Mary-Margaret Brandt

We think that general surgeons are underprepared to respond to mass casualty disasters. Preparedness education is required in emergency medicine (EM) residencies, yet such requirements are not mandated for general surgery (GS) training programs. We hypothesize that EM residents receive more training, consider themselves better prepared, and are more comfortable responding to disaster events than are GS residents. From February to May 2009, the Eastern Association for the Surgery of Trauma-Committee on Disaster Preparedness conducted a Web-based survey cataloging training and preparedness levels in both GS and EM residents. Approximately 3000 surveys were sent. Chi-squared, logistic regression, and basic statistical analyses were performed with SAS. Eight hindered forty-eight responses were obtained, GS residents represented 60.6% of respondents with 39% EM residents, and four residents did not respond with their specialty (0.4%). We found significant disparities in formal training, perceived preparedness, and comfort levels between resident groups. Experience in real-life disaster response had a significant positive effect on comfort level in all injury categories in both groups (odds ratio, 1.3-4.3, p < 0.005). This survey confirms that EM residents have more disaster-related training than GS residents. The data suggest that for both groups, comfort and confidence in treating victims were not associated with training but seemed related to previous real-life disaster experience. Given wide variations in the relationship between training and comfort levels and the constraints imposed by the 80-hour workweek, it is critical that we identify and implement the most effective means of training for all residents.

While clinicians' management of severe sepsis and septic shock has been positively influenced by a number of clinical research studies in the last decade, challenges remain regarding early hemodynamic optimization as envisioned in the Surviving Sepsis Campaign’s (SSC) resuscitation bundle (RB). We examined the impact of a hospital-wide continuous quality improvement (CQI) initiative on patients presenting with severe sepsis and septic shock, and the impact of the sepsis RB on patient outcomes when completed beyond the 6-hour recommendation period. The study was an 18-month, prospective cohort study enrolling patients who met the definition of severe sepsis or septic shock. Compliance with the hemodynamic components of the sepsis RB was defined as achieving goal mean arterial pressure (MAP) ≥65 mm Hg, central venous pressure (CVP) ≥8 mm Hg, and central venous oxygen saturation (ScvO₂) ≥70%. Compliance was assessed at 6 hours and 18 hours after diagnosis of severe sepsis or septic shock. In all, 498 patients with severe sepsis and/or septic shock were evaluated to determine the upper limit of the range of hours that compliance with the RB would still improve outcomes. Using 18 hours as a marker, Compliers at 18 hrs and Non-Compliers at 18 hrs were compared. There were 202 patients who had the RB completed in less than or equal to 18 hours. There were 296 patients who did not complete the RB at 18 hours. The Compliers at 18 hrs had a significant 10.2% lower hospital mortality 37.1% (22% relative reduction) compared to the Non-Compliers at 18 hrs hospital mortality of 47.3% ( P < .03). When the two groups were adjusted for differences in baseline illness severity, the Compliers at 18 hrs had a greater reduction in predicted mortality of 26.8% versus 9.4%, P < 0.01.Conclusions: Initiating the sepsis RB for patients with severe sepsis and/or septic shock decreased mortality. A CQI initiative that monitored the implementation in real-time allowed for improvement in compliance and efficacy of the bundle on outcomes. Multiple studies have shown that compliance to the RB within 6 hours lowers hospital mortality. This study uniquely shows that when bundle completion is extended to 18 hours, the mortality reduction remains significant.

Youth violence is a significant problem in the United States with high recidivism rates. Considering these high recidivism rates in youths after an initial injury, we hypothesized a hospital-based violence prevention program aimed at increasing awareness, empowering positive conflict resolution, and promoting future vocational goals would benefit at-risk youth before they are injured. A feasibility study was completed on our Violence and Injury Prevention (VIP) tour program at our urban Level I trauma center. Participants were at-risk youth, aged 11 years to 17 years. Anonymous data were collected using an Audience Response System. One hundred eighty-five students participated from January 2007 to August 2008. Sixty-three percent were 6th to 8th graders, 70% were boys. Seventy-nine percent stated that they knew someone who had been injured or killed because of violence, with significantly more boys than girls (p = 0.05). More boys than girls stated that they have access to a gun (p < 0.05). Almost 60% of the participants stated that they had engaged in violence within the past 6 months, with no difference by gender (p = 0.085). Of the respondents, 84.2% reported an increase in their awareness on the consequences of violence. This was more significant for girls than boys (p < 0.05). Of the participants, 86.3% reported increased understanding of hospital care for a trauma patient. Participants stated that they would recommend VIP to others. VIP educated local urban youth about violence and increased their awareness of the injuries resulting from violence. In addition, at-risk youths were exposed to career opportunities in health care.