Faculty Bibliography

BACKGROUND:During early spring 2020, New York City (NYC) rapidly became the first US epicenter of the COVID-19 pandemic. With an unparalleled strain on health care resources, we sought to investigate the impact of the pandemic on trauma visits and mortality in the United States' largest municipal hospital system. METHODS:We conducted a retrospective multicenter cohort study of the five level 1 trauma centers in NYC's public health care system, New York City's Health and Hospitals Corporation. Clinical characteristics, mechanism of injury, and mortality of trauma patients presenting during the early pandemic (March 1, 2020, to May 31, 2020) were compared with a similar period in the previous 2 years. To account for important patient and hospital-level confounding variables, we created a propensity score for treatment and applied inverse probability weighting. RESULTS:In March to May 2020, there was a 25% decrease in median number of monthly trauma visits (693 vs. 528; p = 0.02) but a 50% increase (15% vs. 22%; p = <0.001) in patients presenting for penetrating injuries, compared with the same period for 2018 and 2019. Injured patients with COVID were significantly more likely to die compared with those without COVID-19 (10.5% vs. 3.6%; p < 0.001). Overall, there was no significant difference in mortality for non-COVID-injured New Yorkers cared for in 2020 compared with 2018 and 2019. Less severely injured non-COVID patients (Injury Severity Score, <15), however, were significantly more likely to die compared with this same subgroup in 2018 and 2019 (adjusted relative risk, 2.7 [95% confidence interval, 1.5-4.7]). CONCLUSION/CONCLUSIONS:Despite a decline in overall trauma visits during the early part of the COVID pandemic in NYC, there was a significant increase in the proportion of penetrating mechanisms. Less-injured non-COVID patients experienced an increase in mortality in the early pandemic, possibly from a depletion of human and hospital resources from the large influx of COVID patients. These data lend support to the safeguarding of trauma system resources in the event of a future pandemic. LEVEL OF EVIDENCE/METHODS:Prognostic and Epidemiologic; Level III.

BACKGROUND:Patient morbidity and mortality decrease when injured patients meeting CDC Field Triage Criteria (FTC) are transported by emergency medical services (EMS) directly to designated trauma centers (TCs). This study aimed to identify potential disparities in the transport of critically injured patients to TCs by EMS. STUDY DESIGN/METHODS:We identified all patients in the National EMS Information System (NEMSIS) database in the National Association of EMS State Officials East region from January 1, 2018, to December 31, 2019, with a final prehospital acuity of critical or emergent by EMS. The cohort was stratified into patients transported to TCs or non-TCs. Analyses consisted of descriptive epidemiology, comparisons, and multivariable logistic regression analysis to measure the association of demographic features, vital signs, and CDC FTC designation by EMS with transport to a TC. RESULTS:A total of 670,264 patients were identified as sustaining an injury, of which 94,250 (14%) were critically injured. Of those 94,250 critically injured, 56.0% (52,747) were transported to TCs. Among all critically injured women (n = 41,522), 50.4% were transported to TCs compared with 60.4% of critically injured men (n = 52,728, p < 0.001). In a multivariable logistic regression model, critically injured women were 19% less likely to be taken to a TC compared with critically injured men (OR 0.81, 95% CI 0.71-0.93, p = 0.003). CONCLUSIONS:Critically injured female patients are less likely to be transported to TCs when compared with their male counterparts. Performance improvement processes that assess EMS compliance with field triage guidelines should explicitly evaluate for sex-based disparities. Further studies are warranted.

BACKGROUND:Underrepresented minorities in medicine (URiM) are disproportionally represented in surgery training programs. Rates of URiM applying to and completing General Surgery residency remain low. We hypothesized that the patterns of URiM disparities would persist into Surgical Critical Care (SCC) fellowship applicants, matriculants and graduates. METHODS:We performed a retrospective analysis of SCC applicants, matriculants and graduates from 2005-2020 using the Graduate Medical Education (GME) resident survey and analyzed applicant characteristics using the Surgical critical care and Acute care surgery Fellowship Application Service (SAFAS) from 2018-2020. The data were stratified by race/ethnicity and gender. Indicator variables were created for Asian, Hispanic, White and Black trainees. Yearly proportions for each race/ethnicity and gender categories completing or enrolling in a program were calculated and plotted over time with Loess smoothing lines and overlying 95% confidence bands. The yearly rate and statistical significance of change over time were tested with linear regression models with race/ethnicity and gender proportion as the dependent variables and year as the explanatory variable. RESULTS:From 2005-2020, there were a total of 2,481 graduates. Black men accounted for 4.7% of male graduates with a significant decline of 0.3% per year for the study period of those completing the fellowship (p = 0.02). Black women comprised 6.4% of female graduates and had a 0.6% decline each year (p < 0.01). A similar trend was seen with Hispanic men, who comprised 3.2% of male graduates and had a 0.3% annual decline (p = 0.02). White men had a significant increase in both matriculation to and graduation from SCC fellowships during the same interval. Similarly, Black and Hispanic applicants declined from 2019 to 2020, while the percentage of White applicants increased. CONCLUSIONS:Disparities in URiM representation remain omnipresent in surgery and extend from residency training to SCC fellowship. Efforts to enhance the recruitment and retention of URiM in SCC training are warranted. LEVEL OF EVIDENCE/METHODS:Level IV - Therapeutic/Care Management.

Importance/UNASSIGNED:The lack of underrepresented in medicine physicians within US academic surgery continues, with Black surgeons representing a disproportionately low number. Objective/UNASSIGNED:To evaluate the trend of general surgery residency application, matriculation, and graduation rates for Black trainees compared with their racial and ethnic counterparts over time. Design, Setting, and Participants/UNASSIGNED:In this nationwide multicenter study, data from the Electronic Residency Application Service (ERAS) for the general surgery residency match and Graduate Medical Education (GME) surveys of graduating general surgery residents were retrospectively reviewed and stratified by race, ethnicity, and sex. Analyses consisted of descriptive statistics, time series plots, and simple linear regression for the rate of change over time. Medical students and general surgery residency trainees of Asian, Black, Hispanic or Latino of Spanish origin, White, and other races were included. Data for non-US citizens or nonpermanent residents were excluded. Data were collected from 2005 to 2018, and data were analyzed in March 2021. Main Outcomes and Measures/UNASSIGNED:Primary outcomes included the rates of application, matriculation, and graduation from general surgery residency programs. Results/UNASSIGNED:Over the study period, there were 71 687 applicants, 26 237 first-year matriculants, and 24 893 graduates. Of 71 687 applicants, 24 618 (34.3%) were women, 16 602 (23.2%) were Asian, 5968 (8.3%) were Black, 2455 (3.4%) were Latino, and 31 197 (43.5%) were White. Women applicants and graduates increased from 29.4% (1178 of 4003) to 37.1% (2293 of 6181) and 23.5% (463 of 1967) to 33.5% (719 of 2147), respectively. When stratified by race and ethnicity, applications from Black women increased from 2.2% (87 of 4003) to 3.5% (215 of 6181) (P < .001) while applications from Black men remained unchanged (3.7% [150 of 4003] to 4.6% [284 of 6181]). While the matriculation rate for Black women remained unchanged (2.4% [46 of 1919] to 2.3% [52 of 2264]), the matriculation rate for Black men significantly decreased (3.0% [57 of 1919] to 2.4% [54 of 2264]; P = .04). Among Black graduates, there was a significant decline in graduation for men (4.3% [85 of 1967] to 2.7% [57 of 2147]; P = .03) with the rate among women remaining unchanged (1.7% [33 of 1967] to 2.2% [47 of 2147]). Conclusions and Relevance/UNASSIGNED:Findings of this study show that the underrepresentation of Black physicians at every stage in surgical training pipeline persists. Black men are especially affected. Identifying factors that address intersectionality and contribute to the successful recruitment and retention of Black trainees in general surgery residency is critical for achieving racial and ethnic as well as gender equity.

BACKGROUND:The COVID-19 pandemic overwhelmed New York City hospitals early in the pandemic. Shortages of ventilators and sedatives prompted tracheostomy earlier than recommended by professional societies. This study evaluates the impact of percutaneous dilational tracheostomy (PDT) in COVID+ patients on critical care capacity. METHODS:This is a single-institution prospective case series of mechanically ventilated COVID-19 patients undergoing PDT from April 1 to June 4, 2020 at a public tertiary care center. RESULTS:Fifty-five patients met PDT criteria and underwent PDT at a median of 13 days (IQR 10, 18) from intubation. Patient characteristics are found in Table 1. Intravenous midazolam, fentanyl, and cisatracurium equivalents were significantly reduced 48 hours post-PDT (Table 2). Thirty-five patients were transferred from the ICU and liberated from the ventilator. Median time from PDT to ventilator liberation and ICU discharge was 10 (IQR 4, 14) and 12 (IQR 8, 17) days, respectively. Decannulation occurred in 45.5% and 52.7% were discharged from acute inpatient care (Figure 1). Median follow-up for the study was 62 days. Four patients had bleeding complications postoperatively and 11 died during the study period. Older age was associated with increased odds of complication (OR 1.12, 95% CI 1.04, 1.23) and death (OR=1.15, 95% CI 1.05, 1.30). All operators tested negative for COVID-19 during the study period. CONCLUSION/CONCLUSIONS:These findings suggest COVID-19 patients undergoing tracheostomy within the standard time frame can improve critical care capacity in areas strained by the pandemic with low risk to operators. Long-term outcomes after PDT deserve further study.

BACKGROUND:The use of resuscitative endovascular balloon occlusion of the aorta (REBOA) is controversial. We hypothesize that REBOA outcomes are improved in centers with high REBOA utilization. METHODS:We examined the Aortic Occlusion in Resuscitation for Trauma and Acute Care Surgery registry over a 5-year period (2014-2018). Resuscitative endovascular balloon occlusion of the aorta outcomes were analyzed by stratifying institutions into low-volume (<10), average-volume (11-30), and high-volume (>30) deployment centers. A multivariable model adjusting for volume group, mechanism of injury, signs of life, systolic blood pressure at initiation, operator level, device type, zone of placement, and hemodynamic response to aortic occlusion was created to analyze REBOA mortality and REBOA-related complications. RESULTS:Four hundred ninety-five REBOA placements were included. High-volume centers accounted for 63%, while low accounted for 13%. High-volume institutions were more likely to place a REBOA in the emergency department (81% vs. 63% low volume, p = 0.003), had a lower mean systolic blood pressure at insertion (53 ± 38 vs. 64 ± 40, p = 0.001), and more Zone I deployments (64% vs. 55%, p = 0.002). Median time from admission to REBOA placement was significantly less in patients treated at high-volume centers (15 [7-30] minutes vs. 35 [20-65] minutes, p = 0.001). Resuscitative endovascular balloon occlusion of the aorta mortality was significantly higher at low-volume centers (67% vs. 57%; adjusted odds ratio, 1.29; adj p = 0.040), while average- and high-volume centers were similar. Resuscitative endovascular balloon occlusion of the aorta complications were less frequent at high-/average-volume centers, but did not reach statistical significance (adj p = 0.784). CONCLUSION:Resuscitative endovascular balloon occlusion of the aorta survival is increased at high versus low utilization centers. Increased experience with REBOA may be associated with earlier deployment and subsequently improved patient outcomes. LEVEL OF EVIDENCE:Therapeutic/Care Management, level IV.

Introduction: Tracheostomy in COVID-19 patients is a controversial and difficult clinical decision. A recent COVID-19 Severity Score (CSS) was validated to identify high-risk patients requiring hospitalization. We hypothesized that the CSS would be associated with survival in patients considered for tracheostomy.
Method(s): We reviewed 77 mechanically ventilated COVID-19 patients evaluated for percutaneous dilational tracheostomy (PDT) from March-June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Primary end point was survival to discharge. The Youden index identified an optimal CSS cut point for survival.
Result(s): Mean CSS for 42 survivors vs 35 nonsurvivors was significantly different (CSS 52 vs 66; p = 0.003). The Youden index returned an optimal CSS of 55 (area under the curve 0.7; 95% CI, 43 to 72). Median CSS was 40 (interquartile range 27 to 49) in the Low CSS (<55 group) and 72 (interquartile range 66 to 93) in the high CSS (>= 55) group (Fig. 1a). Eighty-seven percent of low CSS patients underwent PDT, with 74% survival, and 61% of high CSS patients underwent PDT with only 41% surviving (Fig. 1b). Patients with high CSS had 77% lower odds of survival (odds ratio 0.2; 95% CI, 0.1 to 0.7).
Conclusion(s): Higher CSS was associated with decreased survival to discharge in patients evaluated for PDT, with a score > 55 predictive of mortality. The novel CSS can be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted. [Formula presented]
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BACKGROUND:Venous thromboembolism (VTE) is a common morbidity in trauma patients. Standard VTE chemoprophylaxis is often inadequate. We hypothesized that weight-based dosing would result in appropriate prophylaxis more reliably than fixed dosing. METHODS:All patients admitted to a Level 1 trauma center over a 6-month period were included unless contra-indications for VTE prophylaxis existed. A prospective adjusted-dosing group was compared to a retrospective uniform-dosing group. The adjusted-dosing approach consisted of initial weight-based dosing of 0.5 mg/kg subcutaneously (subQ) every 12 h (q12h). Peak anti-factor Xa was measured. Patients outside of the prophylactic range had their dose adjusted by ± 10 mg. The uniform-dosing group received 30 mg subQ q12h, without adjustments. RESULTS: = 0.07, p = 0.1). CONCLUSIONS:Weight-based VTE prophylaxis with anti-Xa-based dose adjustment improves prophylactic range targeting relative to uniform dosing and eliminates variances secondary to BSA and weight in trauma patients.

INTRODUCTION/BACKGROUND:Health-care disparities based on race and socioeconomic status among trauma patients are well-documented. However, the influence of these factors on the management of rib fractures following thoracic trauma is unknown. The aim of this study is to describe the association of race and insurance status on management and outcomes in patients who sustain rib fractures. METHODS:The Trauma Quality Improvement Program database was used to identify adult patients who presented with rib fractures between 2015 and 2016. Patient demographics, injury severity, procedures performed, and outcomes were evaluated. Multivariate logistic regression analysis was used to determine the effect of race and insurance status on mortality and the likelihood of rib fixation surgery and epidural analgesia for pain management. RESULTS:A total of 95,227 patients were identified. Of these, 2923 (3.1%) underwent rib fixation. Compared to White patients, Asians (AOR: 0.57, P = 0.001), Blacks or African-Americans (AA) (AOR: 0.70, P < 0.001), and Hispanics/Latinos (HL) (AOR: 0.78, P < 0.001) were less likely to undergo rib fixation surgery. AA patients (AOR: 0.67, P = 0.004), other non-Whites (ONW) (AOR: 0.61, P = 0.001), and HL (AOR 0.65, P = 0.006) were less likely to receive epidural analgesia. Compared to privately insured patients, mortality was higher in uninsured patients (AOR: 1.72, P < 0.001), Medicare patients (AOR: 1.80, P < 0.001), and patients with other non-private insurance (AOR: 1.23, P < 0.001). CONCLUSIONS:Non-White race is associated with a decreased likelihood of rib fixation and/or epidural placement, while underinsurance is associated with higher mortality in patients with thoracic trauma. Prospective efforts to examine the socioeconomic disparities within this population are warranted.