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Editor’s Letter

Written by: Shannon Marie Foster, MD, FACS

Greetings Friends and Colleagues –

Welcome to 2023.  January has been dubbed the month of wellness.  I hope to find all in a place not only where self-assessment is possible, but more importantly, where whatever you need to define your career, your goals, and your needs is possible.  Furthermore – may that ability to introspect and build a safe, productive space be with you not just this month but throughout the year. 

In previous columns we had asked for volunteers to share activities and hobbies outside the workplace that help to bring rejuvenation and joy.  We have seen amazing photography (RS) and quilting (EB) and heard stories of physical fitness milestones.  I found another:  museum purchase parties.  Anyone familiar?  All public owned museums have a largely-volunteer committee or board that reviews new pieces and selections to add to its permanent collection.  My local institution goes a step further to invite members to participate in the process with preliminary educational offerings followed by an evening of exchange, viewing candidates, debate, and finally voting.  A fund raiser, of course, but a great social event and a unique way to engage in the community and learn.  It’s also a very cool moment when you walk the exhibits and can see the art you helped select – there are now 4 paintings on the walls that I voted for! 

Willing to share a unique hobby or interest?  Submissions for The Whole Surgeon feature in this newsletter should be directed to Erin Lillis at [email protected]

In the following links you will find a vignette from the palliative care committee reminding us that goals and expectations can only be found with time and effort; the ACS committee reinforcing the importance of communication and goal-setting in geriatric TBI and time-limited trials; an invitation to join an MCT trial to help delineate best prehospital airway management; Injury prevention initiatives in burn centers from the prevention committee; the DEI committee with a thoughtful and personal commentary leading to a proposal for underrepresented in medicine mentoring formal programs; the pediatric committee summarizing the subset of patients for whom VTE prophylaxis is indicated.  As always, the work of our colleagues is timely and impactful.  Given that committee work is fundamentally a volunteer endeavor, especially in this month of healthy time-management reminders - please remember – or hear for the first time - the membership appreciates every moment you contribute to AAST!

As always, feedback and comments on Cutting Edge content are welcome and should be directed to Erin Lillis at [email protected]

Respectfully –

SMF

Shannon Marie Foster MD FACS

Palliative Care Committee

Palliative Medicine, Hip Fractures, and the Trauma Service

Written by: Christine Toevs, MD

“Hey, we have a hip fracture for you. We have already called Ortho”.

Patients with hip fractures have much better outcomes and fewer complications if they are operatively repaired within 24 hours of arrival to ED (JAMA 2017). In our institution, the Trauma Service drives this process, as time to the OR is not an important goal from a non-surgical service perspective.

We head to the ED to see this 89-year-old nursing home patient, whose family is at the bedside. She had been at home with her family until this past year, and increasingly became too much care for the family. My discussion with the family focuses on her past year, mental and physical decline, weight loss, communication, recognition of family members, functional status. The family tells me she is non-verbal and non-ambulatory and has been bed-ridden for the past two months. I recommend no surgery, comfort measures only and inpatient hospice if we are unable to control her pain. Family agrees this is the best plan for her. I discuss the patient with the Orthopedic Surgeon, and we agree no surgery is appropriate.

Although “we can fix the bone”, the combination of anesthesia, multimodal pain control, new environment, sleep disruption, noise and all the other variables in the hospital setting, worsen the cognitive decline in patients with dementia. Managing expectations for the family regarding outcomes, cognitive decline, functional status, disposition (likely skilled nursing rather than inpatient rehab or home), code status, are a crucial component of the informed consent process. The Orthopedic literature emphasizes the purpose of repairing hip fractures is pain control and to resume ambulation, with some expected cognitive decline in patients with underlying dementia. Realistically, this upfront discussion with the family takes about 30 minutes, depending on their involvement in their loved one’s care. In cases where the patient has some cognitive decline, but has been living independently, we find these discussions take longer, as family often fixates on the “but she was doing fine on her own, before she fell and broke her hip, so of course she can live alone again.”

The debate of the Trauma Service admitting and managing hip fractures is not the purpose of this vignette; rather the purpose is a reminder of the importance of “managing expectations and goals of care discussions prior to operative intervention, regardless of the injury. All surgeons should include in the informed consent process setting goals, both in and out of the hospital. Eliciting patient/family preferences and tailoring surgical interventions takes time and practice. A family meeting about the plan of care for a patient with a hip fracture is not as adrenaline-pumping or exciting as the gunshot wound to the abdomen but is also an important skill to perfect.

ACS committee 

Goal-Concordant Care in Older Adults with Traumatic Brain Injury- The Value of Time Limited Trials

Written by: Stephen P. Miranda, MD, Rachel Morris, MD, FACS, Kathryn Haberman, MD

Traumatic brain injury (TBI) among older adults, typically defined as >65 years of age, is a growing public health crisis. Although older adults represent only 10% of all TBI patients, they account for 50% of TBI-related deaths (1). Many of these injuries, are deadly without surgical intervention, necessitating early, value-laden decisions about life-saving surgery.

One of the major barriers to clinical decision-making is prognostic uncertainty among both clinicians, patients and families. Because neurological and functional outcomes are highly contingent upon early treatment decisions, it is critical to evaluate and improve how clinicians communicate prognostic uncertainty to patients and families in these situations. There are few evidence-based TBI guidelines for older adults, and little guidance for shared decision-making (SDM) (1). For example, regardless of whether surgical intervention is pursued, the Eastern Association for the Surgery of Trauma (EAST) suggests clinicians consider limiting aggressive care if patients do not demonstrate meaningful neurologic recovery within 72 hours (2).  Measurement criteria for “meaningful neurologic recovery”, however, are not well described, and the wide variability in how neurologic improvement is interpreted is well-known (2). The time-limited trial (TLT) model offers an effective communication strategy for managing prognostic uncertainty after TBI. TLTs provide a framework for management: specific treatments or procedures are used for a defined time and with an agreed-upon outcome. 

Time-Limited Trial - What is it?

​​The TLT provides a scaffold for decision-making by establishing a clear timeframe with objective markers for monitoring the patient’s clinical response to a treatment plan, while allowing time for loved ones to adjust to the shock of the injury itself.   TLTs are used to develop treatment plans that account for a range of possible outcomes and align expectations for the patient, their surrogate, and the care team (3). The framework of a TLT requires establishing 3 critical elements:

1. Specific treatments or procedures that will be attempted
2. A defined period of time
3. Agreed-upon outcomes to monitor.

Possible outcomes include signs of worsening (loss of neurological reflexes or reduced responsiveness) or signs of improvement (e.g., following commands or defervescing).  Such a framework may be helpful for managing the prognostic uncertainty during early SDM conversations for older adults after TBI.

Figure 1: Framework for Time-Limited Trials and Shared Decision-Making

Potential Benefits of Time-Limited Trials

TLTs facilitate consensus-building amongst surrogates and the care team.  Because TLTs are inherently negotiated entities, clinicians and families must come to an agreement about what treatments will be trialed, for how long, and to what end.  This may promote more open discussions about when treatments are unlikely to achieve the favored outcome.

Because TLTs explicitly recognize that prognosis can evolve during the trial, medical therapies are viewed not as all-or-none commitments but rather as components of an uncertain process that requires iterative re-evaluation (4). Any response to therapies over the TLT may decrease prognostic uncertainty at the next family meeting and improve shared prognostic understanding amongst clinicians and families over time. Setting pre-specified time limits encourages both parties to confront clinical uncertainty, rather than continually defer decisions to an “ever-more-distant future.” In semi-structured interviews about TLTs, clinicians reported that conceptually outlining the patient’s early disease course as a trial period for specific therapies served as important preparation for a potential shift to comfort-focused care later in the patient’s course if treatments failed to achieve optimal outcomes (3).

Barriers to the Use of Time-Limited Trial

Three main challenges limit the effectiveness of TLTs when applied to older adults after TBI: uncertainty in defining and characterizing prognosis; cognitive biases and prognostic discordance during surrogate decision-making; and ambiguity surrounding appropriate endpoints for TLTs. While these areas are problematic in all forms of SDM in critical illness (5), they uniquely interfere with each step of the TLT strategy, perhaps explaining why neuro-intensivists may find it challenging to implement TLTs in practice.

One of the significant challenges of treating older adults with TBI is the prognostic uncertainty. The literature demonstrates significant heterogeneity in outcomes (1,6,7) and unfortunately the available prognostic models both under- and over- predict mortality in older adults (7).  Additionally, clinicians often inflate their prognostic estimates after TBI, overestimating both favorable outcomes for mild injuries and unfavorable outcomes in severe injuries (8). Better models are needed, because incorporating information on frailty, polypharmacy, and baseline functional status has improved prediction of quality-of-life outcomes among broader populations of older adults after trauma.

An additional challenge lies in the complexities of surrogate decision making and communication- both on the part of the surrogate and of the provider. From the surrogate’s perspective they must judge what projected disabilities would be acceptable to their loved one, while working from a framework that may be flawed from recall bias of prior conversations or from which they underestimate their loved one’s ability to adapt to/overcome a new disability. Communication between providers and surrogates can overall be difficult. As mentioned, clinicians can struggle to give accurate prognoses while the surrogates may have difficulty interpreting the information secondary to grief, anxiety, sleep deprivation, and health care literacy. This may result in prognostic discordance. Furthermore, uncertainty after severe acute brain injury fuels ongoing decisions to continue life-sustaining treatment while at the same time hindering the process of adapting to a “new normal” (9).

This leads into the final challenge: defining what are appropriate endpoints during the TLT with regards to clinical markers and timeframe. Professional societies in neuro-critical care have recommended an observation period of at least 72hrs in patients with severe acute brain injury, as critical prognostic information can emerge within the first 72hrs of intensive care after TBI.  However, beyond this, developing a timeline is frequently difficult, as neurologic status may take up to a year to plateau in older adults. Because of these uncertainties, it is not uncommon for surrogates of clinicians to seek more time, particularly if complications or diagnoses arise that were not initially discussed3.  Setting a time period may also be difficult from a logistics standpoint as the clinician may be subject to a rotating call schedule, which can preclude them from taking ownership of the patient and discussion(3). On the flip side, this waiting period may be agonizing for the surrogates.  As such, it is critical that all parameters of a TLT are clearly communicated to all members of the clinical team and surrogates/families, with an emphasis on providing consistency.

Conclusion

In summary, TLTs may provide structure and guidance to the SDM process for older adults with TBI, as long as clinicians are aware of their limitations. Because we may never have the tools to accurately prognosticate on an individual level after TBI, such a communication framework can help clinicians acknowledge prognostic uncertainty up front and develop a shared prognostic understanding with surrogates as the trial unfolds, so that their expectations are in line with realistic outcomes. Critical barriers to successful implementation of TLTs after TBI still include intense uncertainty inherent to prognostication in this population, cognitive biases faced by both clinicians and surrogates during decision-making, and incomplete evidence on the appropriate clinical measures and timepoints for ending the trial. Improving prognostication remains an area of active research in TBI, and further study is needed to develop models that predict neurologic recovery and quality of life more accurately. Further investigation is required to better understand clinician behaviors and surrogate preferences for prognostic communication.

Key Points

• Time-Limited Trials provide the framework for improved communication between clinicians and surrogates in the setting of an unclear prognosis.
• The 3 critical elements of a Time-Limited Trial are: specific treatments or procedures that will be attempted, a defined period of time, and agreed-upon outcomes to monitor.
• Benefits include: improved consensus between clinicians and surrogates, improved judgements of prognosis as time progresses, a framework in which to manage uncertainty allowing for continued decision-making.
• Challenges include: prognostic uncertainty, personal biases and communication issues in both clinicians and surrogates, unclear clinical endpoints/timeline.

References

1. Gardner RC, Dams-O'Connor K, Morrissey MR, Manley GT. Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions. J Neurotrauma. 2018;35(7):889-906.
2. Calland JF, Ingraham AM, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S345-350.
3. Bruce CR, Liang C, Blumenthal-Barby JS, et al. Barriers and Facilitators to Initiating and Completing Time-Limited Trials in Critical Care. Crit Care Med. 2015;43(12):2535-2543.
4. Neuman MD, Allen S, Schwarze ML, Uy J. Using time-limited trials to improve surgical care for frail older adults. Ann Surg. 2015;261(4):639-641.
5. VanKerkhoff TD, Viglianti EM, Detsky ME, Kruser JM. Time-Limited Trials in the Intnsive Care Unit to Promote Goal-Concordant Patient Care. Clin Pulm Med. 2019;26(5):141-145.
6. Surgeons ACo. ACS TQIP Palliative Care Best Practice Guidelines. Accessed September 15, 2021. https://www.facs.org/-/media/files/quality-programs/trauma/tqip/palliative_guidelines.ashx
7. Goostrey K, Muehlschlegel S. Prognostication and shared decision making in neurocritical care. Bmj. Apr 7 2022;377:e060154. doi:10.1136/bmj-2021-06015431.
8. Moore NA, Brennan PM, Baillie JK. Wide variation and systematic bias in expert clinicians' perceptions of prognosis following brain injury. Br J Neurosurg. Jun 2013;27(3):340-3. doi:10.3109/02688697.2012.754402
9. Rutz Voumard R, Kiker WA, Dugger KM, et al. Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design. Crit Care Med. Aug 1 2021;49(8):1322-1332. doi:10.1097/ccm.0000000000004947

Multicenter Trials Committee

AAST Multicenter Trials Committee Update

Written by: Joseph DuBose, MD

The AAST MCT continues to review and support the implementation of high-quality multicenter research efforts designed and led by our membership.  Several great efforts are being developed that are open to enrollment and support from fellow AAST members.  In this newsletter, we highlight one specific effort we hope you will consider contributing to.

Pre-hospital endotracheal intubation

Prehospital endotracheal intubation is a contentious topic. Few studies have found its practice to be associated with improved neurologic outcomes in the presence of traumatic brain injury; while there is growing evidence that prehospital endotracheal intubation increases a patient’s likelihood of adverse outcomes and mortality, especially in the presence of exsanguination. 

However, secondary to inconsistent study designs, variable prehospital practice patterns, etc., the Eastern Association for the Surgery of Trauma were unable to make any recommendations regarding prehospital intubation in their last updated 2012 Endotracheal Intubation Practice Management Guideline.

The purpose of our study is to explore the use of various airway management techniques in the prehospital setting for patients experiencing acute, physical trauma. Data are needed so the trauma community can devise firm recommendations for prehospital providers regarding optimal airway management for trauma patients.

This study is being led and coordinated by the outstanding team at UC Health University of Colorado under Dr. Michael Cripps. Should your center have an interest in participating in our study, please reach out directly to Shane Urban ([email protected]) at UC Health University of Colorado for more information.

Prevention Committee

Injury Prevention Initiatives in Burn Centers

Written by Edward Cho, MD

Burn injuries are the fourth most common form of trauma, following road traffic collisions, falls, and interpersonal violence. Similar to other forms of trauma, the best prevention is to avoid injuries in the first place. While new programs have been initiated and advances made on burn prevention, much work remains to be done. 

Between 7-11 million people annually seek medical care for burns, and over 100,000 die.¹ About 90% of burn injuries are seen in low- and middle income countries, many of which do not have access to organized burn care. Mortality after burn injury is inversely correlated with  a nation’s Gross Domestic Product or citizen income level.². The large discrepancy between high-income countries and low- or middle income countries is multi-factorial; including advances in infrastructure, more stringent safety measures, and regular use of fire and smoke alarms to name a few. Since the vast majority of burn patients do not have access to health-care systems that are able to document and properly care for burn injuries, the incidence of burns is likely underestimated. This not only leads to difficulty in truly understanding the burden of burn injuries for the healthcare system but also impedes burn injury treatment and prevention. Most of the data regarding the treatment of burn injuries come from hospital systems, usually through the emergency department or specialized burn centers, and miss patients treated in the outpatient setting. The World Health Organization has created a burn registry to better understand the impact that burn injuries have upon health-care systems; however, its use has been limited and may not be an accurate reflection of the incidence of burns worldwide.³

Burn injuries can be categorized in different ways. The most common mechanism for burn injuries is through fire/flame, scalds, contact with hot objects, chemical, and electrical burns. Flame burns are the most common and usually occur at home^.4 Scald and contact burns are more common in children. Different burn mechanisms have different patterns. Scald injuries are typically due to spilled hot liquids usually effecting the lower extremities and the genitalia in younger children in either a ‘V’ or a scattered pattern (from splashing liquid), while flame burns impact older children and involve accelerants 54.9% of the time.⁵ Determination of intentional vs. unintentional burns is based on the pattern of injury. The majority of burn wounds are unintentional; however, early identification of intentional injury helps delineate the need for other resources, such as psychiatric and social work, that should be dedicated to these injuries. It is also important to identify incidents of child or elder abuse in addition to self-harm, if present.

 The treatment of burn injuries has changed significantly over the past few decades. Early excision and grafting of burned tissue has been shown to improve outcomes.⁶ Split-thickness skin grafting is commonly used for large areas, while full-thickness skin grafting is used for small sites of functional importance such as the palm. Due to the limitation of graft size in full-thickness skin grafts, split-thickness skin grafts are more commonly used. Various temporizing alternatives to skin grafting are also utilized if insufficient donor sites are available, including biologics (allograft) and skin substitutes (such as biodegradable temporizing matrix, MatridermÔ, Primatrix, and Integra).

Despite optimal initial burn care, complications such as contractures and hypertrophic scars, especially around joints, can impact patient mobility and function.⁷ Reconstructive options range from laser therapy, contracture releases, to free flaps for better coverage and healing. About 13% of patients treated for burns undergo further reconstructive surgery due to contractures, mostly involving the hands and head/neck.⁸

Due to the high morbidity and mortality associated with burn injuries, prevention is important. Educational programs for the community have been created to prevent burn injuries. In a study by Rieman et al. a curriculum specifically targeted to the Amish population was shown to be a highly effective tool in improving burn prevention knowledge, including a burn safety curriculum as well as evaluation through situational simulations with associated magnet rearrangement.⁹ These educational programs should be culturally appropriate and provide applicable and practical items for the communities to use. Similar educational efforts have been performed in low-income regions with kerosine lamps to improve rates of unintentional burn injuries and have shown improvement.¹⁰

Further prevention initiatives have used legislation to enforce installing various infrastructure and engineering systems designed to decrease burn injury. Perhaps one of the most important of these has been the requirement to install smoke detectors in homes in 1975. The presence of smoke detectors in homes rose from less than 5% in 1970 to 67% in 1982 and further raised to >98% in 2016.^{11, 12} The increase in the presence of smoke detectors has also significantly improved the rate of residential fires as well as fire-related deaths.¹³ In addition to the requirement for smoke detectors to protect homes, local fire departments have assisted in encouraging the community to install these protective devices. Currently 38 states require carbon monoxide detectors in homes through state statute or building code. While carbon monoxide detectors have not directly improved burn rates, they have been instrumental in the prevention of carbon monoxide poisoning.^{14, 15}

Scald burns are the second most common mechanism of burn injuries. These injuries often occur in pediatric patients in the bathroom, usually due to the temperature of hot tap water or spilled hot liquids. In Washington state, due to the high frequency of these injuries, preventative measures were started through the implementation of presetting new water heaters to 120 degrees Fahrenheit. Further analysis following this new law showed 77% of homes had tap water temperatures of less than 129 degrees Fahrenheit compared to 80% of homes pre-legislation.¹⁶ The state also saw a 50% reduction in the incidence of scald burns, showing a significant clinical improvement.

Over the course of the past several decades, significant improvements in burn prevention have occurred. These include numerous educational models, the mandatory installation of smoke detectors, and the decrease in tap water temperature, along with countless others. Despite these significant advancements in education and legislation, burn injuries still remain as the fourth most common form of trauma. The American Burn Association and the National Fire Protection Association are leading the efforts in burn prevention. Current initiatives include the the High Rise Fire Sprinkler Incentive Act, HR 4685 which has been introduced in the House of Representatives and aims at increasing the number of homes protected with automated fire sprinklers as well as the Home Oxygen Burn Prevention initiative. At a state level, New York has introduced bills to decrease the number of fires caused by malfunctioning lithium-ion batteries used to power small electronic mobility devices (S.9596-9697).¹⁷ Further support for smoking cessation can also improve burn prevention as many burn injuries are related to fires or burns started by cigarettes.

Resources

1. James SL, Lucchesi LR, Bisignano C, et al. Epidemiology of injuries from fire, heat and hot substances: global, regional and national morbidity and mortality estimates from the Global Burden of Disease 2017 study. Inj Prev. 2020;26(Supp 1):i36-i45. doi:10.1136/injuryprev-2019-043299
2. Peck M, Pressman MA. The correlation between burn mortality rates from fire and flame and economic status of countries. Burns. 2013;39(6):1054-1059. doi:10.1016/j.burns.2013.04.010
3. Hebron C, Mehta K, Stewart B, Price P, Potokar T. Implementation of the World Health Organization Global Burn Registry: Lessons Learned. Ann Glob Health. 2022;88(1):34. Published 2022 May 18. doi:10.5334/aogh.3669
4. American Burn Association. National Burn Repository, Version 12.0, 2016. https://ameriburn.org/wp-content/uploads/2017/05/2016abanbr_final_42816.pdf
5. Moehrlen T, Szucs T, Landolt MA, Meuli M, Schiestl C, Moehrlen U. Trauma mechanisms and injury patterns in pediatric burn patients. Burns. 2018;44(2):326-334. doi:10.1016/j.burns.2017.07.012
6. Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns. 2006;32(2):145-150. doi:10.1016/j.burns.2005.09.005
7. Stekelenburg CM, Marck RE, Tuinebreijer WE, de Vet HC, Ogawa R, van Zuijlen PP. A systematic review on burn scar contracture treatment: searching for evidence. J Burn Care Res. 2015;36(3):e153-e161. doi:10.1097/BCR.0000000000000106
8. Hop MJ, Langenberg LC, Hiddingh J, et al. Reconstructive surgery after burns: a 10-year follow-up study. Burns. 2014;40(8):1544-1551. doi:10.1016/j.burns.2014.04.014
9. Rieman MT, Kagan RJ. Multicenter testing of a burn prevention teaching tool for Amish children. J Burn Care Res. 2013;34(1):58-64. doi:10.1097/BCR.0b013e318278169a
10. Schwebel DC, Swart D, Simpson J, Hobe P, Hui SK. An intervention to reduce kerosene-related burns and poisonings in low-income South African communities. Health Psychol. 2009;28(4):493-500. doi:10.1037/a0014531
11. Atiyeh BS, Costagliola M, Hayek SN. Burn prevention mechanisms and outcomes: pitfalls, failures and successes. Burns. 2009;35(2):181-193. doi:10.1016/j.burns.2008.06.002
12. Wood RL, Teach SJ, Rucker A, Lall A, Chamberlain JM, Ryan LM. Home Fire Safety Practices and Smoke Detector Program Awareness in an Urban Pediatric Emergency Department Population. Pediatr Emerg Care. 2016;32(11):763-767. doi:10.1097/PEC.0000000000000943
13. Liao CC, Rossignol AM. Landmarks in burn prevention. Burns. 2000;26(5):422-434. doi:10.1016/s0305-4179(00)00026-7
14. Christensen GM, Creswell PD, Theobald J, Meiman JG. Carbon monoxide detector effectiveness in reducing poisoning, Wisconsin 2014-2016. Clin Toxicol (Phila). 2020;58(12):1335-1341. doi:10.1080/15563650.2020.1733592
15. Taira BR, Cassara G, Meng H, et al. Predictors of sustaining burn injury: does the use of common prevention strategies matter?. J Burn Care Res. 2011;32(1):20-25. doi:10.1097/BCR.0b013e318204b2eb
16. Erdmann TC, Feldman KW, Rivara FP, Heimbach DM, Wall HA. Tap water burn prevention: the effect of legislation. Pediatrics. 1991;88(3):572-577.
17. Krueger, L. Krueger introduces bill to address rapid increase in fires caused by lithium-ion batteries. NY Senate. Accessed Jan 6 2023. https://www.nysenate.gov/newsroom/press-releases/liz-krueger/krueger-introduces-bills-address-rapid-increase-fires-caused

Diversity, Equity, and Inclusion Committee

Allocating a Scarce Resource and the Importance of Mentorship In DEI

Written by: Francisco Alvarado, MD

Diversity in the workplace is quickly being prioritized in multiple fields including medicine. Medical schools and residency programs often have diversity, equity and inclusion (DEI) committees to provide fair opportunities to and exposure of applicants from groups underrepresented in medicine (URiM) which consists of African Americans/Blacks, Hispanic/Latino, Native Americans, Pacific Islanders, and those who come from disadvantaged backgrounds. Those racial and ethnic groups that experience the most barriers to obtaining health care, have poorer overall health status, and have higher levels of physician distrust are the same groups least represented in medicine. Racial/ethnic diversity within surgical training programs have decreased over all in the past 10 years. With that in mind, one of the questions these DEI committees seek to answer is how can the URiM recruitment strategy improve? While I think URiM recruitment is multifactorial (i.e. Faculty representation, mentorship, location, support for URiM applicants, etc.), URiM applicants and mentors are a “scarce resource”. So how do we best currently allocate this scarce resource so that patients are more positively benefited from being cared for by URiM physicians and going beyond a system that is simply seeking to fill a quota?

I completed residency in the Bronx which demographically consists of mostly Black/African American and Hispanic patient population. I am Puerto Rican and Dominican, so I purposely sought a program that catered to a population that I was familiar with. There were not many days I can remember in residency that I did not have to rely on my ability to speak Spanish to communicate with patients. There was a sense of pride in that, being able to serve a community that I could associate with. Not only from the language spoken, but also being able to relate to the culture, socioeconomic disadvantages, and healthcare barriers patients faced as it was like those my own family have encountered.

I come from a low socioeconomic background and was the first person in my family to graduate high school, and since then the only person that has attended college. While I did break out of the cycle of poverty, it was not without the help of mentorship along the way. Though, as I moved onto medical school and residency, I realized that mentorship was limited. The resources on how or where to seek out mentorship were not always readily apparent or accessible when I needed them. I assumed by going to a residency program that primarily caters to an underserved community, the faculty and resident demographic would reflect that. However, this was not the case. I personally struggled to get through some the next steps of my career without guidance from a mentor.  

In two papers published^1,2 on mentorship, it is noted that URiM physicians are less likely to have mentors both as trainees and faculty. The reasons are again multifactorial but not limited to institutional support and lack of URiM mentors to provide mentorship.  Interestingly, programs that have published^3,4 on URiM mentorship report retention in their URiM trainees into faculty positions.  The proposal of mentorship as a mechanism to address disparities for URiM applicants, trainees, and attendings has been associated with increased career satisfaction, research productivity, and preparedness for junior faculty³.

Thus, I propose the following questions: Would there be any utility in DEI committees at national levels to seek out established URiM attendings to provide mentorship? As this is a, scarce resource, should these mentors be paired specifically with URiM applicants and trainees at programs where institutional support may be lacking? These are questions that can be answered with the development of formal mentorship programs for URiM trainees and faculty, and we can start by building and studying the effects of these relationships within surgical training.  Mentorship, I believe is the key in continuing a sustainable future for URiMs in surgery.

References:

1. Ramanan RA, Taylor WC, Davis RB, Phillips RS. Mentoring matters. Mentoring and career preparation in internal medicine residency training.J Gen Intern Med. 2006;21(4):340–345. 
2. Nivet MA, Taylor VS, Butts GC, et al. Diversity in academic medicine no. 1 case for minority faculty development today.Mt Sinai J Med. 2008;75(6):491–498.
3. Bonifacino E, Uformata EO, Farkas AH, Turner R, Corbelli JA. Mentorship of Underrepresented Physicians and Trainees in Academic Medicine: a Systematic Review. Gen Internal Med. 2021 Apr;35(4):1023-1034. doi:10.1007/s11606-020-06478-7. Epub 2021 Feb2. PMID:33532959; PMCID: PMC7852467
4. Benson CA, Morahan PS, Sachdeva AK, Richman RC. Effective faculty preceptoring and mentoring during reorganization of an academic medical center. Med Teach. 202;24(5):550-557.

Pediatric Trauma Committee

Use of VTE Prophylaxis in the Pediatric Trauma Patient

Written by: Dr. Andrew Litwin

While the use of chemical VTE prophylaxis in the adult trauma population has been well established, there has been less of a consensus regarding its use in the pediatric trauma population. Children are at a much reduced risk for developing VTE likely due to their lack of acquired risk factors and physiologic differences in the pediatric coagulation system (1). As such, there has been a long standing question as to whether or not chemical prophylaxis is even needed in this population. This lack of consensus seems to stem not only from the low incidence of DVT/PE in pediatric trauma patients, but also its lack of use due to concerns for bleeding, and questions as to its effectiveness on preventing VTE (2), all leading to inconsistent use of chemical prophylaxis across the board. Many studies have been performed over the years in hopes to identify the incidence of DVT/PE development in the pediatric trauma population as well as to determine the existence of risk factors or predisposing factors to the development of VTE in this population. Recently, this data has started to become scrutinized in attempts to identify which, if any, of the pediatric trauma patients should be routinely started on chemical prophylaxis. While most studies conclude that more investigation into this question is required, the past few years has seen the development of a number of guidelines to help identify the pediatric trauma patient who would best benefit from VTE prophylaxis (3).

Incidence of VTE in the pediatric trauma population has been reported at anywhere from 1-9% though the overall average appears to fall along the lower end of that range (4,5). The difficulty in establishing a more accurate incidence of disease appears to stem from the wide range of ages, and physiologic states that fall under the term “pediatric,” with patients aged 13 and older often being more predisposed to developing VTE in the setting of trauma possibly due to the maturation of the coagulation system in puberty. Other factors noted to have an impact on the development of VTE in the pediatric population include but are not limited to: high ISS, TBI, spinal cord injury, long bone fractures, immobilization, elevated BMI, mechanical ventilation, and the presence of a central line (6).

Most guidelines do agree that chemical VTE prophylaxis in the pediatric trauma population is effective in reducing the incidence of VTE.  Joint guidelines from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma society recommend VTE prophylaxis in admitted pediatric trauma patients over the age of 15 at low risk of bleeding as well as patients under 15 years old but post pubertal and an ISS over 25 (7). VTE prophylaxis is recommended against in prepubertal trauma patients. The goal then becomes how to identify the patients that would benefit from this intervention without causing undo harm.

Since the incidence of a pediatric trauma patient developing a VTE has been found to be less than 10%, exposing these patients to increased bleeding risk may in fact do much more harm than good, especially in the setting of polytrauma. TBI provides its own set of difficulties. As previously mentioned, pediatric trauma patients who have sustained a TBI are at increased risk for developing a VTE while at the same time being at risk for a dangerous rebleed in the setting of anticoagulation. In these patients it is prudent to avoid the use of chemical DVT prophylaxis, even in patients with higher risk for VTE (older age, higher ISS), as the risk of bleeding is likely higher than the risk of VTE.  Additionally, the use of long-term femoral line use should be avoided in pediatric trauma patients as it increases the risk of VTE (8).

Another important point to consider when deciding whether to start chemical VTE prophylaxis is the use of mechanical VTE prophylaxis. While again, the data in this area is not ideal, studies have shown similar results as far as VTE prevention in pediatric trauma patients when comparing mechanical and chemical prophylaxis (3). With that in mind, should a patient present with a high risk of VTE as well as a high risk for bleeding in the setting of a recent trauma (TBI, solid organ injury), the current data does support the use of mechanical VTE prophylaxis alone.  

In conclusion, the current data does identify a subset of pediatric trauma patients for which chemical VTE is appropriate. We would recommend considering VTE prophylaxis immediately in patients aged 15 and up or younger but still post pubertal with an ISS over 15 as long as there is a low risk of bleeding (absence of solid organ injury, TBI or known hematomas). Once stability has been established from these other injuries and the risk of bleeding has minimized, VTE prophylaxis can then be considered. We do not recommend use of chemical VTE prophylaxis for any prepubertal children. As the incidence of pediatric trauma rises, further study in this area will be critical to help clinicians best care for this extremely delicate and at risk patient population.

Resources

1. Jinks S, Arana A. Venous thromboembolism in paediatrics. BJA Educ. 2019;19(9):305-312. doi:10.1016/j.bjae.2019.05.003
2. Petty JK. Venous thromboembolism prophylaxis in the pediatric trauma patient. Semin Pediatr Surg. 2017 Feb;26(1):14-20. doi: 10.1053/j.sempedsurg.2017.01.001. Epub 2017 Jan 5. PMID: 28302279.
3. Mahajerin A, Petty JK, Hanson SJ, Thompson AJ, O'Brien SH, Streck CJ, Petrillo TM, Faustino EV. Prophylaxis against venous thromboembolism in pediatric trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma and the Pediatric Trauma Society. J Trauma Acute Care Surg. 2017 Mar;82(3):627-636. doi: 10.1097/TA.0000000000001359. PMID: 28030503.
4. Georgeades C, Van Arendonk K, Gourlay D. Venous thromboembolism prophylaxis after pediatric trauma. Pediatr Surg Int. 2021 Jun;37(6):679-694. doi: 10.1007/s00383-020-04855-1. Epub 2021 Jan 19. PMID: 33462655.
5. Leeper CM, Vissa M, Cooper JD, Malec LM, Gaines BA. Venous thromboembolism in pediatric trauma patients: Ten-year experience and long-term follow-up in a tertiary care center. Pediatr Blood Cancer. 2017 Aug;64(8). doi: 10.1002/pbc.26415. Epub 2017 Jan 9. PMID: 28067012.
6. Thompson AJ, McSwain SD, Webb SA, Stroud MA, Streck CJ. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg. 2013 Jun;48(6):1413-21. doi: 10.1016/j.jpedsurg.2013.02.059. PMID: 23845640.
7. Hanson, Sheila J. MD, MS; Punzalan, Rowena C. MD; Arca, Marjorie J. MD; Simpson, Pippa PhD; Christensen, Melissa A. BS; Hanson, Sydney K.; Yan, Ke PhD; Braun, Kristin MS, RN; Havens, Peter L. MD, MS. Effectiveness of clinical guidelines for deep vein thrombosis prophylaxis in reducing the incidence of venous thromboembolism in critically ill children after trauma. The Journal of Trauma and Acute Care Surgery 72(5):p 1292-1297, May 2012. | DOI: 10.1097/TA.0b013e31824964d1
8. Labuz DF, Cunningham A, Tobias J, et al. Venous thromboembolic risk stratification in pediatric trauma: A Pediatric Trauma Society Research Committee multicenter analysis. J Trauma Acute Care Surg. 2021;91(4):605-611. doi:10.1097/TA.0000000000003290

The Journal of Trauma and Acute Care Surgery

JTACS 2022 in Review and 2023 Perspectives

Written by: Raul Coimbra, MD, PhD, FACS, Editor-in-Chief, The Journal of Trauma and Acute Care Surgery

Many great things happened in The Journal of Trauma and Acute Care Surgery (JTACS) in 2022, and many more will be hapenning in 2023.

2022 ACCOMPLISHMENTS/FACTS:

• New Editorial Management Team led by Michelle Gaffney (Managing Editor), Carissa Holaska and Shreya Sinha (Editorial Associates).
• Successful Contract Renewal with Wolters Kluwer.
• First Double Anonymous Peer Reviewed Surgical Journal in North America.
• Reorganization of the JTACS website. Please visit it at jtrauma.com
• DEI Efforts: Updated JTACS Instruction for Authors to include guidance on disparities research & inclusive language. Added a new DEI Resources page to the JTACS website.
• Excellent Military Supplement published in August 2022.
• Publication of 14 National Trauma Research Action Plan (NTRAP). These manuscripts can be found in the journal’s website (jtrauma.com) under “Collections”.
• An extensive Social Media Approach has increased global visibility of JTACS (> 3.5 Million Impressions and > 350% increase in Tweeter Engagement). Thanks to Kenji Inaba, Erin Lillis (AAST) and the US and International JTACS Social Media Committee members for your engagement and successful work.
• New Journal Cover listing the Picture of the Month and the “Best of….” articles in Trauma, Surgical Critical Care, Emergency General Surgery, and Basic/Translational Research.
• Updated Instructions for Authors. Check it out often before manuscript submission, as we are always updating it to make submission easier for authors.
• Addition of Visual Abstracts and Media Summary for all submissions accepted for publication, which are used in conjunction with authors’ videos for Social Media dissemination. Visit the JTACS website and search the visual abstracts and video libraries.
• Updated and improved website with more information on the home page and easily accessible.
• Implemented Reviewer of the Month to highlight the outstanding reviews being conducted

2023 ACCOMPLISHMENTS/FACTS AND FUTURE PLANS: 

• Excellent Pediatric Traumatic Hemorrhagic Shock Supplement (published in January 2023).
• Addition of the Chest Wall Injury Society as a new affiliated society to JTACS.
• Request Editorial Board Members, Ad Hoc reviewers, and authors to update their profiles in Editorial Manager, primarily focusing on Classifications (the research topics they are experts on and willing to review for JTACS). This will improve our ability to match manuscripts to reviewers based on their expertise.
• Editorial Board Members completing their many years of great services to JTACS:
  • Dennis Bansard
  • James Betts
  • Susan Briggs
  • Thomas Cogbill (in memoriam).
  • David Harrington
  • Elliott Haut
  • David Herndon
  • Lewis Kaplan
  • Riyad Karmy-Jones
  • Reuven Rabonivici
  • Christian Schinkel
  • Dennis Vane
  • George Velmahos
  • David Wesson
  • Steven Wolf

• New Editorial Board Members starting a 3-year term as of February 2023:
  • Megan Brenner
  • Rachel Callcut
  • Andrew Cap
  • Weidun Alan Guo
  • Joaquim Havens
  • Lucy Kornblith
  • Koji Morishita
  • Matthew Neal
  • Gustavo Parreira
  • Joao Rezende-Neto
  • Susan Rowell
  • Babak Sarani
  • Angela Sauaia
  • Kevin Schuster
  • Kristan Staudenmayer

The Editorial Board of JTACS is saddened by the passing of one of its most active members and long-time reviewer Thomas Cogbill, MD on December 31, 2022.