Monthly Archives: January 2013

General

The Return On Investment Of A Career As An Intensivist

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There is a shortage of intensivists in the US, particular in the field of surgical critical care. The are many possible reasons, from “graying” of the workforce and increased workloads to decreased reimbursement and increased legal risks. As usual, money is at the root of most problems in some form or another. So is being an intensivist actually “worth” it, and how do we figure something like that out?

A group at Chapel Hill attacked this question from a financial business/financial standpoint. They looked at the lifetime return on investment of choosing a critical care career compared to non-critical care practitioners in the same fields (surgery, medicine, pediatrics). They included income data, debt burden, opportunity costs and taxes in their analysis.

Using standard financial analysis techniques, the authors found that:

  • The financial value of the career choice of medical and pediatric intensivists was nearly identical to their non-critical care peers
  • The financial value of choosing a surgical critical care career was significantly less than that of a general surgeon
  • The lower value of a surgical critical care career was largely due to the opportunity costs of two years of lower salary during the fellowship
  • The relative value of an academic critical care career was always lower, and was most pronounced among internists

Bottom line: There are many factors that go into the choice of a career in critical care. They include job satisfaction, quality of life, and many other intangibles. But money frequently intrudes into the decision making process. It appears that choosing surgical critical care incurs some degree of financial penalty, and this may  be a factor that will exacerbate the shortage of these specialists.

Reference: The economic impact of intensivist fellowship training. Poster presentation at the EAST annual scientific session, January 2013.

General

The Three Strikes And You’re Out Airway Rule

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Rapid airway control is key in critically injured trauma patients. But too many times, I’ve seen trauma professionals take far too much time to establish one. Here’s a good rule of thumb to use in these situations.

After pre-oxygenating the patient, your first pro gets a crack at it. They generally have the most time available, often 3-5 minutes before sats begin to drop.

In the unlikely situation that they are not successful, strike 1. Stop trying and resume bagging the patient. At this point, someone (trauma surgeon, lead medic) must get the crich set out. Then the next most experienced intubator gets a shot.

If they are not successful, strike 2. Resume bagging and open the crich set.

The most experienced intubator now gets their chance, using any advanced technology available. No success even now? Strike 3, use the crich set!

Bottom line: We should never allow more than 3 airway attempts, and sometimes clinical conditions will dictate fewer tries. Examples that come to mind are severe brain injury patients (hypoxia is bad) and patients who do not recover from oxygen desaturation when they are bagged. Don’t lose track of time and the number of attempts!

General

Best Of: Paging And The Trauma Pro

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People who work in hospitals, particularly physicians, physician assistants, nurse practitioners and residents are throwbacks who still use old-fashioned paging technology. My colleague, the Skeptical Scalpel, recently lamented this fact in one of his blog posts. But they do seem to be a necessary evil, since cellular coverage is often limited deep inside of buildings.

But how much to trauma professionals get paged? An oral presentation at the recent Congress of Neurological Surgeons described a study that monitored paging practices between nurses and neurosurgical residents.

Medical students were paid to follow neurosurgical residents during 8 12-hour call shifts. They recorded the paging number and location, priority, and what the resident was doing when paged. The results were enlightening but not surprising:

  • 55 pages were received per shift, on average, ranging from 33 to 75
  • An average of 5 pages per hour were received, with a range of 2 to 7
  • A substantial number of pages were received during sleep times (4 per hour)
  • It took an average of 1.4 minutes to return the page
  • 68% of pages were non-urgent
  • 65% interrupted a patient care activity
  • An average of 1.1 hours was spent returning pages per shift

Bottom line: Yes, we are throwbacks using an old technology. But it does serve us well. Unfortunately, it’s an old technology being used in an inefficient manner. I recommend that nursing units make it a practice to maintain a “page list” of nonurgent items. The trauma professional can then stop by or call each unit periodically (every 2 hours or some other appropriate time interval) and deal with all of them at once. Obviously, urgent and emergent problems should still be called immediately. This will ensure that routine issues are taken care of in a timely manner and the trauma pro can attend to their other duties as efficiently as possible.

Related posts:

Reference: Oral Paper 113: An Observational Study of Hospital Paging Practices and Workflow Interruption Among On-call Junior Neurosurgery Residents. Presented at the Congress of Neurological Surgeons 2012.

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State Laws And Pediatric Firearms Injuries

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The US federal government records some basic statistics regarding firearm injuries, mostly related to deaths. However, the Agency for Healthcare Research and Quality maintains a database that contains detailed information on pediatric hospitalizations, including injury information. A group at Tufts University used this database to compare injury trends in pediatric firearm injury (age 0-20) in states with and without a Stand Your Ground law (SYG). Stand Your Ground laws, which many first became aware of after the death of Trayvon Martin in Florida, allow an individual to defend themelves from an unlawful threat without having to retreat first.

The database used was fairly robust. Data were submitted from 44 states, and 4 years were reviewed for the study. Over 19,000 pediatric firearm injury records were analyzed. The following interesting reslts were uncovered:

  • Nearly two thirds were assualts, and 27% were accidental injury.
  • Average length of stay for both mechanisms was about 3 days
  • Hospital cost for assault was $61,000 and for accidental injury was $46,000, per child
  • Children were about 10% more likely to suffer a firearm assault in SYG states
  • Kids in SYG states were also more likely to suffer accidental firearm injury and commit suicide with a firearm(?!)
  • Statistical association of firearm injury with the usual culprits (race, age > 16, male sex, socioeconomic status) was also noted

Bottom line: At best, this is a weak observational study. And of course, it is impossible to say that Stand Your Ground laws are the cause of a greater number of pediatric firearm injuries. The fact that (even greater) increases in accidental injury and suicide were noted points out this weakness even better. Although it is tempting to blame SYG laws on this perceived increase in injuries, it’s not correct. Much better analyses need to occur before we can really draw any actionable conclusions on the effects of these laws..

States with Stand Your Ground laws: AL, AK, AZ, CA, FL, GA, IA, IL, IN, KS, KY, LA, ME, MI, MS, MO, MT, NH, NC, ND, OH, OK,, PA, RI, SC, SD, TN, X, UT, WV, WI, WY

General

Pigtail Cathers Instead Of Chest Tubes?

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I reviewed this abstract a few months ago, and now I’ve had the opportunity to hear it and see the data. Here’s an update on whether this is worthwhile..

This was a relatively small, prospective study, and only 40 of 74 eligible patients were actually enrolled over 20 months at a Level I trauma center in the US. Pain was measured using a standard Visual Analog Scale, as was complication and failure rate, tube duration and hospital stay.

The following interesting findings were noted:

  • Chest wall pain was similar. This is expected because the underlying cause of the pneumothorax, most likely rib fractures, is unchanged.
  • Tube site pain was significantly less with the pigtail
  • The failure rate was the same (5-10%)
  • Complication rate was also the same (10%)
  • Time that the tube was in, and hospital stay was the same

There were a few questions regarding blinding of the pain scale raters, but other than the small sample size, the study was nicely done.

Bottom line: There may be some benefit in terms of tube site pain when using a smaller catheter instead of a chest tube. But remember, this is a very small study, so be prepared for different results if you try it for your own trauma program. If you do choose to use a smaller tube or catheter, remember to do so only in patients with a pure pneumothorax. Clotted blood from a hemothorax will not be completely evacuated.

Related posts:

Reference: A prospective randomized study of 14-French pigtail catheters vs 28F chest tubes in patients with traumatic pneumothorax: impact on tube-site pain and failure rate. EAST Annual Surgical Assembly, Oral paper 12, Jan 17, 2013.