104.20 Varsity Sports and Surgical Training Success

Posted on January 31, 2019

A. Tanious1, C. Jokisch2, H. McMullin2, L. T. Boitano1, P. A. Armstrong2, M. Harrington3, M. F. Conrad1, M. L. Shames2  1Massachusetts General Hospital,Vascular Surgery,Boston, MA, USA 2University Of South Florida College Of Medicine,Vascular Surgery,Tampa, FL, USA 3University Of South Florida College Of Medicine,Plastic Surgery,Tampa, FL, USA

Introduction:

Our goal was to understand if a correlation exists between participation in varsity level sports and positive experiences during one’s surgical clerkship or surgical residency.

Methods:

            Surveys were sent to the program directors of all surgical residencies, all surgical residents, as well as all third and fourth year medicals students at our institution. Data collected included level of training, participation in varsity sports, and the last level of competitive sports played.  Likert scales where used to assess the level of enjoyment of surgical education, teaching style (i.e. Socratic method), and surgical training.

Results:

            Seventy-eight of our surgical residents (48%), and 87 of our medical students participated in the study (26%).  Sixty-three percent of medical student responders and 82% of surgical resident responders participated in varsity level sports.  Significant correlations were found between participation in varsity level sports and enjoyment of teaching style during surgical residency (P = .04).  Individuals with higher levels of sports involvement (high school and collegiate level involvement) had significantly increased positive interactions with other trainees as well as level as significantly increased feelings of preparedness for surgical residency (P = .01 and P = .04 respectively).  Six of 10 program directors responded and showed no preference towards students who participated in varsity sports.

Conclusions:

            The opinions of trainees suggest that participation in varsity sports may aid in preparing one for surgical training. It may also improve interactions amongst trainees during residency. While program directors do not consider this an essential characteristic, it may help discern which applicants are better suited for the hardships faced by surgical training and its associated teaching methods.

104.19 Faculty mentoring: Early experience with a Formal Mentoring Committee

Posted on January 31, 2019

P. N. Redlich1, T. A. DeRoon-Cassini1, R. Treat1, R. Spellecy1, M. Zarka1, M. A. Zimmerman1, T. P. Webb1, B. D. Lewis1, D. M. Gourlay1, G. Lomberk1, K. R. Brown1, M. F. Otterson1, D. B. Evans1, T. S. Wang1  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA

Introduction: Faculty represent the most important asset of academic departments. Effective faculty mentoring is the cornerstone of career success. Studies have demonstrated the importance of mentoring, yet only half of surgical departments have mentoring programs. Our department sought to enhance its mentoring program by establishing a formal Mentoring Committee (MC) in 2016 to supplement support by the Chair and Division Chiefs. The goals of this study were to obtain junior faculty perceptions on mentoring and their perceived value of the MC. In addition, senior faculty participation in the MC was tracked as a measure of interest in, and support of, junior faculty mentoring.

Methods:
The MC was constituted to have broad representation with 11 senior faculty members from 8 Divisions and one from another academic department. Concomitant with the formation of the MC, a questionnaire (Survey 1) was sent to all assistant and associate professors surveying demographics, perceived mentoring components, and past mentoring experiences. Assistant professors (both newly hired [NH] and those beyond their first year [BFY]) met individually with the MC. Attendance at meetings was recorded, including MC members and invited mentors of NH faculty. The MC reviewed the mentee’s current and planned clinical, academic and professional activities while providing detailed feedback, guidance, and support in a 45-60-minute session. Comprehensive minutes were provided within 2-3 weeks along with a post-meeting survey (Survey 2) to include invited feedback. Both surveys were constructed using a Likert scale from 1-5 (5=strongly agree; most important). Significance was determined by the Mann-Whitney U-test.

Results:
Survey 1 had a response rate of 44% (14/32). Highest rated items defining mentoring were: professional development advice (5.0 [median]), support in societies (5.0), support of scholarly projects (5.0), and assisting with research (4.0). Over 2 years, 10 BFY and 16 NH assistant professors met with the MC. Survey 2 had a response rate of 100% (26/26). The highest rated items included: information provided was valuable (5.0), meeting time allotted was sufficient (5.0), and post-meeting communications were helpful (5.0). “Pre-meeting materials were helpful” was rated higher by NH faculty (4.0 vs 3.5, p=0.011) whereas “meeting time allotted was sufficient” was rated higher by BFY faculty (5.0 vs 4.5, p=0.04). The mean number of senior faculty who attended meetings was 6.3 (SD=1.6; range 4-11).

Conclusion:
A formal MC was well-received by junior faculty and enthusiastically supported by senior faculty. A focused meeting of the MC devoted to an individual faculty member has created a visible symbol of the importance of career mentoring. Interest from other departments has provided impetus for enhanced mentoring across the institution. Long-term evaluation of specific outcomes of our MC is ongoing.
 

104.15 Attributes of Medical School Curricula that Promote the Development of Self-Directed Learning Skills

Posted on January 31, 2019

S. Stauder1, N. Kugler1, T. Webb1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA

Introduction:
Self-Directed Learning (SDL) is a critical component of medical education beginning in medical school and continuing throughout the career of physicians. Medical schools are now required to demonstrate evidence of medical student SDL within the curriculum. However, there is no consensus on what constitutes a self-directed learner, nor how medical schools or residencies may better provide SDL opportunities to learners. Our project aimed to develop a consensus on the attributes and behaviors of a self-directed learner and the components of medical education curricula that promote SDL skills in medical students.

Methods:
Surveys were distributed to members of the Society of Teaching Scholars at the Medical College of Wisconsin, which is comprised of 75 full time faculty who have been elected based on demonstrated excellence in educational scholarship and leadership. The initial phase consisted of a survey asking two open-ended questions: 1) What are the observable characteristics (behaviors) of a self-directed learner? 2) What specific components of a medical school course or clerkship do you believe promote self-directed learning? Based on open-ended survey results, a new survey consisting of SDL characteristics and curriculum components was sent to the STS following the Delphi method of surveying, ranking attributes on a Likert scale of 1-7. Using attributes which received a 4+ rating from ≥50% of respondents, a second and final Delphi round was performed, and a consensus of final attributes was compiled using those which received a 5+ rating from >70% of respondents. Afterward, all attributes were classified into core themes to provide an outline of self-directed learners and components of a curriculum that foster SDL skills.

Results:
30 STS members completed the open-ended survey, 37 completed the Delphi 1st round, and 25 completed the Delphi 2nd round. 44 SDL characteristics and 50 curriculum components were used in the Delphi surveys. Final survey results obtained 33 unique SDL characteristics and 36 curriculum components which received a 5+ rating from >70% of respondents. These attributes were subsequently classified into themes with similar attributes. In total, 8 core themes of SDL characteristics and 8 core themes of curriculum components that promote SDL skill development were identified.

Conclusion:
Attributes of SDL related to the learner and educational environment can be classified into core themes that may be used for further curriculum development and demonstration of promotion of SDL. Further studies should analyze validity and reliability of using these themes in student assessment and curricular evaluation.

104.14 BioInnovate: Medical Student Experiential Education in Technology Innovation and Entrepreneurship

Posted on January 31, 2019

B. R. Fogg3, J. T. Langell1,2,3,4  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Department Of Bioengineering,Salt Lake City, UT, USA 3University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 4VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA

 

Introduction: Joint M.D. programs are becoming increasingly popular as more medical students seek additional professional development training. These programs have direct costs (tuition and living expenses) and opportunity costs (delayed training and compensation). Potential benefits include enhancing future career opportunities and knowledge acquisition in additional fields to increase future professional impact.

 

Here we present our 6-year experience with BioInnovate, a combined degree program for medical students and residents focused on medical technology innovation and entrepreneurship. BioInnovate is an accelerated 1-year Master of Science track in bioengineering. Students in the program combine their healthcare background with engineering and business training to identify clinical problems and create technology solutions to improve healthcare delivery. The program focuses on experiential education and interdisciplinary teams composed of graduate students with backgrounds in medicine, engineering, business, design and law. The curriculum is based on the complete product development lifecycle including design inputs, design processes, technology verification and validation and the commercial translation process.

 

Methods: Background and outcomes data was gathered through our program database and an anonymous online survey to assess medical student participant characteristics and program impact, including student academic and entrepreneurial accomplishments. Additional data was collected to assess how the program impacted future career choices and opportunities. 

 

Results:69% of BioInnovate medical students had no previous experience with technology development and only 2 had minor experience with business start-ups. No student had experience with FDA regulations or medical technology reimbursement pathways. On average during their BioInnovate year, students filed 2 patents (range 0-3), raised $37.5k in funding (range $6k-$120k), completed 4 peer-reviewed publications or national academic presentations on their BioInnovate work (range 1-6) and all filed at least 1 IRB clinical trial applications. Additionally, 100% of BioInnovate students later matched in one of their top-3 residency choices (national average 78%), 69% are currently engaged in healthcare technology development, 90% plan to conduct medical technology innovation and development as part of their professional careers and 90% recommend this training for all medical students and residents.

 

Conclusions:The BioInnovate program has been effective in providing medical students with an experience in comprehensive medical technology innovation and commercialization. It has impacted students’ future career decisions and their academic and entrepreneurial success metrics. Over the first 6-years, the program has trained 13 medical students who developed 21 medical technologies, filed 22 patents and launched 14 startup companies.

104.11 Do Words Matter? The "Chair" Title and Gender Gaps in Academic Surgery

Posted on January 31, 2019

C. Peck1, S. J. Schmidt2, D. A. Latimore1, M. I. O’Connor1  1Yale University School Of Medicine,New Haven, CT, USA 2Yale Law School,New Haven, CT, USA

Introduction:  Gender-marked titles have shown to be exclusionary of women in a variety of professional settings. The purpose of this study was to analyze and compare the use of the words "chair" and "chairman" on academic websites for both surgical and non-surgical departments in the US. 

Methods:
Orthopedics, Neurosurgery, Obstetrics and Gynecology, and Pediatrics departments from 139 US allopathic medical schools were reviewed. Official websites were screened for use of the word chair or chairman. Any use of the word chairman was classified according to type of use and location on the website. Patterns of chair use were compared by specialty, region, and gender of the current chair. 

Results:
Overall, 59.8% of all academic departments used only the gender-neutral term chair. In surgical specialties, this number was significantly lower (p<.001)—40.3% in Orthopedics and 42.5% in Neurosurgery, compared to 70.1% and 64.0% in Obstetrics/Gynecology and Pediatrics respectively. Departments with female chairs used gender-neutral titles 89% of the time, compared to 53.1% in departments led by males. Gender-neutral title use was highest in the West across specialties (p<.01). The proportion of female chairs was highest in Obstetrics and Gynecology at 32.5%, compared to 26.0% in Pediatrics, 4.3% in Neurosurgery, and 0.8% in Orthopedics. Use of the word chair correlated with a 437% increase in the likelihood of having a female chair (p<.01).

Conclusion:
Our studies show persistence of the gender-marked title "chair" across academic specialties—particularly in surgical specialties—and suggest a association between title use and overall gender diversity. Increasing the use of gender-neutral titles may be a simple way to promote gender parity in academic surgery. 

104.10 Assessing Knowledge and Skills of Surgical Leaders in Optimizing Organizational Culture

Posted on January 31, 2019

K. Brown1, P. Angelos8, A. Banerjee10, R. Britt4, K. B. Dunn7, G. Kennedy9, R. Kim2, J. Lau5, V. Nfonsam3, R. Radhakrishnan6, K. Brown1  1University of Texas Austin Dell Medical School,Surgery And Perioperative Care,Austin, TX, USA 2Southern Illinois University School Of Medicine,Surgery,Springfield, IL, USA 3University Of Arizona,Surgery,Tucson, AZ, USA 4Eastern Virginia Medical School,Surgery,Norfolk, VA, USA 5Stanford University,Surgery,Palo Alto, CA, USA 6University Of Texas Medical Branch,Surgery,Galveston, TX, USA 7University Of Louisville,Surgery,Louisville, KY, USA 8University Of Chicago,Surgery,Chicago, IL, USA 9University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA 10Roosevelt University,Industrial-Organizational Psychology,Chicago, IL, USA

Introduction:  Leadership skills have become an important competency for successful academic surgeons. Informed by research in Industrial-Organizational Psychology across multiple business settings, analyzing and optimizing the culture of an organization can significantly impact the effectiveness of the unit. These concepts have begun to influence leaders in academic medicine, but there are few data on leaders’ use of these tools or their impact. The purpose of this study is to explore SUS members’ knowledge and use of leadership skills relating to optimizing the culture of the units they lead, as a needs assessment for future educational activities.

Methods:  Survey questions were constructed in collaboration with a PhD Industrial-Organizational Psychologist and piloted on a sample of members of the SUS. The revised survey was distributed to the members of the SUS via email, with one follow-up reminder email. Responses were analyzed with descriptive statistics.

Results: Our response rate was 20% (98/492 members contacted). Respondents’ leadership units included academic divisions or sections (n=49), clinical programs (n=14), training programs (n=15), and research programs (n=7). There were 14 Vice Chairs and 4 Department Chairs. Nine respondents had more than 1 leadership role. The number of faculty and staff led by respondents was 10 or less for 37%, 11-25 for 37% and >26 for 26%. Only 8% of respondents reported “a good working knowledge” of selection science and organizational psychology (figure). Respondents learned about organizational culture most often through self-directed study, followed by learning from colleagues and through non-degree courses. Six percent of leaders routinely use formal culture assessment; 15% routinely assess potential hires for cultural fit, and 15% routinely use interventions aimed at cultural change. 73% of respondents reported “a great deal of interest” in learning about interventions to change culture; 56% in developing an aspirational culture, and 54% in assessment tools for potential hires. When asked about preferred methods for learning, attending workshop at a national meeting was strongly preferred by 35% and 51% would use that if available. Dedicated workshops and targeted reading materials were strongly preferred by 30% and 19% respectively.

Conclusion: SUS survey respondents serve significant leadership roles in academic and clinical units. These leaders have notable knowledge gaps in leadership skills used in high-performing organizations in industries outside of medicine. Targeted education to develop knowledge and skills may benefit surgical leaders in improving the performance of their clinical, administrative, research and educational units.

 

104.09 5-Year Follow-up of a Leadership Development Program: Impact on Culture in a Surgery Department

Posted on January 31, 2019

C. A. Vitous1, S. Shubeck1,2, A. Kanters1,2,3, M. Mulholland1,2, J. B. Dimick1  1University Of Michigan,Center For Healthcare Outcomes And Policy,Ann Arbor, MI, USA 2University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA 3University Of Michigan,National Clinician Scholars Program At The Institute For Healthcare Policy & Innovation,Ann Arbor, MI, USA

Introduction: Although a growing body of literature has been focused on the impacts of Leadership Development Programs on individual surgeons, little effort has been focused on understanding the long-term impact these programs can have on surgical culture. The purpose of this study was to explore the impact of implementing a Leadership Development Program on the culture of the Department of Surgery at the University of Michigan.

Methods: Qualitative interviews were conducted with 14 surgical faculty in the first cohort of a Leadership Development Program at the University of Michigan, 5 years after completion of the program. Using NVivo (version 11.4.3), thematic analysis was used to locate, analyze, and report patterns within the data.

Results: Thematic analysis demonstrated that participation in the Leadership Development Program influenced surgical culture in the following ways: 1) promoted a more participative leadership style, providing tools for surgeons to create a more collaborative environment; 2) increased the culture of diversity, with leaders in the department valuing a more inclusive and wide range of skill sets; and 3) strengthened the collegial environment as evidenced by improved morale and relationships within the department. Additionally, several participants expressed difficulty in teasing out what was a direct benefit of the Leadership Development Program versus what could be attributable to other factors, referred to here as the chicken or egg argument.

Conclusion: Reflecting on the past 5 years, almost all of the participants expressed experiencing at least some long-term changes that they thought were related to the Leadership Development Program. This research may provide insight into the broader implications that programs like these have on surgical culture.

 

104.03 National Study Identifies Surgeons and Medical Students Under-Reporting Sharp Injury

Posted on January 31, 2019

J. Yun1, D. Berera1, D. Vyas1  1San Joaquin General Hospital,General Surgery,French Camp, CA, USA

Introduction:

A majority of sharps-related injuries in U.S. hospitals are not reported. Even with the passage of the Needle-stick Safety and Prevention Act, estimates suggest that the underreporting rate remains unchanged. Few studies have quantified the incidence of underreporting and even fewer studies have evaluated the underlying reasons for not reporting sharps-related injuries. The primary objective of this study was to quantify the incidence of sharps-related injuries, reporting behaviors, and reasons for not reporting sharps-related injuries by healthcare practitioners (HCPs) in U.S. hospitals.

Methods:

An online, anonymous survey consisting of 15 questions was designed and distributed to attending physicians, residents and fellows, medical students and nurses; 3500 emails were sent to residency programs, hospitals, and medical schools across the U.S.

Results:

Data from a total of 434 respondents were evaluated; 57% (n=247) of total respondents indicated they have experienced at least one sharps injury during their career. When asked about their most recent sharps injury, only 56% (n=139) reported the injury. Among those experiencing a sharps-related injury, medical students had the lowest incidence of reporting the injury (40%, n=12), followed by attending physicians (54%, n=53), residents (62%, n=63). Stratification by medical specialty revealed that HCPs from general surgery had the lowest incidence of reporting a sharps-related injury (49%, n=31) compared to other medical specialties. The three most common reasons for not reporting an injury were: (1) the HCP perceived no or minimal risk based on the patient’s medical history (2) excessive time required to report injuries, and (3) the perception that reporting offered no benefit.

Conclusion:

This national survey indicates that sharps-related injuries are underreported in U.S. hospitals. Sharps-related injury education and improved reporting processes may be beneficial to all practitioners, which may help reduce the risk of injury and infection.
 

104.02 The National Science Foundation I-Corps Program: A Tool to Promote Technology Innovation in Surgery

Posted on January 31, 2019

J. Whittle2, T. Petelenz2,4, T. D’Ambrosio2,5, J. Langell1,2,3,4  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Center for Medical Innovation,Salt Lake City, UT, USA 3VA Salt Lake City Health Care System,Center of Innovation,Salt Lake City, UT, USA 4University Of Utah,Department Of Bioengineering,Salt Lake City, UT, USA 5University Of Utah,Lassonde Entrepreneurship Institute,Salt Lake City, UT, USA

Introduction: Many universities have embraced the concept of faculty-driven innovation, invigorating a new generation of physician entrepreneurs focused on translating discoveries to commercial products. New federal funding programs have been created that are designed to support faculty commercialization of academic research. Innovation Corps (I-Corps) a program developed by the National Science Foundation (NSF) provides educational support and seed funding to educate research faculty on business principles of technology commercialization. 

Our university is a funded I-Corps training site focused on healthcare technology. Our curriculum teaches Lean Start-up and Business Model Canvas principles, customer discovery and elements focused on unique aspects of health technology commercialization. Annual faculty cohorts are selected to participate in a 20-week I-Corps program and assigned entrepreneurial partners to create interdisciplinary teams. Teams attend the I-Corps training program composed of didactic lectures and workshops (table 1) and assigned an industry mentor.  Teams also receive $3000 seed grants and conduct market assessments. At the end of the program teams with viable commercial technologies concepts are provided ongoing support. Here we present our I-Corps experience, curriculum and the impact it had in educating faculty and supporting entrepreneurial activities over our first 4-years of implementation.

Methods: Team data was collected to assess participant characteristics, faculty assessment of program quality and program impact.  Data was acquired through our I-Corps program database, participant objective self-reporting of commercialization metrics and subjective quality surveys.

Results: During the first 4-years, we trained 102 faculty-led entrepreneurial teams in the I-Corps program. This included 81 physicians (34 Surgeons), 22 medical students, 37 engineering faculty and 41 engineering graduate student. 21 of 102 teams responded to our commercialization progress surveys.  Of these, 20 continue to pursue technology commercialization forming 14 companies and filing 22 patents.  These companies have generated 30 employees, 5 federal SBIR grants, 7 licensing agreements and >$11.5M in funding. Eight team faculty leads reported publishing their efforts in peer-reviewed journals and 11 presented their work at national academic conferences.

Conclusions: Our NSF I-Corps program tailored to healthcare technologies has successfully promoted physician innovation and entrepreneurship. Interdisciplinary programs like I-Corps designed to educate and support faculty innovation and entrepreneurship are important tools to promote the translation of research into clinical solutions.

103.19 Evaluation of Cardiothoracic Surgery Residency and Fellowship Program Websites

Posted on January 31, 2019

V. M. Miller1, L. A. Padilla1,2, A. Schuh3, D. Mauchley1, D. Cleveland1, Z. Aburjania1, R. Dabal1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Department Of Epidemiology,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction:  

The internet is a valuable resource for residency and fellowship candidates when deciding where to apply. Interviewing can affect medical debt, clinical scheduling, and institution finances, yet program websites have shown critical deficiencies in accessibility and content. Until now no analysis of cardiothoracic surgery program websites has been performed.

Methods:  

The Electronic Residency Application Service (ERAS), the Fellowship and Residency Electronic Interactive Database Access (FREIDA), the Accreditation Council for Graduate Medical Education (ACGME), the Thoracic Surgery Directors Association (TSDA) and Google® were used to identify integrated, 4+3, and traditional cardiothoracic surgery residency and fellowship programs. The accessibility of websites from each of these sources was assessed and the presence or absence of content deemed relevant to applicants was evaluated by two reviewers.

Results: 

Eighty nine active programs were identified and 86 had functional websites. Website content and accessibility were overall suboptimal in all 86 of these programs. Google® was the most reliable means of accessing a program’s website. Fifty percent of integrated program websites and 60% of traditional fellowship websites contained less than half of the content assessed. Information on 4+3 programs was extremely limited.

Conclusion:
Cardiothoracic surgery residency and fellowship websites remain difficult to access and are failing to provide important information. Improving website accessibility and content may have implications for attracting the most competitive applicants,limiting associated costs, and increasing match satisfaction for both the applicant and the institution.
 

103.11 Brachial Vessel Injuries: An Analysis of the National Trauma Data Bank

Posted on January 31, 2019

D. R. Rigg1, A. Person1, M. Dale1, G. Mendoza1, S. Brown1, D. Keleny1, J. Dabestani1, D. Agrawal1, J. Asensio1  1Creighton University Medical Center,Department Of Trauma Surgery And Surgical Critical Care,Omaha, NE, USA

Introduction:  Brachial vessel injuries remain uncommon, even in busy urban trauma centers, and therefore many trauma surgeons have limited experience with these types of injuries. Despite being a relatively uncommon injury, the brachial artery is the most frequently damaged artery in the upper extremity due to its vulnerability and close proximity to upper extremity bony structures. Therefore, trauma surgeons must be familiar with this injury and its associated outcomes. The objective of this study are: 1) review of the nationally reported experience with these injuries; 2) Identify predictors of outcome; 3) Compare predictors of outcome; 4) Report total charges incurred in the management of these injuries.

Methods:  The National Trauma Data Bank (NTDB) was queried for pre-hospital admission data for brachial vessel injuries. Data extracted included demographics, vital signs on admission, and mechanism of injury. Univariate and stepwise logistics regression statistical analysis was used

Results: There were 1,799 patients sustaining 1,900 brachial vessel injuries out of 1,466,887 patients registered in the NTDB from 2001 to 2005. Incidence was calculated to be 0.12%. Mean age at injury was 30 ± 14, mean RTS 7.23 ± 1.8, mean Glasgow Coma Scale 13.6 ± 3.5, mean ISS 11.5 ± 9.5. Mechanism of Injury: penetrating n=1,114 (61.9%), blunt n=699 (37.1%), and non-specific n=16 (1%). Mean initial SBP 119 ± 32.5; overall and adjusted survival rates: survivors 94.7%; non-survivors 5.3%. Patients underwent surgical repair n=671. Stratified as primary arteriorrhaphy 369 (55%), RSVG 165 (24.5%), resection of upper limb vessel with replacement 116 (17.3%), PTFE 21 (3.2%). Analysis revealed an increased ISS in the blunt injury group vs penetrating (10.65±8.82 vs 13.09±10.43; p<0.001). In survivors vs non-survivors, initial systolic blood pressure, glasgow coma scale, revised trauma score, and injury severity score were all statistically significant between the two groups (see table).

Conclusion: Brachial vessel injuries remain a low incidence injury as is shown in the NTDB. The injury severity score has a higher correlation with morbidity based on mechanism of injury. The overall cost of all brachial injuries was $22,954,998 in patient with extractable information (n=727).

 

103.05 Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis

Posted on January 31, 2019

C. Deyholos1, M. Systek1, S. Smith1, J. Cardella1, K. C. Orion1  1Yale University School Of Medicine,Section Of Vascular Surgery, Department Of Surgery,New Haven, CT, USA

Introduction: Temporal arteritis (TA) or giant cell arteritis (GCA) is a systemic inflammatory vasculitis of unclear etiology that affects medium sized vessels. The gold standard for diagnosis has traditionally been histological by TA biopsy.  Due to the risk of permanent vision loss if the disease is left untreated, standard of care is to begin steroid therapy prior to confirming the diagnosis.  In up to one third of GCA patients, the temporal arteries are not involved and there has been reported facial nerve injury during TA biopsy. Improved imaging modalities such as color duplex, PET CT or MRI have been increasingly used to aid diagnosis and are  recommended in the newest 2018 European (EULAR) Guidelines.  We hypothesize that a negative TA biopsy result does not change management in patients for whom temporal arteritis is strongly suspected and that duplex ultrasound can be successfully used as a screening tool.

Methods: A retrospective review of patients undergoing TA biopsy between May 1, 2012 and December 31, 2015. We reviewed patient's age, gender, co-morbidities, symptoms, histology, and whether patients were prescribed steroids prior to or following biopsy. We also began small prospective series of 3 patients where ultrasound of the bilateral temporal arteries was performed prior to biopsy, using a high frequency linear transducer to evaluate for wall thickening. Radiology report and pathology report were then reviewed.

Results: Within period of study, 171 temporal artery biopsies were performed. 7.6% positive (n=13) 92.4% negative (n=158) for acute GCA.  Patients with positive biopsy result had mean age 80± 6 (Range 69-88). Patients with negative biopsy had mean age of 72± 11 (Range 17-95). We also performed subgroup analysis on patients with negative biopsies (n=158). Cases in which there was no documentation of steroids prior to or after biopsy were excluded (n=15). 20% of patients who had negative biopsies were not on steroids prior to the procedure (n=28). 31% of patients with negative biopsies continued on steroids despite the negative result (n=45).  In series of 3 ultrasounds, all 3 correlated with subsequent biopsy histology. 1 was positive, and 2 were negative.

Conclusion:  Our results suggest that the yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce number of unnecessary temporal artery biopsies performed.

102.20 Atraumatic Splenic Rupture Does it Mandate Intervention? A Case Series and Review of the Literature

Posted on January 31, 2019

A. Rogers1, L. Sadri1, V. Eddy2, O. Kirton1, T. Vu1  1Abington Jefferson Health,Department Of Surgery,Abington, PA, USA 2Maine Medical Center,Department Of Surgery,Portland, ME, USA

Introduction:
Management of acute splenic trauma and injury has been well studied. National trauma societies have published guidelines to support clinical decision making. Meanwhile, splenic “injury” not associated with trauma is confined to the realm of case reports and antidote. Most cases discussing the management of “atraumatic splenic injury” focus on an underlying diseased spleen and advocate for aggressive management. We aim to better define the literature and propose a guideline for management of splenic injury in non-trauma patients.

Methods:
We reviewed a series of 5 cases between two institutions over the period of two years focusing on patient presentation, hemodynamic stability, underlying disease, choice of management, and ultimate outcome. We then conducted a review of the available literature regarding the management of atraumatic splenic rupture and injury. We focused on operative (splenectomy) compared non-operative (embolization or expectant management) treatment strategies.

Results:
Each case we reviewed was handled differently and showed significant variation at the discretion of the attending surgeon. Treatment ranged from ICU admission with serial exams and laboratory studies to splenectomy. There appeared to be a mild correlation between initial presentation and imaging results and aggressive management, variations did not appear to alter ultimate patient outcome.

Conclusion:
The management of splenic injury in the absence of trauma or on the diseased spleen is poorly studied and lacks any standardization or existing guidelines. Based on our review of cases at our two institutions we would propose that conservative management of splenic injury in the diseased spleen with minimal to no preceding trauma can be safely managed in a similar manner to that of an acute injury associated with a traumatic event. 
 

102.19 The Hazards of Ingesting Wire Grill-Brush Bristles: Optimizing Prevention, Diagnosis and Management.

Posted on January 31, 2019

K. A. Calabro1,2, J. Y. Zhao2, E. A. Bowdish1,2, C. M. Harmon1,2, K. Vali1,2  1John R. Oishei Children’s Hospital,Department Of Pediatric Surgery,Buffalo, NY, USA 2University at Buffalo Jacobs School of Medicine and Biomedical Sciences,Department Of Surgery,Buffalo, NY, USA

Intro:
Accidental wire grill-brush ingestion is a largely unidentified threat to children. Injuries affect multiple organ systems, resulting in morbidity and even mortality. We sought to review available literature to characterize wire grill-brush injury.

Methods:
A review of Ovid MEDLINE ®, PubMed, Google Scholar, and two injury databases National Electronic Injury Surveillance System (NEISS), and Safer Products (SP) government database was conducted by two independent auditors. The literature search was performed using the terms “bristle brush,” “grill brush,” and “wire brush.” The injury database search required that all events had one of the following codes linked with it: (41) ingestion, or (56) foreign body, (0) internal, (88) mouth, or (89) neck, (480) household cleaning products, (837) wire unspecified, (3218) charcoal or wood-burning grills, (3229) electric grills, (3248) gas or LP grills or stoves, (3230) kerosene grills or stoves, (3233) other grills or stoves, (3249) grills not specified. Variables of interest included common symptomatology, associated foods, time to presentation, and treatment course.

Results:
A total of 92 cases of wire grill-brush injury were identified; 43 from literature review, 35 from NEISS, and 14 from SP. The combined case list was reviewed and data was extracted. Complete case information was missing in a majority of patients, but in general, genders were affected equally and 10% of patients were under 19 years of age. The most common foods were hamburgers and grilled chicken. The main diagnostic imaging tests were CT scan (38%), and XR (29.3%). Of the known 58 cases 22.4% required intervention using a combination of laryngoscopy, endoscopy and surgery. Operative management alone was used in 23 (39.7%), whereas 6 (10.3%) were treated by laryngoscopy alone and 6 (10.3%), endoscopy alone. The majority of known cases (18, 58.0%) presented over 24 hours after suspected ingestion; of those, 7 (22.6%) presented over 1 week after suspected ingestion. Injuries involving the head and neck were more frequent (53.2%) than abdominal injuries (23.9%), and a significant amount of the injuries were unknown/unlisted (22.8%). Neck exploration occurred in 6.8%, abdominal surgery (laparoscopy or laparotomy) in 29.3%, laryngoscopy or endoscopy in 27.5%, and 3.4% required multiple operative procedures that resulted in failed retrieval.

Conclusions:
Wire grill-brush associated injuries are variable, and often present with a significant delay after presumed ingestion. Diagnostic imaging modalities are quite variable, and significant proportions of patients treated for ingestion require operative intervention. More information is needed to better characterize rare but perhaps underappreciated injuries stemming from wire grill-brush ingestion, and to better inform prevention strategies.

102.18 Follow the Guidelines: Overtriage of Blunt Trauma Patients Does Not Capture More Injured Patients

Posted on January 31, 2019

A. Fulginiti4, A. Jambhekar1, Z. Nasrawi2, V. Chan3, B. Fahoum2, J. Rucinski2  1Columbia University College Of Physicians And Surgeons,Breast Surgery Division,New York, NY, USA 2New York Presbyterian Brooklyn Methodist Hospital,Department Of Surgery,Brooklyn, NY, USA 3Abington Memorial Hospital,Department Of Medicine,Abington, PA, USA 4Monmouth Medical Center,Department Of Obstetrics/Gynecology,Long Branch, NJ, USA

Introduction:  The American College of Surgeons (ACS) provides guidelines for the triage of patients at Trauma Centers.  Several studies have shown that activations based on mechanism have been ineffective at predicting patient outcome.  The objective of our study is to evaluate injury severity in overtriaged blunt trauma activations based on mechanism.

Methods:  Data was prospectively gathered on 1,298 blunt trauma patients from April 1st 2015 to December 31st 2016.  Patients over 14 years old who were overtriaged as a level one or two activation (n=153) were compared to trauma consults (n=1145) by age, injury severity score (ISS), length of stay (LOS), time to evaluation and mechanism of injury using the unpaired Student T Test and Chi Square analysis.

Results: Overall, 11.79% of patients were overtriaged, most involving motor vehicle or bicycle related trauma (Table 1). The age (years), LOS (days), and time to evaluation (hours) of overtriaged patients were significantly decreased compared to consults.  The ISS scores were similar. There were no missed injuries.

Conclusion: Patients who were overtriaged by mechanism of injury underwent earlier evaluation although the ISS was similar and hospital stay was shorter than trauma consult patients. Based on these results, mechanism of injury is not an accurate predictor of outcome in blunt trauma patients. More stringent application of the ACS trauma triage guidelines may lead to optimal use of trauma team resources.

 

102.17 Pediatric Train Injuries: A 10 Year Review from the Pennsylvania Trauma Outcomes Study Database

Posted on January 31, 2019

C. Pennell1, E. Lindholm1, J. Latreille2, S. Kadakia2, A. D. Nanassy1, S. Ciullo1, L. Arthur1, H. Grewal1, R. Prasad1  1St. Christopher’s Hospital for Children,Department Of Pediatric General, Thoracic, And Minimally Invasive Surgery,Philadelphia, PA, USA 2Drexel University,College Of Medicine,Philadelphia, PA, USA

Introduction: Pediatric train trauma can result in severe injuries requiring significant resource utilization.  We sought to review train injuries in the state of Pennsylvania to determine the burden of these injuries on the pediatric trauma system.

Methods: We queried the Pennsylvania Trauma Outcomes Study Database to identify all patients <21 years of age suffering traumatic injuries resulting from a train accident between 2007-2016. Demographics, hospital course, outcomes, and health resource utilization was reviewed.

Results: Forty-eight patients suffered train-related injuries in the study period with an average age of 15.3 years (range 1-20). A majority of patients were male (77.1%), Caucasian (60.4%), and resided in urban environments (81.3%).  Injuries occurred most often in the spring (31.3%) and least often in the winter (16.7%). Alcohol screen was positive in 50% of patients.  Transfer from the initial hospital was required in 22.9% of cases and usually occurred within 24 hours of arrival (81.2%). The average length of stay was 12.4 days (range 0-121) and overall mortality of 10.4%. Over half of patients (56.3%) required ICU admission with an average ICU stay of 5.3 days. Injury Severity Score on arrival and Functional Independence Measure (FIM) Score on discharge averaged 17.3 and 16.4, respectively. On average, 7.1 services were consulted per patient with the most common being physical and occupational therapy (64.5%), social services (60.4%), and orthopedic surgery (52.1%). Among the 48 patients included, 41.7% experienced at least 1 long-bone or pelvic fracture. Intracranial hemorrhage occurred in 25.5% of patients, major traumatic amputation in 16.7%, concussion in 27.7%, and pneumothorax in 20.8%. Solid organ injuries occurred in 12.5% of patients with the most common being spleen (6.3%), kidney (6.3%), and liver (4.2%) injuries. Surgical management of injuries was common with 60.4% of patients requiring at least one operative intervention, most commonly internal fixation of a fracture (33.3%) or amputation (20.8%). Laparotomy was rare (6.3%) as was thoracotomy (4.2%). Overall, 75.0% of patients experienced a major injury, defined as one resulting in death, requiring surgical repair, or discharge to a rehabilitation or long-term care facility.

Conclusion: Injuries caused by trains can be severe, with a majority of admitted patients experiencing a major injury. Orthopedic injuries are the most common followed by traumatic brain injuries. Train traumas in children can be costly injuries that require a multi-disciplinary approach to care.

 

102.16 Femoral Vessel Injuries: A Review of Cases from the National Trauma Data Bank.

Posted on January 31, 2019

D. J. Keleny1, A. D. Person1, G. Mendoza-Barrera1, S. R. Brown1, D. Rigg1, M. Dale1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Trauma Surgery And Surgical Critical Care,Omaha, NE, USA

Introduction: Femoral vessel injuries are the most frequent vascular injuries seen at Trauma Centers accounting for 70% of all peripheral large blood vessel injuries treated in large volume hospitals. This makes it important to determine parameters contributory to morbidity and mortality with such injuries in an effort to optimize management and predict outcome. Our objective is to review the National Trauma Data Bank with respect to location of femoral vessel injuries with related mortality, to identify predictors of patient outcome, and to report the outcomes of these injuries based on the aforementioned predictive variables including mechanism of injury.

 

Methods: The National Trauma Data Bank was queried for pre-hospital and admission data for femoral vessel injuries. The primary outcome measured was survival. Statistical analysis included univariate and stepwise logistic regression.

 

Results: A total of 2,021 patients were identified with a total of 2,693 femoral vessel injuries from 1,466,887 patients in the National Trauma Data Bank. This is an incidence of 0.13%, with the number of survivors being 1,788 (89%). Mean age of patients was 34.1±17.34. The mean revised trauma score (RTS) for survivors was 7.2±1.67 ; for non-survivors 3.57±3.35. The mean GCS for survivors was 13±3.65 ; for non-survivors 6.59±5.11. The mean injury severity score (ISS) for survivors was 16.73±6.32 ; for non-survivors 28.0±13.88. Mechanism of injury was documented in 1,996 patients, with the majority due to penetrating injuries (1,419; 71%). The most commonly injured vessel was the superficial femoral artery (1,044; 39%). The next most commonly injured vessels were the femoral vein (817 ; 30%), the common femoral artery (645; 24%), and the femoral nerve (153; 5.7%). The highest mortality was 19%, in patients with injuries to the common femoral artery.

 

Conclusion: Although there is a relatively high survival rate for femoral vessel injuries, they incur high complication rates. Initial admission parameters correlate well with morbidity and mortality, including neurological status and hemodynamic stability. When comparing mortality rates by location of injury, common femoral vessel injuries had a significantly higher mortality rate although the most commonly injured vessel is by far the superficial femoral artery. Femoral vein injuries were also more lethal than superficial femoral artery injuries. These correlations should be looked to for optimization of management.

102.15 Demographics and Outcomes of the Acutely Intoxicated Trauma Patient

Posted on January 31, 2019

M. Fleury1, H. Hakmi1, J. Vosswinkel1, J. Mccormack1, E. Huang1, R. Jawa1  1Stony Brook University Medical Center,Trauma/Surgical Critical Care,Stony Brook, NY, USA

Introduction: A hsitory of alcohol use is often reported in injured patients.  We evaluated the association of elevated BAL with outcomes.

Methods: Retrospective analysis of a single ACS verified level 1 trauma center’s registry. Trauma patients >16yrs old, discharged between 1/1/16 and 12/31/17 were included. Emergency room deaths, isolated hip fracture patients, and injuries in nursing homes were excluded.  Patients with BAL values were separated into three groups consisting of negative BAL (NBAL <10mg/dl), low positive BAL (LBAL 11-79mg/dl), and high positive BAL (HBAL ≥80mg/dl).

Results: 1797 patients met the study criteria: 17.3% HBAL, 4.6% LBAL, and 78% NBAL. Median [IQR] BAL level was 200.5 [142-265] mg/dL in HBAL and 40 [27-58] in LBAL. The most common mechanisms of injury were: MVC/MCC in the hBAL group (35.3%), MVC/MCC in LBAL (44.6%), and falls in the nBAL group (47.4%). The HBAL group more often had pedestrians struck (12.8% vs 7.2% LBAL, 8.2% NBAL, p=0.03). The elevated BAL groups more often sustained penetrating trauma (7.0% HBAL, 6.0% LBAL, 3.4% NBAL p=0.01) or were assaulted (6.7% HBAL, 4.8% LBAL, 2.14% LBAL, p<0.001).  The median Injury Severity Score (ISS) was 10 in all 3 groups, p=0.68. There were no significant differences in major injury patterns (Abbreviated Injury Score>3) amongst the groups, except for a difference in major face injuries (0.1% NBAL vs 1.2% LBAL vs 1.6% HBAL).  The groups had a similar frequency of comorbidities (70.0% NBAL, 69.9% LBAL, 73.1% LBAL, p=0.56). The overall (major and minor) complication rate was higher in the HBAL group (14.4% vs 7.2% LBAL, 0.3% NBAL, p<0.001). However, there was no significant difference in hospital length of stay (7 [4-14] hBAL, 7 [3-11] LBAL, 6[4-11] NBAL, p=0.67), major complications (8.0% HBAL, 6.0% LBAL, 7.5% NBAL, p=0.83), or mortality (2.2% HBAL, 2.4% LBAL, 3.3% NBAL, p=0.55) amongst groups.  In multivariate analysis, an elevated BAL level was also not associated with mortality.  Additional demographics and outcomes are presented in Table 1.

Conclusion: Principal findings of this study were: 22% of admitted patients were intoxicated; over 79% of those were highly intoxicated. The data suggest that alcohol intoxication is hazardous even when not driving: patients with elevated BALs were more often assaulted, sustained penetrating trauma, or were struck by motor vehicles,  Elevated BAL patients had a higher overall complication rate and more frequently experienced alcohol/drug withdrawal.  However, a negative admission BAL did not preclude the presence of alcoholism or the development of withdrawal.

102.14 Pattern of Vascular Injuries From The Colombian Military Conflict

Posted on January 31, 2019

G. E. Mendoza-Barrera1, W. Sanchez2, S. R. Brown1, A. Person1, D. Keleny1, D. Rigg1, M. Dale1, J. Dabestani1, D. K. Agrawal1, J. A. Asensio1  1Creighton University Medical Center,Surgery,Omaha, NE, USA 2Colombian Military Hospital,Nueva Granada Military School Of Medicine,Bogota, BOGOTA, Colombia

Introduction:  Recent military conflicts have changed from more conventional to guerrilla and counter insurgency warfare with the subsequent refinement of newer antipersonnel devices such as improvised explosive devices (IEDs). The Iraq and Afghanistan conflicts have shown newer injury patterns with a subsequent decrease in definitive extremity vascular injury repairs, along with a significant increase in single and multiple limb amputations. Objectives of this study are to analyze the Colombian military experience with combat related extremity vascular injuries. Describe distribution of wounds, mechanisms of injury related to vascular injuries incurred in combat. Identify predictors of outcomes and validate conventional  wounding patterns.

Methods: Retrospective review of 13 year prospective data base. Statistical analysis: Chi square, T test, ANOVA and stepwise logistic regression which included mode of injury (MOI), MOI over time, ISS, RTS, type of vascular injury, time to definitive surgical care, procedures performed, incidence of amputation and mortality.

Results: 204 patients sustained 390 vascular injuries 159 (40.8%) arterial and 231(59.2%) . Weapons: Automatic Rifles (RIF) n=124 (60.7%), Improvised Explosive Devices (IEDs) n=42 (20.7%) and Land Mines (LMs) n=38 (18.6%). 70 patients (36.8%) were directly transferred from the field and 134 (63.2%) from MASH units. Mode of injury (MOI) remained unchanged. Extremity vascular injuries accounted for 86%: – 61% upper and 25% lower.  Neck 10% , abdominal injuries 4%. 20 patients (9.8%) required amputation (19 LE and 1 UE). Amputation was independent of MOI – RIF 9.7%, IEDs 13.1% and LM 9.8%, – p < 0.05. Amputation was dependent on presence of combined arterial-venous injuries (AVI), ligation of a named vein and performance of fasciotomy. 11/20 (55%) with lower extremity amputations sustained arterial-venous (AV) injuries, popliteal vessel injury managed with arterial interposition vein graft and popliteal vein ligation. Overall mortality 3.9% (8/204).

Conclusion: For combatants sustaining vascular injuries automatic rifles remain responsible for majority of these injuries. Extremity vascular injuries are as in other wars most prevalent. Strategies to decrease the rate of amputation for popliteal artery injuries: avoid ligation of popliteal vein  and perform complete fasciotomy. Trauma surgeons must remain adept at vascular injuries management.

102.13 Causes of Death and Wounding Patterns in Firearm-Related Violence in Washington DC

Posted on January 31, 2019

C. S. Hendrix1, M. Matecki1, S. Maghami1, K. Mahendran1, R. Mitchell2, F. Diaz2, J. Estroff1, E. R. Smith3, G. Shapiro3, B. Sarani1  1George Washington University School Of Medicine And Health Sciences,Surgery,Washington, DC, USA 2George Washington University School Of Medicine And Health Sciences,Pathology,Washington, DC, USA 3George Washington University School Of Medicine And Health Sciences,Emergency Medicine,Washington, DC, USA

Introduction:  Approximately 30,000 people die from gunshot wounds (GSW) annually in the United States. However, there are no reports of the injury patterns and exact causes of death in this cohort. The purpose of this study is to elucidate cause of death due to gun-related violence. We hypothesize that the mechanism of death following urban GSW is the same as has been reported following civilian public mass shooting events (CPMS).

Methods:  The autopsy reports of all gun related deaths in Washington, DC were reviewed from January 1, 2016 to December 31, 2017. Demographic data including age, gender, race, manner of death, type of firearm used, number and anatomic location of GSWs, and organ(s) injured were abstracted. Each GSW was catalogued by body region: head, neck, chest/upper back, abdomen/lower back and extremity. The organ injury resulting in death was noted. 

Results:182 autopsy reports were reviewed. The median age was 28 years old and 91% were male. There were 167 (92%) homicides, 13 (7%) suicides, and 0.5% accidental or unknown deaths. Handguns were implicated in 180 (98.9%) events. The median number of GSW per victim was 3 (25, 75 IQR 2, 7). Of 367 total GSW, 109 (30%) were to the chest/upper back, 85 (23%) to the head, 77 (21%) to an extremity, 70 (19%) to the abdomen/lower back, and 26 (7%) to the neck. The leading 5 mechanisms of death were injury to the brain (39%), lung parenchyma (37%), heart (27%), thoracic aorta (19%), and liver (19%) (Figure 1). 59% were transported to a trauma center. Patients with head wounds were significantly less likely (45% v 55%, p=0.003) and patients with abdominal wounds were significantly more likely (45% v 29%, p=0.03) to be transported to a trauma center. Transported patients were younger (26 v 31 years, p=0.011). There were 39 thoracotomies, 15 laparotomies, 7 vascular repairs, and 5 craniectomies performed.

Conclusion:Compared to previous reports regarding CPMS, there was little difference noted in the mechanism of death between urban GSW and CPMS events in this single city study. Over 50% of urban GSW are to the head/chest. Whereas gunshots to the extremity are common, they are rarely fatal. Based on the organs injured, rapid transport to a trauma center remains the best option for mitigating death following all GSW events. 

 

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