of Gender and Racial Diversity in Academic General Surgery

Posted on January 31, 2019

L. Marcia1, A. Moazzez1,2, R. Miranda1, D. Y. Kim1,2, C. DeVirgilio1,2  1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 2Harbor-UCLA Medical Center,Surgery,Torrance, CA, USA

Introduction:  For years there has been ongoing efforts to diversify medicine as the United States (US) population continues to change. Our objective was to assess the past and current state of gender and racial diversity in general surgery.

Methods:  Demographic data from 1997-2016 was obtained from publications on graduate medical education by the Journal of American Medical Association, and the Association Medical Colleges. The percent change per year was calculated using a linear regression model.

Results: In 2016, women represented 50.8% of the US population, but only 10.4% of full professors, 20.0% of associate professor, 26.7% of assistant professors and 49.2% on instructors. The highest increase per year was seen among female instructor 1.16%, p<0.001) and the least among full professor (0.39%, p<0.001). From 1997 to 2016, the percentage of female general surgery residents increased from 20.5 to 38.4. Hispanic/Latino represented 17.8% of the population, but only 4.96% of faculty, and 8.24% of general surgery residents. African American represented 13.3% of population, but only 2.69% of faculty, and 5.50% of general surgery residents. American Indian/Alaskan Native represented 1.3% of population, but only 0.10% of faculty and 0.19% of general surgery residents.

Conclusion: In the last 20 years, there has been increase in gender and racial diversity in surgery. However, women, American Indian, African American and Hispanic continue to be underrepresented in certain categories of the surgical pipeline. 
 

20.04 Trends in United States Residency Match Rates for International Medical Graduates

Posted on January 31, 2019

C. Buonpane1, S. Hayek1, M. Fluck1, H. Ellison1, M. Shabahang1  1Geisinger Medical Center,General Surgery,Danville, PA, USA

Introduction: Every year the United States (US) Main Residency Match seeks to couple medical school graduates with available residency positions. Historically, there have been more applicants than available positions. The majority of applicants completed their undergraduate medical education in the US; however, a growing portion of applicants are coming from international medical schools. International medical graduates (IMGs) play a crucial role in the physician work force in the US, filling shortages that cannot be met by US allopathic and osteopathic graduates alone. This study seeks to examine the trends in match rates of IMGs into US allopathic residency positions over the past thirty years.

Methods: US residency match data was obtained from the National Resident Matching Program (NRMP) for the years of 1986 to 2016. Linear trends were used to evaluate match data over time and subspecialty analysis was performed. Longitudinal 10-year match rate projections were also made.

Results:

In 1986, IMGs composed 4,965 of 21,357 applicants and 27.8% of IMGs successfully matched into a US allopathic residency. In 2016, IMGs composed 6,638 of 35,476 applicants and 52% matched (87% increase). IMGs were then separated into American citizens (US-IMG) and those who did not have American citizenship (non US-IMG). From 1986 to 2016, US-IMG match rates increased by 40% and non-US IMG match rates increased by 110%. 

 

Allopathic residencies in primary-care specialties demonstrated overall growth in available positions over the study period and an increase in reliance on US-IMGs to fill those positions.  Internal medicine filled 4.8% of 4,682 positions with US-IMGs in 1986 and 14.6% of 6,938 positions in 2016 (204% increase).  Family medicine programs filled 4.3% of 1,960 positions in 1986 and 23.6% of 3,083 positions in 2016 (449% increase).  Longitudinal ten-year match rate projections suggest that 15.3% of internal medicine and 30.2% of family medicine US allopathic residency positions will be filled by US-IMGs in 2026.  

 

Categorical general and orthopedic surgery positions were also analyzed. In general surgery, US-IMG filled positions increased over 400% (from 1.3% of 1,249 positions in 1986 to 6.6% of 1,239 positions in 2016) with a projection of 8.1% of positions being filled by US-IMGs in 2026. In orthopedic surgery, US-IMGs filled 0.29% of 342 positions in 1986 and 0.83% of 717 positions in 2016 (186% increase).

 

During the study period, non US-IMG match rates also increased.  Non US-IMG applicant filled positions increased from 9-29% in internal medicine (222% increase), 1.8-12.4% in family medicine (589% increase), 3.8-4.6% in general surgery (21% increase) and 0.58-1.1% in orthopedic surgery (90% increase).

Conclusion:The percentage of IMGs filling US allopathic residency positions has increased over the last 30 years and is projected to continue increasing. This increase in reliance on IMGs has been particularly strong in primary care fields. 
 

20.03 Medical Student Grit: Impact of Third Year on Medical Students’ Perseverance of Effort

Posted on January 31, 2019

N. E. Anton1, M. A. Rendina1, K. Stanton1, J. N. Choi1  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA

Introduction:
Grit, a psychological trait characterized by passion and perseverance for long-term goals, enables individuals to work towards the completion of long-term goals in spite of repeated challenges, failure, and adversity. Grit has been identified as a predictor of resident attrition in surgical residency, and a marker of residents at risk for poor psychological well-being in the future. Among medical students, grit is associated with learning and performance in gross anatomy, which may indicate that grit is an important element of medical student success. However, in United States medical schools, the third year of medical school (MS3) presents unique challenges related to patient care, interacting with diverse senior healthcare providers, and determining one’s eventual career path. Thus, unlike the first two years of medical school, the distinct challenges of MS3 may erode medical students’ grit. Accordingly, our goal in the present study was to assess the impact of MS3 on medical students’ grit.

Methods:
Incoming MS3s were recruited to voluntarily participate in our study at the start of their third year. Following informed consent, participating MS3s completed the Short Grit Scale, which is an eight-item self-report measure of grit. A single grit score is derived, in addition to two subscales, which include consistency of interest and perseverance of effort. At the conclusion of their third year, participating MS3s were contacted via electronic mail to complete Short Grit Scale again. Paired two-tailed t-tests were utilized to assess pre- to post-MS3 differences in grit and the two subscales. P-values less than 0.05 were considered significant.

Results:
One hundred and seven MS3s (39.8% Female) completed both Short Grit Scales. From pre-MS3 to post-MS3, there was a significant decrease in grit scores (Pre: 3.99±0.46 to Post: 3.87±0.49, p<0.001). Regarding subscale items, there were no differences in pre- to post-MS3 consistency of interest scores. However, there was a significant decrease in perseverance of effort from pre- to post-MS3 (Pre: 4.18±0.48 to Post: 4±0.51, p<0.001).

Conclusion:
Medical student grit, particularly perseverance of effort, may be at risk to decrease significantly due to the rigors of their third year, which consists of unique challenges that they have not been previously exposed to, as well as important decisions regarding their future career paths. It is currently unclear what specific factors contribute to medical students’ decreased grit during their third year, but it is apparent that there is a need for dedicated training to enhance medical student grit due to its importance for their psychological well-being in residency. Accordingly, interventions designed to promote medical student resilience and grit during their third year are warranted.
 

20.02 Medical Student Perception of Morbidity and Mortality Conference

Posted on January 31, 2019

A. P. Worden1, P. Kandagatla1, A. H. Gupta1, C. Steffes1  1Henry Ford Health System/Wayne State University,Surgery,Detroit, MICHIGAN, USA

Introduction:  Morbidity and mortality (M&M) conference has long been a vital educational tool for medical students, residents, and staff. It allows for learning and quality improvement through discussion of noteworthy cases. There is, however, a paucity of data on the how M&M is perceived by medical students, especially as a function of their interest, or lack thereof, in surgery. The objective of this study was to fill this void by measuring the perceptions of medical students regarding M&M conference.

Methods:  Medical students in a single medical school class voluntarily took part in a survey after their surgical rotation. The survey gauged students’ interest in surgery as a career and their overall rating of M&M. Students were specifically asked to recall if specific types of cases (resident at fault, medical error, non-therapeutic operation, pre- or post-operative mismanagement, multiple levels of error, and preventable or non-preventable error) were discussed. They were also asked to recall if tenets of surgical care (patient safety, quality improvement, root cause analysis, never events, time out/critical pause, complication vs preventable error) were discussed during M&M. Responses were tabulated and descriptive statistics were performed to summarize the data. Univariate analysis with a Chi-squared test, or Fisher’s Exact test when appropriate, was performed for association.

Results: A total of 251 students were surveyed over four clinical sites. Of these students, 236 (94.0%) felt they understood the purpose of M&M, and 233 (88.8%) students felt they understood quality improvement in medicine and surgery. However, only 136 (54.2%) students reported M&M as a valuable learning experience. Discussion of the following was associated with a positive experience: examples of patient safety (93.4% vs 84.3%, p=0.02), preventable (91.2% vs 75.4%, p<0.01) or non-preventable (76.5% vs 55.3%, p<0.01) errors, quality improvement (95.6% vs 71.9%, p<0.01), and root cause analysis (59.6% vs 40.4%, p<0.01). Students were less likely to have a positive experience if they perceived M&M as a resident ‘grilling session’ (31.6% vs 51.4%, p<0.01). There was no association between interest in a surgical subspecialty and perceiving M&M as a positive learning experience (48.5% vs 50.5%, p = 0.29).

Conclusion: Overall, only a very small majority of medical students view M&M as a positive learning experience. Introducing structured concepts focusing on quality improvement may serve as a viable strategy to enhance the learning experience. Prospective studies incorporating such a curriculum are warranted.

20.01 Correlation Between Burnout, Stress, Work-Family Conflict, and Self-Efficacy in Surgical Faculty

Posted on January 31, 2019

M. R. Smeds1, M. Harlander-Locke2, H. K. Sandhu3, S. Allen4, K. Amankwah5, P. Ansari6, K. Charlton-Ouw3, D. Hess7, P. Jackson8, M. Johnson9, M. K. Kimbrough10, D. Knight11, G. M. Longo12, B. Shames13, J. Shelton14, P. Yoo15, M. Smeds1  1Saint Louis University School Of Medicine,Division Of Vascular And Endovascular Surgery,St. Louis, MO, USA 2Lake Erie College of Osteopathic Medicine,Bradenton, FL, USA 3McGovern Medical School at UTHealth,Houston, TX, USA 4Penn State Hershey Medical Center,York, PA, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6Lenox Hill Hospital,New York, NY, USA 7Boston University,Boston, MA, USA 8Medstar Georgetown University Hospital,Washington, DC, USA 9University of South Dakota,Vermillion, SD, USA 10University of Arkansas for Medical Sciences,Little Rock, AR, USA 11Waterbury Hospital,Waterbury, CT, USA 12University Of Nebraska College Of Medicine,Omaha, NE, USA 13University of Connecticut School of Medicine,Farmington, CT, USA 14University Of Iowa,Iowa City, IA, USA 15Yale University School Of Medicine,New Haven, CT, USA

Introduction:
Burnout is a work-related syndrome involving emotional exhaustion, depersonalization, and a sense of reduced personal accomplishment that has become prevalent in all areas of medicine.  We sought to understand factors associated with burnout in surgical faculty including self-efficacy, perceived stress, work-family relationship and depression.

Methods:
Anonymous electronic surveys consisting of demographic information as well as validated scales for burnout, depression, perceived stress, self-efficacy, social support, and work-family conflict were sent to all surgical faculty at 14 general surgery residency programs.  Respondents were grouped into quartiles based on burnout level, and predictors of burnout were determined using univariate and multivariate analysis comparing those in the highest quartile to all others.

Results:
Of 731 invitations sent, 240 (33%) surgeons responded.  Those in the highest quartile of burnout were younger (45.5 vs. 48.1, p=0.049), more likely to have higher perceived stress (p<0.001), work-family conflict (p<0.001), and moderate or severe depression (p<0.001) and lower perceived social support (p<0.001) and self-efficacy (p<0.001).  Amount of educational debt, years out from training, gender, marital status, proximity of immediate family, and having children did not correlate with burnout, nor did work-related factors of frequency of call, number of hospitals covered, percent clinical involvement, number of cases performed per week, attainment of divisional/departmental leadership roles or overall compensation.  On multivariate logistic regression analysis, higher perceived stress (OR 1.51, p<0.001), depression (OR 2.730, p=0.004), and work-family conflict (OR 1.2, p=0.012) were related to higher levels of burnout while self-efficacy was protective against burnout (OR 0.89, p=0.046).  Those with the highest levels were unlikely to select surgery as a career if they could do it all over again (OR 0.093, p=0.001).

Conclusion:
Burnout in surgical faculty is associated with depression, high perceived stress, increased work-family conflict, and low self-efficacy.  Improving work-family balance and self-efficacy and decreasing stress may improve levels of burnout in surgical faculty.
 

15.13 Meta-Analysis of Superficial Temporal Artery Anatomy

Posted on January 31, 2019

C. D. Liao1, S. Svoboda1, M. Applebaum1,2, J. Thompson1,2  1Virginia Tech Carilion School of Medicine,Roanoke, VA, USA 2Carilion Clinic,Department Of Plastic And Reconstructive Surgery,Roanoke, VA, USA

Introduction:  

In head and neck reconstruction, the superficial temporal artery (STA) and vein are often the first-choice recipient vessels for tissue flaps. Thorough understanding of STA anatomy and variability is crucial for avoiding surgical complications.

To date, no study has determined the influence of patient characteristics such as ethnicity, age, and sex on anatomical variations in the STA, underscoring a need to record these data in future studies. Additionally, study designs of reports documenting STA anatomy vary considerably. Therefore, more robust and comprehensive studies are necessary to accurately capture STA anatomy, enable more skillful dissections, and minimize complications.

A comprehensive review of the current literature offers an appropriate starting point. This study aims to provide surgeons with accurate and reliable measurements of STA architecture to promote safe dissection.

Methods:

We screened 1,105 studies by title/abstract. We consolidated data from 16 primary reports, all of which were examined for study design, patient characteristics, and relevant anatomical data.

Results:

The 16 studies represent patient populations in 11 different countries and yielded a total of 961 STAs for analysis. About half of the studies were cadaveric; the other half were angiographic. The male-to-female ratio is 57:43 among the studies that specified these details (N = 343 subjects). On average, only about 6 out of 16 of the studies documented important patient descriptors such as health status, sex, ethnicity, and age.

About 98% of STAs were reported to have two branches. About 74% of STAs bifurcated above the zygomatic arch; furthermore, we discovered considerable variation in the level of bifurcation among the 16 studies. Forest plots demonstrated that the average diameters of the STA, frontal branch, and parietal branch differ significantly from the pooled average in all categories, indicating cross-study inconsistencies. The pooled average diameters of the STA, frontal branch, and parietal branch were 2.03 ± 0.09 mm, 1.53 ± 0.06 mm, and 1.48 ± 0.06 mm, respectively. Distance of the STA anterior to the pinna was also inconsistent among the 3 studies that reported this information; the pooled average was 1.46 ± 0.12 cm. Comparing radiologic and cadaveric studies demonstrated significant differences in reported parietal and frontal artery diameters, but no differences in STA diameter, level of bifurcation, and number of branches.

Conclusion:

This meta-analysis provides a necessary first step in revisiting anatomical architecture and variability of the STA, which can promote positive outcomes for patients requiring flaps for head and neck reconstruction. Future work will entail collection of anatomical data with consistent documentation of patient characteristics.
 

15.10 Implications of incidental abdominal CT angiography findings on free flap breast reconstruction

Posted on January 31, 2019

L. M. Ngaage1,2, D. Ghorra3, G. Oni3, B. C. Koo4, J. Ang2, S. L. Benyon3, M. S. Irwin3, C. M. Malata3,5,6  1Imperial College Trust,Foundation School,London, ENGLAND, United Kingdom 2University of Cambridge,School Of Clinical Medicine,Cambridge, ENGLAND, United Kingdom 3Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic & Reconstructive Surgery,Cambridge, ENGLAND, United Kingdom 4Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Department Of Radiology,Cambridge, ENGLAND, United Kingdom 5Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust,Cambridge Breast Unit,Cambridge, ENGLAND, United Kingdom 6Anglia Ruskin University,School Of Medicine,Chelmsford & Cambridge, ENGLAND, United Kingdom

Introduction:
Preoperative CT angiography (CTA) of the abdominal wall vessels is routinely used when planning free flap breast reconstruction (FFBR) because it provides a surgical roadmap, which facilitates flap harvest. However, there are few reports on the effect of incidental findings on the operative plan.

Methods:
A retrospective study of all FFBRs performed at a tertiary referral centre for breast reconstruction over a six-year period (November 2011 to June 2017) was conducted. One consultant radiologist (BCK) reported on the findings. Details on patient demographics, CTA reports, and intraoperative details were collected.

Results:
200 patients received preoperative CTAs. 14% of patients (n=28) had incidental findings. Of the incidental findings, 18% were vascular anomalies; 36% tumour-related and 46% were “other”. In four patients, findings were severe enough to prevent surgery. They comprised of mesenteric artery aneurysm, absent DIEVs due to previous surgery, bilateral occluded DIEAs, and significant bone metastasis. Another patient had no suitable vessels for a free flap and the surgical plan converted to a pedicled TRAM flap. The remaining incidental findings had no impact on the surgical plan or appropriateness of a free flap breast reconstruction. Nearly a quarter of those with incidental findings went on to have further imaging before their operation. 

Conclusion:
CTA in breast reconstruction can have a wider impact than facilitating surgical planning and reducing operative times.  Incidental findings can influence the surgical plan, and in some instances, avoid doomed to fail and unsafe surgery. It is important that these scans are reported by an experienced interventional radiologist. 
 

15.06 Bipedicled DIEP & SIEA Lower Abdominal Perforator Free Flaps For Unilateral Breast Reconstruction

Posted on January 31, 2019

I. See1,3, D. T. Ghorra2,3, L. MacLennan3, N. G. Rabey3, C. M. Malata3,4,5  1University Of Auckland,Auckland, AUCKLAND, New Zealand 2University of Alexandria,Alexandria, ALEXANDRIA, Egypt 3Cambridge University Hospitals NHS Foundation Trust,Department Of Plastic And Reconstructive Surgery,Cambridge, CAMBRIDGE, United Kingdom 4Addenbrooke’s University Hospital,Cambridge Breast Unit,Cambridge, CAMBRIDGE, United Kingdom 5Anglia Ruskin University School of Medicine,Cambridge & Chelmsford, CAMBRIDGE & CHELMSFORD, United Kingdom

Introduction: Double-pedicled lower abdominal free flaps are an effective technique for postmastectomy autologous reconstruction of patients who are slim, nulliparous, large-breasted relative to their abdominal pannus or have midline abdominal scars. These are particularly useful when adjuvant radiotherapy is planned or implant-based reconstruction is declined. Studies suggest they carry no increased morbidity over unipedicled flaps. Both extraflap (independent) and intraflap (dependent) microvascular anastomoses have been employed but utilizing rib-sacrifice technique of internal mammary recipient vessel exposure. We report a consecutive series of 40 patients (80 flaps) undertaken with both configurations without recourse to rib sacrifice. An algorithm incorporating CT angiography of the lower abdominal wall is presented.

Methods: Patients undergoing bipedicled flap unilateral breast reconstruction by a single surgeon (2010-2018) were reviewed with respect to flap type, anastomotic configuration, intercostal space(s) used for the microsurgery and the flap outcomes.

Results: 40 consecutive double-pedicled free flaps (20% of the all breast free flaps) utilizing both intra-flap (n=11) and extra-flap (n=29) techniques with no partial or total flap losses and only one postoperative re-exploration for flap salvage were undertaken in 40 patients with a median age of 46 years (range 27-66). 32 reconstructions were immediate, 3 delayed, and 5 salvage (tertiary). The series comprised 67 deep inferior epigastric artery perforator (DIEP) and 13 superficial inferior epigastric artery (SIEA) flaps. All 80 anastomoses but three (which used the thoracodorsal system) were performed to the internal mammary vessels using the total rib-preserving method. The combinations used were DIEA/DIEA (29), DIEA/SIEA (9) and SIEA-SIEA (2). The median surgery duration was 697 (range 468-790) with a first flap ischemia time of 104 minutes. The 2nd space was used in 22 patients and both 2nd and 3rd in 18 patients. The vein of the 2nd flap was anastomosed anterogradely to the bifurcated IMV vein in 10 cases, retrograde limb in 25, intraflap continuity in 10 and to the thoracodorsal vein in two. The arterial anastomosis of the 2nd pedicle was performed to the retrograde IM artery in 24 cases. Five breasts were liposuctioned for reshaping and three showed minor fat necrosis, which did not require excision.

Conclusion: Bipedicled free abdominal perforator flaps are a reliable option for unilateral breast reconstruction. In view of their technical complexity and prolonged surgical duration, our algorithm facilitates microsurgical flap design in terms of flap pedicle, recipient vessels, and anastomotic permutations to enable successful execution of these operations. CT angiography helps to predict those patients who will benefit from intraflap anastomoses (Moon & Taylor type II vascular anatomy) and thus do not need apriori exposure of the 3rd intercostal space.

105.17 Why Interested Surgeons Not Choose Rural Surgery: What can We Do Now?

Posted on January 31, 2019

N. Frohne1, M. Sarap1, A. Alseidi2, L. Buckingham1, P. P. Parikh1  1Wright State University,Department Of Surgery,Dayton, OH, USA 2Virginia Mason Medical Center,Seattle, WA, USA

Introduction: There is a growing deficit of rural general surgeons and preparation to meet this need is inadequate. Further, there is limited data focusing on the factors of rural general surgery training that surgeon’s use to decide on practijce location. More research into stratifying factors that specifically influence choice in rural versus urban practice is needed.

Methods:  Rural was defined as a population of less than 50,000 per the U.S Census Bureau. An IRB approved Qualtrics survey was distributed to general surgeons and surgery residents nationwide through the American College of Surgeons (ACS) and American College of Osteopathic Surgeons (ACOS). This completely voluntary survey included questions related to prior rural experience, reasons for selecting or not selecting rural practice, and factors that could increase rural retention.  Further, the respondents were requested to provide narrative comments on how to improve recruitment and retention of rural surgeons. The responses were   analyzed for themes using constant comparative method. 

Results: Out of total 416 respondents, 74% were male. Further, 287(69%) respondents had previous exposure to rural surgery (Fig1). Of those with prior rural experience, 71 (25%) chose or would not choose to not continue with a rural career due to lack of professional/hospital support and lifestyle of a rural surgeon. Other reasons such as job opportunities, specialty practice, and no opportunities for teaching or pursuing academic surgery also hindered their choice of considering rural surgery career.  A broad scope of practice was most important among rural surgeons (52%) who chose rural practice without any previous rural experience. Over 60% of respondents without prior rural experience agreed that improved lifestyle and financial advantages would attract them to rural practice. Thematic analysis suggests that more tie ups with academic institutions, more support from the rural hospitals, rural rotations earlier in training, more mentoring and rural surgeon as a role model would help increase the number of rural surgeons.

Conclusion: Our results help focus specific resources in the rural setting. Providing appropriate hospital support in these areas and promoting specific aspects of rural practice to those in training could help grow interest in rural surgery. Strong collaboration with academic institutions for teaching, learning and mentoring opportunities for rural surgeons could lead to higher satisfaction, security, and potentially higher retention rate. A rural surgeon mentor would further influence the choice of practice location. Improving rural economic factors can provide some of the larger urban center qualities in a rural setting that may appeal to urban leaning surgeons.

105.12 What Is Global Surgery? Identifying Misconceptions Among Medical Students and Health Care Professionals

Posted on January 31, 2019

M. N. Abraham2, P. J. Abraham1, H. Chen1, K. M. Hendershot1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA

Introduction:  Over the last five years, global surgery has emerged as a new field within academic surgery. Global surgery has been defined as “an area for study, research, practice, and advocacy that places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by surgical conditions or have a need for surgical care.” Despite such unifying attempts to provide a common definition, it is unclear whether health care professionals and medical students understand what is meant by the term “global surgery.” This study aims to characterize the understanding of global surgery and what it means to be an academic global surgeon.

Methods: One hundred medical students, residents, physicians, nurses, and allied health care professionals were interviewed on their perceptions of global surgery using a six-question qualitative survey. Respondents were categorized based on gender and apparent age <40 or >=40 years old. Survey responses were coded and analyzed for common themes by two reviewers independently. SPSS was utilized for statistical analysis.

Results: Of the 100 health care professionals surveyed, 61% did not know the meaning of global surgery. While there was no difference between men and women, participants under age 40 were significantly more likely to relay an accurate definition (51% vs 17%, p=0.001). Of participants with knowledge of global surgery, 44% had previous exposure to a global health field and 85% expressed interest in global health or global surgery. Respondents described components of academic global surgery as “research”, “teaching,” “practicing,” and using “evidence-based medicine.” An effective career in global surgery was most often categorized as “sustainable” and “impactful.”

Conclusion: Although often used in academic surgical settings, the term “global surgery” is not well-understood among health care professionals and medical students. Even among those who are familiar with the term, there is no clear consensus on what it means to be a global surgeon or what constitutes a successful career in global surgery.

 

105.11 Implementation of Hemorrhage-Control Training Into The Medical School Curriculum

Posted on January 31, 2019

J. T. Gowen1, J. D. Wolfe1, K. W. Sexton1, C. R. Thrush1, A. Privratsky1, W. C. Beck1, J. R. Taylor1, B. Davis1, M. K. Kimbrough1, R. D. Robertson1, A. Bhavaraju1  1University Of Arkansas for Medical Sciences,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Little Rock, AR, USA

Introduction:  To comply with the ACS goal of zero preventable deaths from trauma, we incorporated hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of medical students with controlling major hemorrhage, and they will find this a valuable skillset for physicians and other health care professionals to possess.

Methods:  After IRB and institutional approval was obtained, hemorrhage-control training was taught to all third-year medical students during their surgery clerkship, beginning in May 2018. The training was completed in accordance with the American College of Surgeons’ Stop the Bleed (STB) program, details of which can be found at www.bleedingcontrol.org. Using a prospective study design, all trainees completed pre- and post-training surveys to gauge their prior experiences and comfort levels with controlling major hemorrhage, and their confidence levels with the techniques taught during the program. A knowledge quiz was completed immediately following the training. JMP Pro V13 (SAS; Cary, NC) was used for statistical analysis with significance set at p = 0.05.

Results: 47 students were trained and completed surveys. 43 out of 47 students (91%) reported only minimal first aid training or no experience at all with hemorrhage control; 1 student reported prior training. Comfort level with hemorrhage control and confidence level with all basic hemorrhage-control techniques showed statistically significant increases after training, with 100% of students reporting feeling confident or very confident in the application of these techniques. There was a trend towards, but not a statistically significant difference in students’ perceptions of the importance of this training for physicians (p=0.06) and the need to include STB training in medical school curricula (p=0.59) before and after STB training, which we attribute to the high positive response rates on the pre-survey. The mean percent correct on the quiz was 97.1%.

Conclusion: Hemorrhage-control training can be easily and effectively incorporated into the formal medical school curriculum with minimal effort via a single 2-hour Stop The Bleed course, increasing students’ comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education, and possibly that of other healthcare professionals. We believe this should be a standard part of undergraduate medical education. Further work needs to be done to determine retention of these skills over time and if this training can be similarly incorporated into the curricula of other allied health professional schools.

 

105.10 Training Global Surgery Advocates: Strengthening the Global Surgery Voice

Posted on January 31, 2019

D. Vervoort1, X. Ma2  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2Université de Montréal,Montréal, QUÉBEC, Canada

Introduction:  Five billion people worldwide lack access to safe surgery when needed, causing 17 million preventable deaths each year and responsible for one-third of the global burden of disease. Despite the increasing recognition as an indispensable part of healthcare, surgery remains perceived as a luxury, and difficulties of scaling up surgical care remain widespread. InciSioN – International Student Surgical Network – is the world’s leading trainee global surgery network comprising over 3,000 medical students, residents, and young doctors from over 70 countries. InciSioN provides a platform to foster the development of future generations of global surgeons, anaesthesiologists, and obstetricians around the world.

Methods:  To strengthen, unify, and escalate InciSioN’s voices around the world, Training Global Surgery Advocates (TGSA), a standardized three-day advocacy workshop, was created. The 27-hour workshop is built on traditional didactic lectures, role-play exercises, and small working group activities, as well as advocacy and diplomacy training to provide participants with the needed knowledge and skills to effectively advocate for global surgery. During the pilot program, participants performed a baseline elevator pitch advocating for global surgery on day 1 and a prepared elevator pitch at the end of day 3 to formally assess progress. A questionnaire on the perceived familiarity, knowledge and motivation regarding the workshop and its topics was filled by participants before the beginning of the workshop and immediately after the workshop. Assessment was done using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) for 18 components.

Results: 25 participants were selected from a pool of 52 applicants, of which 14 medical students from 14 different countries (7 high-income countries, 7 low- and middle-income countries) were able to attend the workshop in Quebec City, Canada. 11 students were unable to participate due to restrictions by visa issues (9 people) or personal reasons (2 people). An average net increase of 1.73 points across all 18 components was observed among participants. Participants lauded the mix of theory and practical exercises to integrate knowledge into practice, the diversity of participants, and the focus on soft skills for advocacy and diplomacy. During the post-assessment, all participants agreed or strongly agreed (average of 4.64 points) on their motivation to train other medical students in their respective countries to become global surgery advocates.

Conclusion: TGSA significantly improved participants’ knowledge and advocacy skills in the field of global surgery. This type of mixed didactic and hands-on workshop appears to be feasible, enjoyable for participants, and effective in improving medical students involvement in the emerging field of global surgery.

 

105.09 In-person hemorrhage control training effectiveness and comprehension in low-resource rural Kenya

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. A. Sullivan3, H. Jung2, K. L. Long1  3University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Division Of Trauma, Acute Care Surgery, Burn And Surgical Critical Care/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
The American College of Surgeons Committee on Trauma developed the Stop the Bleed (STB) program in 2015 as a mechanism to prepare the public for response to life-threatening bleeding or mass casualty incidents. Assessments of STB in the United States (US) have shown the training’s effectiveness in improving comfort and skill in aiding a trauma victim. While the program continues to spread throughout the US, to the best of our knowledge, it has not been conducted and evaluated in low or middle-income countries. Kenya has a high burden of injuries and violence accounting for 88.4 deaths per 100,000 people. Addressing this burden is a healthcare priority in the country. STB training represents a potential intervention that could reduce trauma morbidity and mortality in a country with limited healthcare resources. The purpose of this study was to assess the effectiveness and retention of STB training in Kenya as compared to implementation in the US, the population for which it was originally designed.  

Methods:
This quasi-experimental study assessed differences between a STB intervention post-test conducted in the US and in Kenya. The two samples consisted of volunteer participants with no medical background. The STB training was advertised, and any willing participants were recruited into the study. The population of interest was recruited in Migori Kenya (n=19), the comparison population in Wisconsin, United States (n=12). Each group received the same STB training course in July 2018 by physicians trained to give STB instruction from the same US institution. After completing the course, each group received the same 5-question post-test, designed to assess effectiveness and comprehension of the material. The quizzes were anonymous and taken voluntarily. The quiz scores between each group were compared using the Mann-Whitney U Test.

Results:
There is a statistically significant (p=0.04) difference in the quiz scores between the US (n=12) and Kenya samples (n=18). The Kenyan and US mean scores were 3.9 and 4.7 out of a possible 5, respectively. If one quiz question is excluded from analysis, there is no significant difference between the two group’s quiz scores (p=0.41). The individual question that significantly lowered the mean score in the Kenyan sample was: “What is the first step when approaching an injured, bleeding person?”, which may identify a difference in interpretation of the material.

Conclusion:
In general, both samples studied demonstrated good comprehension of the STB core concepts.  In detailed review of the post-test scores, only one question was significantly different in answers among the Kenya and US participants.  Additional studies to assess long-term retention of these concepts will be necessary in both populations.  Understanding the discrepancies between the assessments in differing populations may contribute to the validation and utility of this STB post-intervention evaluation.

105.08 EARLY ENGAGEMENT HAS A SUSTAINED POSITIVE IMPACT ON MEDICAL STUDENTS' PERCEPTIONS OF SURGICAL CAREERS

Posted on January 31, 2019

P. S. Virtanen1, L. Timsina1, T. Esposito2, G. Rozycki1, J. Hartwell1  2University of Illinois,Peoria, ILLINOIS, USA 1Indiana University School Of Medicine,General Surgery,Indianapolis, IN, USA

Introduction:
Prior studies have demonstrated that brief, early exposure of medical students to surgery  is effective, creates positive perceptions of surgical career options and helps overcome negative stereotypes medical students may have of surgery . Opportunities for preclinical medical student (MS1, MS2) exposure to surgical careers are not universally available nor are the long term effects of such engagement well understood. 

Methods:
Our institution’s Surgery Student Interest Group (SIG) created a trauma shadowing experience which included observation of rounds, trauma resuscitation, operative procedures and interactions with resident and attending staff. Students were recruited via a SIG website announcement and an on-line registration form. Follow-up electronic surveys were sent immediately after the experience to all participants (n=109). If one year had elapsed during the study period (December 2016-July 2018) since the shadowing experience, a 1-year follow up survey was sent (n=77). Data gathered included demographics, student perceptions about surgery, and the experience itself. Fisher’s exact tests and matched Wilcoxon signed-rank tests were performed.

Results:
Overall, 59 immediate surveys (54.1%) and 24 1-year follow up surveys (31.2%) were returned. Of the 59 immediate responses, 55.9% (n=33) were female, and 93.2% self-identified as MS1/MS2 (n=55). Of the immediate responses, 94.9% (n=56) would “definitely” or “somewhat” agree to recommend the experience to a peer. Significantly more immediate responders stated they were either “strongly considering” or “considering” a career in surgery after the experience compared to before the experience (69.5% vs 61.0%, p=0.012). This was particularly evident in female responders (72.7% vs 57.6%, p=0.0112). The experience was felt to be relevant to the career choice process by 94.9% of students immediately after and 92.2% at 1-year follow up (p=0.90). At immediate follow up, 96.6% (n=57) of students recalled a specific trauma team member who made a positive impression on them and this was sustained (87.5%, n=21) at 1-year follow up (p=0.142).  

Conclusions:
Student participants reported a positive impact on their perceptions of, and were significantly more likely to consider, a career in surgery after the shadowing experience. Student recall of the personal connection made to the trauma team is sustained over a 1-year period. Early, informal shadowing experiences may increase interest in surgical careers, particularly for female students, and this engagement appears to be sustained over time.

105.07 Assisting Youth Bystanders Become First-Responders To "Stop The Bleed"

Posted on January 31, 2019

B. J. Ringhouse1, R. Gonzalez1, H. Ton-That1, M. Anstadt1, D. Lavigne1, J. Justiniano1, P. Patel1  1Loyola Universtiy Medical Center,Surgery,Maywood, IL, USA

Introduction: Uncontrolled hemorrhage remains one of the leading causes of preventable traumatic death. The "Stop the Bleed" campaign teaches lay people how to control life-threatening bleeding allowing for earlier intervention and improving outcomes. This study aims to assess the impact of this course on participant preparedness and willingness to intervene when faced with life-threatening bleeding.

Methods: This survey-based study utilized a pre and post intervention questionnaire. The intervention consisted of an hour long "Stop the Bleed" didactic and interactive lesson focused on recognition of life-threatening bleeding and methods of bleeding control including direct pressure and tourniquet application. The survey focused on preparedness and willingness to assist in situations of life-threatening bleeding and barriers to providing assistance. Data was collected and analyzed to evaluate trends.

Results: 54 people participated in the course, of which 44 individuals submitted a pre and post questionnaire and were included in the study analysisi. Most were inner-city youth with median age of 17, mihnoritiues, and had no first-aid experience. After the "Stop the Bleed" course, willingness to assist increased to 100%. The reported comfort in using direct pressure techniques increased by 54% (pre 46%; post 100%) and in applying a tourniquet increased by 72% (pre 28%; post 100%). In addition, there was a reduction in barriers to intervening in life-threatening bleeding, specifically the fear of making a mistake or causing more harm.

Conclusion: This study demonstrates that after a 1-hour intervention, 100% of participants felt trained to use direct pressure and tourniquets to control bleeding and were willing to assist in the setting of life-threatening bleeding. Our results establish the "Stop the Bleed" campaign as a meaningful resource to train bystanders in an at-risk population and possibly reduce preventable deaths due to uncontrolled bleeding.

 

105.06 Stop The Bleed: Effective Training In Need Of Improvement

Posted on January 31, 2019

C. Villegas1, S. Liu1, J. Rosenberg1, R. Winchell1, M. Narayan1  1Weill Cornell Medical College,The Division Of Trauma, Burns, Critical And Acute Care Surgery,New York, NY, USA

Introduction:
The “Stop the Bleed” (StB) campaign was instituted to educate laypersons on how to perform bleeding control techniques in the event of mass casualty events that result in life-threatening hemorrhage.  Participants currently undergo a 90-min instructional and practice session, the latter incorporating a mannequin on which participants practice. We hypothesized participants would 1) increase content knowledge after StB participation: and 2) find that the training could be improved by a more life-like modification of the mannequin.

Methods:
From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training.  Participants provided demographic data regarding prior emergency training and experience and were asked pre- and post-test questions (5-point Likert scale) regarding likelihood of and confidence in responding to hemorrhage.  Individuals also evaluated the mannequin on whether it would improve their education if it were more life-like.  Scores were reported as medians with interquartile ranges (IQR).  Wilcoxon paired and unpaired tests were used as appropriate to evaluate differences with α=0.05 and subset analysis stratified by experience.

Results:
Of 402 participants, 310 had complete data on demographic and outcome data of interest.  On a composite, pre-test self-assessment of willingness and confidence to respond to hemorrhage in emergency situations, participants had a median score of 24 out of 30 points (IQR 19-27).  Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 26-30, p < 0.05).  Participants’ composite score on mannequin realism assessing compression, packing, and tourniquet application was 13 out of 15 (IQR 12-15), yet the participants reported that more realistic model would increase their confidence in technique (median 15, IQR 12-15).  Subset analysis of those individuals without prior training or experience in emergency response or hemorrhage control (n=117) demonstrated that they had the largest gains in pre- and post-test differentiation (median difference 8.5, IQR 4.3-12.0) compared to those with prior experience (n=193, median difference of 3.0, IQR 0.0-6.0, p <0.05).  Both subgroups reported that training would be enhanced if the mannequins were more realistic (median 15, IQR 12-15 for both groups).

Conclusion:
StB is an effective education program resulting in improved confidence in wound compression, packing, and tourniquet application. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement.  Regardless of background, participants overwhelmingly reported that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating cessation of hemorrhage is required to enable learners to actually “Stop the Bleed”. 
 

105.05 Effectiveness of Bleeding Control Training in Improving Confidence To Intervene

Posted on January 31, 2019

E. G. Andrade1, J. M. Hayes1, L. J. Punch1  1Washington University,Acute & Critical Care Surgery,St. Louis, MO, USA

Introduction: Injury is the leading cause of death for individuals aged 1-44 years old in the United States. More specifically, gun violence (GV) is the leading cause of death for black males aged 15-24, outweighing the nine following most common causes of death combined. Hemorrhage is the leading cause of preventable trauma death. Thus, bystander abillity to control life-threatening hemorrhage is an important area for intervention to decrease preventable trauma deaths. We sought to ascertain if the Bleeding Control (BC) 1.0 course from the American College of Surgeons (ACS) is effective in teaching hemorrhage control to community members (CM) and medical professionals (MP) and if the provision of BC kits influences participant willingness to intervene in the setting of life-threatening bleeding.

Methods: Faculty and volunteers from a level 1 trauma center held BC courses on location for CM and on site for medical students, surgical residents, and surgical staff. The course was taught in concordance with the standards set for BC 1.0 by the American College of Surgeons. Participants then assembled their own BC kits, which included personal protective equipment, a combat application tourniquet, hemostatic gauze, adhesive compression tape, a permanent marker, and trauma shears. Pre- and post-course surveys were administered to assess exposure to severe bleeding (SB), knowledge of BC technique, and willingness to intervene with and without the kit. Surveys were compared using Pearson's chi-squared.

Results: Eighty CM and sixty MP completed BC training. Personal exposure to SB varied greatly between groups; among CM, 54% had experienced SB in themselves, a relative or close friend, compared with 13.6% in MP. After BC training, confidence among MP to stop life-threatening bleeding improved from 25.9% to 83.6%(p< 0.01). For CM, confidence improved from 6.7% to 57%(p<0.01). With BC training and the BC kit, 88.3% of MP and 91% of CM reported there was no reason why they could not stop life-threatening bleeding. When asked to consider their ability to stop life-threatening bleeding after the course without a BC kit, 53.8% of MP were confident compared with 36.1% of CM.

Conclusion: Although participants with a medical background start at a higher level of confidence with bleeding control techniques, both groups had significant improvement in their level of confidence with stopping life threatening bleeding after taking the BC course. The importance of the bleeding control kit was more evident in the community group.

 

105.04 The Choices We Make: Ethical Dilemmas in Trauma

Posted on January 31, 2019

P. N. Chotai1, M. B. Patel1, B. M. Dennis1, O. D. Guillamondegui1, K. G. Meador2, K. A. Wallston3, A. B. Peetz1  1Vanderbilt University Medical Center,Division Of Trauma And Acute Care Surgery, Department Of General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Center For Biomedical Ethics And Society At Vanderbilt,Nashville, TN, USA 3Vanderbilt University Medical Center,Institute Of Medicine And Public Health,Nashville, TN, USA

Introduction:
Trauma surgeons may often encounter complex patient situations that can be considered ethical challenges. These may require unique decision-making skills. Current literature is scarce in describing and characterizing ethical issues encountered by practicing trauma surgeons. We hypothesize variable incidence and estimates of self-efficacy of trauma surgeons’ ability to manage ethical problems in clinical practice.

Methods:
We surveyed members of the Eastern Association for the Surgery of Trauma (EAST) from January 5 to February 7, 2018 to ascertain their opinions and readiness on handling ethically challenging scenarios in their clinical trauma practice using a web-accessible survey via e-mail. The survey instrument was developed using published ethics literature and informal cognitive interviews of small focus groups that included trauma surgeons, physicians, ethicists, and other practitioners. Domains covered included perceived frequency and ability to manage ethical situations that present problems in trauma surgery practice. Common situations were defined as those situations that respondents encountered monthly or weekly. The ethical problems were categorized within seven larger categories: General ethics, Autonomy, Communication, Justice, End of Life, Conflict, and Other. Quantitative and qualitative analyses of the data were performed.

Results:
The response rate for the survey was 30.6% (548 respondents from 1794 invites); 28% of the respondents were female. Most respondents were white (74.6%) and under 55 years old (72.6%). A majority (85.4%) of respondents had completed fellowship training in either surgical critical care or trauma/acute care surgery.  Most respondents (86.6%) reported clinical practice in an American College of Surgeons (ACS) verified level I or II trauma center. The most commonly encountered ethical categories were Generic Ethical and Communication (79% of respondents reported that these were common issues in their clinical practice). Issues involving Conflict were least frequent (only 21% of respondents encountered these conflict issues on a monthly or weekly basis). Respondents’ ability to handle ethical situations did not differ among race or gender groups, size or geographic location of city of practice, completion of a fellowship training in trauma surgery, or trauma center verification level. Surgeons who reported high ability to handle ethical situations were more likely to be older (p=0.003), had been in practice 15 years or longer (linear relationship, rho = 0.21, p<0.001), had previously served on an ethics committee (p=0.038), and more frequently experienced ethically challenging situations in their clinical practice (p<0.05). Table 1 summarizes commonly encountered ethical situations in trauma surgery practice.

Conclusion:
An overwhelming majority of trauma surgeons encounter a range of ethical challenges on a regular basis in their clinical practice. Compared to younger and early career trauma surgeons, older and advanced career trauma surgeons reported higher ability and self-efficacy to manage ethical issues in clinical practice. To our knowledge, this is the first study to describe some of the unique ethical challenges that trauma surgeons face. We also identify a gap in knowledge regarding how trauma surgeons develop in addressing these problems effectively.
 

105.03 The Effect Of Body Mass Index On Penetrating Trauma Severity: A National Trauma Data Bank Analysis

Posted on January 31, 2019

L. A. De Leon Castro1, E. A. Alore1, J. W. Suliburk1, C. T. Wilson1, M. A. Davis1, S. R. Todd1  1Baylor College Of Medicine,Surgery,Houston, TX, USA

Introduction: The effect of body mass index (BMI) on penetrating injuries is not well described. The aim of this study was to describe the effect of BMI on the severity of penetrating injuries by abbreviated injury score (AIS). We hypothesized that increasing BMI would be protective against higher injury severity in patients with penetrating mechanisms.

Methods:  This was a retrospective analysis of penetrating trauma patients ≥ 16 years old from the 2007-2015 National Trauma Data Bank (NTDB). Patients transferred, dead on arrival, or with isolated brain injury were excluded. Patients were classified by BMI category as underweight (<18.99kg/m2), normal (19-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2), and morbidly obese (≥40kg/m2). AIS severity was defined as minor (AIS 1-3) or major (AIS 4-6). Univariate and multivariate analyses were performed to assess association with BMI (significance, p<0.05).

Results: 83,826 patients were evaluated. The median age was 30 (IQR 23-41); 87% were men. Median BMI was 25.9 kg/m2 (IQR 23-30). The mechanism of injury was stab wound in 43% and firearm in 57%. The median AIS by region was 2 (IQR 1-3) for the abdomen, 3 (IQR 1-3) for the thorax, and 1 (IQR 1-2) for the extremities. The median injury severity score (ISS) was 5 (IQR 1-11). Overall mortality was 5.3%. On univariate analysis by BMI category, AIS severity was not significant for the abdomen (p=0.316), thorax (p=0.267), or extremities (p=0.184). This lack of significance continued when analyzed by mechanism of injury: stab wound – abdomen (p=0.350), thorax (p=0.471), or extremities (p=0.074); firearm – abdomen (p=0.172), thorax (p=0.340), or extremities (p=0.318). On multivariate analysis, AIS severity was not associated with BMI category for the abdomen (p=0.729), thorax (p=0.226), or extremities (p=0.232). Variables significantly associated with AIS severity were systolic blood pressure (abdomen: OR=0.986, CI=0.984-0.987, p<0.001; thorax OR=0.984, CI=0.982-0.985, p<0.001; extremities OR=0.977, CI=0.973-0.980, p<0.001), heart rate (abdomen: OR=1.008, CI=1.006-1.010, p<0.001; thorax OR=1.004, CI=1.002-1.006, p<0.001; extremities OR=1.021, CI=1.017-1.025, p<0.001) and firearm mechanism of injury (abdomen: OR=7.548, CI=6.562-8.681, p<0.001; thorax OR=2.223, CI=2.006-2.463, p<0.001; extremities OR=13.873, CI=8.752-21.992, p<0.001). Mortality did not vary significantly (p=0.552) across BMI categories.

Conclusion: Increased BMI is not associated with protection from penetrating injuries. Mortality did not vary significantly across BMI categories.

 

105.02 Medical Malpractice and Trauma Surgery, What Pays Out

Posted on January 31, 2019

M. S. Sussman1, M. Mulder1, S. Carranco1, E. L. Ryon1, B. Sussman1, S. Madiraju1, V. Hart1, K. Proctor1  1University Of Miami,Trauma Surgery/critical Care,Miami, FL, USA

Introduction:  Medical malpractice litigation is a source of anxiety for many surgeons. Previous studies indicate that a general surgeon’s chance of being involved in a malpractice claim by age 65 approaches 99%. Although single site analysis has indicated no increased risk of lawsuit for trauma surgeons, a review of a large, national, legal database is lacking. The purpose of this study is to explore the malpractice environment surrounding trauma surgery and acute care surgery services.

Methods:  Lexis Nexis is a mode of legal research that uses databases of court opinions, statutes, court documents, and secondary material. We searched 1987-2017, of all state and federal cases using the Boolean search Terms: “trauma” AND “medical malpractice” AND “case summary” AND NOT copyright.  Pediatrics, obstetrics, ophthalmologic and incomplete cases were excluded.

Results: During a 30-year period 231 malpractice cases were identified. Several trauma subspecialties were implicated in the lawsuits. These included trauma surgeons, acute care general surgeons (ACS), trauma orthopedics (TO), trauma neurosurgery (TN), and trauma anesthesia (TA). A majority of the cases involved emergent surgery (148/231, 64%). Preoperative assessment was responsible for 82 suits (35%). A total of 62 cases (27%) resulted in death.  A total of 20 cases (9%) resulted in monetary award to the plaintiff (patient) for an average payout of $1.1M (range, $35K – $6.4M). Examining trauma surgeons as a separate cohort, 12 malpractice suits resulted in payouts, eight of these (66%) were a result of delayed/missed diagnosis. Technical error was sited in 15% and neglect in 8% of cases where a payout was awarded. Looking at the other subspecialties (ACS, TO, TN, TA) involved, 8 cases resulted in payout, 100% of these cases were as a result of technical error.

Conclusion: Only a small fraction of medical malpractice cases that are filed result in a payout.  The majority of suits brought against trauma surgeons arise from delayed/missed diagnosis, whereas all of the suits brought against other subspecialties arise from technical error.  This is likely due to the fact that trauma surgeons serve as the frontline diagnosticians and must make rapid assessments. This study highlights the importance of the trauma assessment and time to diagnosis as targets for education on litigation prevention. Further investigation is warranted to understand the underlying causes for malpractice suits between trauma surgeons and other trauma subspecialties.

 

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