Publications by authors named "Maureen McCunn"

48 Publications

Collaboration and Decision-Making on Trauma Teams: A Survey Assessment.

West J Emerg Med 2021 Jan 11;22(2):278-283. Epub 2021 Jan 11.

University of Maryland School of Medicine, Program in Trauma, Baltimore, Maryland.

Introduction: Leadership, communication, and collaboration are important in well-managed trauma resuscitations. We surveyed resuscitation team members (attendings, fellows, residents, and nurses) in a large urban trauma center regarding their impressions of collaboration among team members and their satisfaction with patient care decisions.

Methods: The Collaboration and Satisfaction About Care Decisions in Trauma (CSACD.T) survey was administered to members of ad hoc trauma teams immediately after resuscitations. Survey respondents self-reported their demographic characteristics; the CSACD.T scores were then compared by gender, occupation, self-identified leader role, and level of training.

Results: The study population consisted of 281 respondents from 52 teams; 111 (39.5%) were female, 207 (73.7%) were self-reported White, 78 (27.8%) were nurses, and 140 (49.8%) were physicians. Of the 140 physician respondents, 38 (27.1%) were female, representing 13.5% of the total surveyed population. Nine of the 52 teams had a female leader. Men, physicians (vs nurses), fellows (vs attendings), and self-identified leaders trended toward higher satisfaction across all questions of the CSACD.T. In addition to the comparison groups mentioned, women and general team members (vs non-leaders) gave lower scores.

Conclusion: Female residents, nurses, general team members, and attendings gave lower CSACD.T scores in this study. Identification of nuances and underlying causes of lower scores from female members of trauma teams is an important next step. Gender-specific training may be necessary to change negative team dynamics in ad hoc trauma teams.
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http://dx.doi.org/10.5811/westjem.2020.10.48698DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972389PMC
January 2021

Anesthetic Management of Patients After Traumatic Injury With Resuscitative Endovascular Balloon Occlusion of the Aorta.

Anesth Analg 2019 11;129(5):e146-e149

Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a temporizing maneuver for noncompressible torso hemorrhage. To our knowledge, this single-center brief report provides the most extensive anesthetic data published to date on patients who received REBOA. As anticipated, patients were critically ill, exhibiting lactic acidosis, hypotension, hyperglycemia, hypothermia, and coagulopathy. All patients received blood products during their index operations and received less inhaled anesthetic gas than normally required for healthy patients of the same age. This study serves as an important starting point for clinician education and research into anesthetic management of patients undergoing REBOA.
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http://dx.doi.org/10.1213/ANE.0000000000004130DOI Listing
November 2019

Sex Differences in In-hospital Complications Among Older Adults After Traumatic Brain Injury.

J Surg Res 2019 11 3;243:427-433. Epub 2019 Jul 3.

Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland.

Background: Older adults have the highest rates of hospitalization and mortality after traumatic brain injury (TBI) and suffer poorer outcomes compared with younger adults with similar injuries. Non-neurological complications can significantly impact outcomes. Evidence suggests that women may have better outcomes after TBI. However, sex differences in in-hospital complications among older adults after TBI have not been studied. The objective of this study was to assess sex differences in in-hospital complications after TBI among adults aged 65 y and older.

Methods: We conducted a retrospective cohort study of adults aged ≥65 y treated for isolated moderate to severe TBI at the R Adams Cowley Shock Trauma Center between 1996 and 2012. Using the Shock Trauma Center registry, we identified TBI using the International Classification of Disease, Ninth Revision, Clinical Modification codes and required an abbreviated injury scale head score ≥3, abbreviated injury scale scores for other body regions ≤2, and a blunt injury mechanism. We searched the Shock Trauma Center registry for the International Classification of Disease, Ninth Revision, Clinical Modification codes representing in-hospital complications.

Results: Of 2511 patients meeting inclusion criteria, 1283 (51.1%) were men and 635 (25.1%) developed an in-hospital complication. Men were more likely than women to develop an in-hospital complication (28.1% versus 22.0, P < 0.001). In an adjusted analysis, men were at increased risk of any in-hospital complication (hazards ratio 1.23; 95% confidence interval 1.05, 1.44) compared with women.

Conclusions: Older men were more likely to have any in-hospital complications than women.
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http://dx.doi.org/10.1016/j.jss.2019.05.053DOI Listing
November 2019

Racial Differences in Discharge Location After a Traumatic Brain Injury Among Older Adults.

Arch Phys Med Rehabil 2019 09 4;100(9):1622-1628. Epub 2019 Apr 4.

Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.

Objective: To determine if there were racial differences in discharge location among older adults treated for traumatic brain injury (TBI) at a level 1 trauma center.

Design: Retrospective cohort study.

Setting: R Adams Cowley Shock Trauma Center.

Participants: Black and white adults aged ≥65 years treated for TBI between 1998 and 2012 and discharged to home without services or inpatient rehabilitation (N=2902).

Main Outcome Measures: We assessed the association between race and discharge location via logistic regression. Covariates included age, sex, Abbreviated Injury Scale-Head score, insurance type, Glasgow Coma Scale score, and comorbidities.

Results: There were 2487 (86%) whites and 415 blacks (14%) in the sample. A total of 1513 (52%) were discharged to inpatient rehabilitation and 1389 (48%) were discharged home without services. In adjusted logistic regression, blacks were more likely to be discharged to inpatient rehabilitation than to home without services compared to whites (odds ratio 1.34, 95% confidence interval, 1.06-1.70).

Conclusions: In this group of Medicare-eligible older adults, blacks were more likely to be discharged to inpatient rehabilitation compared to whites.
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http://dx.doi.org/10.1016/j.apmr.2019.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6874209PMC
September 2019

Modern Day Trauma Care for the Anesthesiologist.

Anesthesiol Clin 2019 Mar 10;37(1):xv-xvi. Epub 2018 Dec 10.

Department of Anesthesiology and Critical Care Keck School of Medicine of the University of Southern California, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, USA. Electronic address:

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http://dx.doi.org/10.1016/j.anclin.2018.11.001DOI Listing
March 2019

The Gun Violence Epidemic: Time for Perioperative Physicians to Act.

J Cardiothorac Vasc Anesth 2018 06 6;32(3):1097-1100. Epub 2018 Mar 6.

Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR.

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http://dx.doi.org/10.1053/j.jvca.2018.03.002DOI Listing
June 2018

Use of Survey and Delphi Process to Understand Trauma Anesthesia Care Practices.

Anesth Analg 2018 05;126(5):1580-1587

Department of Anesthesiology, University of Maryland, Division of Trauma Anesthesiology, Baltimore, Maryland.

Background: Few trauma guidelines evaluate and recommend anesthesiology practices and there are no trauma anesthesia-specific guidelines. There is no information on how anesthesiologists perceive clinical practice patterns. Our objective was to understand the perceptions of anesthesiologists regarding trauma anesthesia practices.

Methods: A survey assessing anesthesia management of trauma patients was distributed to 21,491 anesthesiologists. A subset of 10 of these questions was subsequently reviewed by a trauma anesthesiology focus group through a 3-round web-based Delphi process. A question was deemed to have respondent consensus if the response with the highest percentage of agreement was unchanged between rounds 1 and 2.

Results: A total of 2360 anesthesiologists (11% response rate) responded to the survey. Results demonstrated that the practitioners' answers conflicted with existing surgical trauma society recommendations (ie, when to transfuse component therapy), and several areas that lacked any guidelines, resulted in response variability among anesthesiologists where not 1 answer achieved >75% agreement (ie, intubation technique of choice for patients with uncleared cervical spine). Thirteen trauma anesthesiologists participated in round 1 (response rate 100%), and 12 responded in rounds 2 and 3 (response rate 92%) of the Delphi process. None of the questions received 100% agreement. Consensus was achieved on 9 of 10 statements pertaining to trauma anesthesia care. Consensus was not reached on the intubating technique in a hemodynamically unstable patient with an uncleared cervical spine with deficits. Delphi participant opinion conflicted with existing guidelines on 2 statements: the use of cricoid pressure, and when to begin blood component therapy.

Conclusions: There are several important areas of trauma anesthesia practice where guidelines do not exist and several where existing guidelines are not endorsed by the majority of practitioners who completed our survey. The lack of consensus on trauma anesthesia management and the variation in survey responses demonstrate a need to develop evidence-based trauma anesthesia guidelines.
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http://dx.doi.org/10.1213/ANE.0000000000002863DOI Listing
May 2018

Trauma Anesthesiology as Part of the Core Anesthesiology Residency Program Training: Expert Opinion of the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP).

Anesth Analg 2017 09;125(3):1060-1065

From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; †Department of Anesthesiology and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, California; ‡Department of Anesthesiology, University of Maryland School of Medicine Divisions of Trauma Anesthesiology and Surgical Critical Care R Adams Cowley Shock Trauma Center, Baltimore, Maryland; Departments of §Anesthesiology and Pain Medicine, ‖Orthopedic Surgery and Sport Medicine, and ¶Neurological Surgery (Adj.), Harborview Medical Center, University of Washington, Seattle, Washington; #Division of Anesthesiology and Critical Care, UT MD Anderson Cancer Center, Houston, Texas; **Department of Anesthesiology, University of Connecticut School of Medicine, Quinnipiac University, Frank H. Netter MD School of Medicine, Hartford, Connecticut; ††Cardiothoracic Anesthesia, Texas Heart Institute, Baylor College of Medicine, Houston, Texas; ‡‡Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; and §§Department of Anesthesiology, University of Miami Miller School of Medicine, Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida.

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http://dx.doi.org/10.1213/ANE.0000000000002330DOI Listing
September 2017

The Acute Care Anesthesiologist as Resuscitationist.

Int Anesthesiol Clin 2017 ;55(3):109-116

Department of Anesthesiology, Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1097/AIA.0000000000000148DOI Listing
February 2019

Resuscitative Endovascular Balloon Occlusion of the Aorta and the Anesthesiologist: A Case Report and Literature Review.

A A Case Rep 2017 Sep;9(5):154-157

From the *Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center; †Division of Vascular Surgery, Department of Surgery; ‡Division of Orthopaedic Traumatology; §R Adams Cowley Shock Trauma Center; and ‖Division of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland.

The most common preventable cause of death after trauma is exsanguination due to uncontrolled hemorrhage. Traditionally, anterolateral emergency department thoracotomy is used for temporary control of noncompressible torso hemorrhage and to increase preload after trauma. Resuscitative endovascular balloon occlusion of the aorta is a minimally invasive technique that achieves similar goals. It is therefore imperative for the anesthesiologist to understand physiologic implications during resuscitative endovascular aortic occlusion and after balloon deflation. We report a case of a patient with significant pelvic and lower-extremity trauma who required acute resuscitative endovascular balloon occlusion of the aorta deployment, aggressive resuscitation, and extensive intraoperative hemorrhage control.
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http://dx.doi.org/10.1213/XAA.0000000000000461DOI Listing
September 2017

Sex differences in mortality following isolated traumatic brain injury among older adults.

J Trauma Acute Care Surg 2016 09;81(3):486-92

From the Department of Epidemiology and Public Health (J.S.A., G.S.S.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Anesthesiology (M.M.), Divisions of Trauma Anesthesiology and Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (D.M.S.), Division of Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland; Department of Pharmaceutical Health Services Research (L.S-W.), University of Maryland School of Pharmacy, Baltimore, Maryland; and Shock, Trauma and Anesthesiology Research (STAR) - Organized Research Center (G.S.S.), National Study Center for Trauma and Emergency Medical Services, University of Maryland, Baltimore, Maryland.

Background: Older adults have the highest rates of hospitalization and mortality from traumatic brain injury (TBI), yet outcomes in this population are not well studied. In particular, contradictory reports on the protective effect of female sex on mortality following TBI may have been related to age differences in TBI and other injury severity and mechanism. The objective of this study was to determine if there are sex differences in mortality following isolated TBI among older adults and compare with findings using all TBI. A secondary objective was to characterize TBI severity and mechanism by sex in this population.

Methods: This was a retrospective cohort study conducted among adults aged 65 and older treated for TBI at a single large Level I trauma center from 1996 to 2012 (n = 4,854). Individuals treated for TBI were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Isolated TBI was defined as an Abbreviated Injury Scale score of 0 for other body regions. Our primary outcome was mortality at discharge.

Results: Among those with isolated TBI (n = 1,320), women (45% of sample) were older (mean [SD], 78.9 [7.7] years) than men (76.8 [7.5] years) (p < 0.001). Women were more likely to have been injured in a fall (91% vs. 84%; p < 0.001). Adjusting for multiple injury severity measures, female sex was not significantly associated with decreased odds of mortality following isolated TBI (odds ratio, 1.01; 95% confidence interval, 0.66-1.54). Using all TBI cases, adjusted analysis found that female sex was significantly associated with decreased odd of mortality (odds ratio, 0.73; 95% confidence interval, 0.59-0.89).

Conclusion: We found no sex differences in mortality following isolated TBI among older adults, in contrast with other studies and our own analyses using all TBI cases. Researchers should consider isolated TBI in outcome studies to prevent residual confounding by severity of other injuries.

Level Of Evidence: Prognostic/epidemiologic study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5001875PMC
September 2016

Anesthesia Care Capacity at Health Facilities in 22 Low- and Middle-Income Countries.

World J Surg 2016 May;40(5):1025-33

Surgeons OverSeas (SOS), New York, NY, USA.

Background: Globally, an estimated 2 billion people lack access to surgical and anesthesia care. We sought to pool results of anesthesia care capacity assessments in low- and middle-income countries (LMICs) to identify patterns of deficits and provide useful targets for advocacy and intervention.

Methods: A systematic review of PubMed, Cochrane Database of Systematic Reviews, and Google Scholar identified reports that documented anesthesia care capacity from LMICs. When multiple assessments from one country were identified, only the study with the most facilities assessed was included. Patterns of availability or deficit were described.

Results: We identified 22 LMICs (15 low- and 8 middle-income countries) with anesthesia care capacity assessments (614 facilities assessed). Anesthesia care resources were often unavailable, including relatively low-cost ones (e.g., oxygen and airway supplies). Capacity varied markedly between and within countries, regardless of the national income. The availability of fundamental resources for safe anesthesia, such as airway supplies and functional pulse oximeters, was often not reported (72 and 36 % of hospitals assessed, respectively). Anesthesia machines and the capability to perform general anesthesia were unavailable in 43 % (132/307 hospitals) and 56 % (202/361) of hospitals, respectively.

Conclusion: We identified a pattern of critical deficiencies in anesthesia care capacity in LMICs, including some low-cost, high-value added resources. The global health community should advocate for improvements in anesthesia care capacity and the potential benefits of doing so to health system planners. In addition, better quality data on anesthesia care capacity can improve advocacy, as well as the monitoring and evaluation of changes over time and the impact of capacity improvement interventions.
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http://dx.doi.org/10.1007/s00268-016-3430-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842804PMC
May 2016

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Anesth Analg 2015 Dec;121(6):1668-73

From the *Division of Trauma Anesthesiology and Surgical Critical Care, R Adams Cowley Shock Trauma Center, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland; †Anesthesia Quality Institute, Schaumburg, Illinois; ‡American Society of Anesthesiologists, Schaumburg, Illinois; §Department of Anesthesiology and Critical Care, University of Chicago, Chicago, Illinois; ¶Division Head of Spine and Orthopaedic Anesthesia Services, Harborview Medical Center, University of Washington, Seattle, Washington; Departments of ∥Anesthesiology and Pain Medicine, #Orthopedics and Sport Medicine, and **Neurological Surgery (Adj.), Harborview Medical Center, University of Washington, Seattle, Washington; ††Department of Anesthesiology, Ryder Trauma Center, University of Miami Miller School of Medicine, Miami, Florida; ‡‡Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; §§Commander, Medical Corps, US Navy, Uniformed Services University, Bethesda, Maryland; ¶¶Department of Anesthesiology, UTHealth Medical School, The University of Texas Health Science Center at Houston, Houston, Texas; ∥∥Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, Connecticut; ##Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama; ***Division of Trauma Anesthesiology, Department of Anesthesiology and Critical Care, University of Maryland School of Medicine, Baltimore, Maryland; and †††Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, Washington.

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http://dx.doi.org/10.1213/ANE.0000000000000782DOI Listing
December 2015

Management of the Traumatized Airway.

Anesthesiology 2016 Jan;124(1):199-206

From the Department of Anesthesiology, Alameda Health System, Oakland, California (U.J.); Divisions of Trauma Anesthesiology and Surgical Critical Care, Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, Baltimore, Maryland (M.M.); Department of Anesthesiology, Metrohealth Medical Center, Case Western Reserve University, Cleveland, Ohio (C.E.S.); and Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama (J.-F.P.).

There is a lack of evidence-based approach regarding the best practice for airway management in patients with a traumatized airway. General recommendations for the management of the traumatized airway are summarized in table 5. Airway trauma may not be readily apparent, and its evaluation requires a high level of suspicion for airway disruption and compression. For patients with facial trauma, control of the airway may be significantly impacted by edema, bleeding, inability to clear secretions, loss of bony support, and difficulty with face mask ventilation. With the airway compression from neck swelling or hematoma, intubation attempts can further compromise the airway due to expanding hematoma. For patients with airway disruption, the goal is to pass the tube across the injured area without disrupting it or to insert the airway distal to the injury using a surgical approach. If airway injury is extensive, a surgical airway distal to the site of injury may be the best initial approach. Alternatively, if orotracheal intubation is chosen, spontaneous ventilation may be maintained or RSI may be performed. RSI is a common approach. Thus, some of the patients intubated may subsequently require tracheostomy. A stable patient with limited injuries may not require intubation but should be watched carefully for at least several hours. Because of a paucity of evidence-based data, the choice between these approaches and the techniques utilized is a clinical decision depending on the patient's condition, clinical setting, injuries to airway and other organs, and available personnel, expertise, and equipment. Inability to obtain a definitive airway is always an absolute indication for an emergency cricothyroidotomy or surgical tracheostomy.
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http://dx.doi.org/10.1097/ALN.0000000000000903DOI Listing
January 2016

Increased Rates of Mild Traumatic Brain Injury Among Older Adults in US Emergency Departments, 2009-2010.

J Head Trauma Rehabil 2016 Sep-Oct;31(5):E1-7

Department of Epidemiology and Public Health (Drs Albrecht, Hirshon, and Smith), Department of Emergency Medicine (Dr Hirshon), and Department of Anesthesiology, Divisions of Trauma Anesthesiology and Surgical Critical Care, R. Adams Cowley Shock Trauma Center (Dr McCunn), University of Maryland School of Medicine, Baltimore; Departments of Physical Medicine and Rehabilitation (Dr Bechtold) and Psychiatry & Behavioral Sciences (Dr Rao), Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore (Dr Simoni-Wastila); and Shock, Trauma and Anesthesiology Research (STAR)-Organized Research Center, National Study Center for Trauma and Emergency Medical Services, University of Maryland, Baltimore (Drs Hirshon and Smith).

Objective: To estimate rates of emergency department (ED) visits for mild traumatic brain injury (TBI) among older adults. We defined possible mild TBI cases to assess underdiagnoses.

Design: Cross-sectional.

Setting: National sample of ED visits in 2009-2010 captured by the National Hospital Ambulatory Medical Care Survey.

Participants: Aged 65 years and older.

Measurements: Mild TBI defined by International Classification of Diseases, Ninth Revision, Clinical Modification, codes (800.0x-801.9x, 803.xx, 804.xx, 850.xx-854.1x, 950.1x-950.3x, 959.01) and a Glasgow Coma Scale score of 14 or more or missing, excluding those admitted to the hospital. Possible mild TBI was defined similarly among those without mild TBI and with a fall or motor vehicle collision as cause of injury. We calculated rates of mild TBI and examined factors associated with a diagnosis of mild TBI.

Results: Rates of ED visits for mild TBI were 386 per 100 000 among those aged 65 to 74 years, 777 per 100 000 among those aged 75 to 84 years, and 1205 per 100 000 among those older than 84 years. Rates for women (706/100 000) were higher than for men (516/100 000). Compared with a possible mild TBI, a diagnosis of mild TBI was more likely in the West (odds ratio = 2.31; 95% confidence interval, 1.02-5.24) and less likely in the South/Midwest (odds ratio = 0.52; 95% confidence interval, 0.29-0.96) than in the Northeast.

Conclusions: This study highlights an upward trend in rates of ED visits for mild TBI among older adults.
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http://dx.doi.org/10.1097/HTR.0000000000000190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834064PMC
March 2018

CASE 6—2015: Penetrating Biventricular Cardiac Injury in a Trauma Patient: Heart Versus Machete.

J Cardiothorac Vasc Anesth 2015 8;29(3):797-805. Epub 2015 Jan 8.

Department of Clinical Anesthesiology, Division of Trauma Anesthesiology, Ryder Trauma Center-Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL.

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http://dx.doi.org/10.1053/j.jvca.2015.01.017DOI Listing
February 2016

Developing sustainable trauma care education in Egypt: sequential trauma education program, steps to success.

J Surg Educ 2015 Jul-Aug;72(4):e29-32. Epub 2015 Jan 16.

Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland; Charles McC. Mathias Jr. National Study Center for Trauma and EMS, Baltimore, Maryland.

Introduction: As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of U.S. and Egyptian physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country.

Methods: We describe the development, transition, and host nation sustainability of a trauma care training course between a high-income Western nation and a lower-middle-income Middle Eastern/Northern African country, including the number of physicians trained and the challenges to program development and sustainability.

Results: STEPS was developed at the University of Maryland, based in part on World Health Organization's Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. To date, 639 physicians from multiple specialties have taken the 4-day course through the Ministry of Health and Population or public/governmental universities. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. Multiple Egyptian medical schools and the Egyptian Emergency Medicine Board now require STEPS or its equivalent for physicians in training.

Conclusions: Success of this collaborative educational program is demonstrated by the numbers of physicians trained, the adoption of STEPS by the Egyptian Emergency Medicine Board, and program continuance after transitioning to in-country leadership and trainers.
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http://dx.doi.org/10.1016/j.jsurg.2014.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4469532PMC
April 2016

Gender-specific issues in traumatic injury and resuscitation: consensus-based recommendations for future research.

Acad Emerg Med 2014 Dec 24;21(12):1386-94. Epub 2014 Nov 24.

Department of Emergency Medicine and the Division of Hyperbaric Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD.

Traumatic injury remains an unacceptably high contributor to morbidity and mortality rates across the United States. Gender-specific research in trauma and emergency resuscitation has become a rising priority. In concert with the 2014 Academic Emergency Medicine consensus conference "Gender-specific Research in Emergency Care: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," a consensus-building group consisting of experts in emergency medicine, critical care, traumatology, anesthesiology, and public health convened to generate research recommendations and priority questions to be answered and thus move the field forward. Nominal group technique was used for the consensus-building process and a combination of face-to-face meetings, monthly conference calls, e-mail discussions, and preconference surveys were used to refine the research questions. The resulting research agenda focuses on opportunities to improve patient outcomes by expanding research in sex- and gender-specific emergency care in the field of traumatic injury and resuscitation.
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http://dx.doi.org/10.1111/acem.12536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4313572PMC
December 2014

International disparities in trauma care.

Curr Opin Anaesthesiol 2014 Apr;27(2):233-9

aDepartment of Anesthesiology and Pain Medicine, Department of Orthopaedics and Sport Medicine, Harborview Medical Center, University of Washington, Seattle, Washington bDivision of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania cAnesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Purpose Of Review: Trauma care has been a low priority topic in the global health agenda until recently, despite its social and economic impact. Although prevention is the key, provision and quality of trauma care has been the weakest link in the survival chain. We aim to summarize the differences in global trauma care to propose solutions in this article.

Recent Findings: Patients with life-threatening injuries are six times more likely to die following a trauma in a low-income country than in a high-income country. Unintentional injuries currently rank fourth in the global causes of death, resulting in 5.8 million premature deaths and millions more with disability. The WHO member countries started the first global Decade of Action for Road Safety 2011-2020 initiative in May 2011. Governments across the world agreed to take steps to improve the safety of roads and vehicles, enhance the behavior of all road users and strengthen post-trauma care.

Summary: Several core strategies have been identified: human resource planning; physical resources (equipment and supplies); and administration (quality improvement and data collection) need to be developed for effective and adaptable prehospital care, patient transfer, in-hospital care and rehabilitation systems for injured persons worldwide. Clear definition of the problem to propose solutions is critical.
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http://dx.doi.org/10.1097/ACO.0000000000000049DOI Listing
April 2014

Are attendings different?. Intensivists explain their handoff ideals, perceptions, and practices.

Ann Am Thorac Soc 2014 Mar;11(3):360-6

1 Department of Anesthesiology and Critical Care.

Purpose: What is known about physician handoffs is almost entirely limited to resident practice, but attending physicians ultimately determine care plans and goals of care. This study sought to understand what is unique about attending intensivist handoffs, to identify perceptions of the ideal content and format of intensive care unit (ICU) attending handoffs, and to understand how ideal and reported practices are aligned in the delivery of care.

Methods: Intensivists in active practice in U.S. adult academic ICUs were purposively sampled and interviewed over 9 months in 2011 to 2012.

Measurements And Main Results: Thirty attendings from 15 institutions in nine U.S. states were interviewed. Subjects' specialties included anesthesiology, emergency medicine, internal medicine, and surgery. The "perfect handoff" was described as succinct, included verbal plus written communication, and took place in person. Respondents believed that the attending handoff should be less detailed than resident handoffs. Most attendings participated in handoffs at the end of each ICU rotation (n = 26). Standardized handoff practice was rare (n = 1). Media used for handoffs included combinations of telephone conversations (n = 25), in-person communications (n = 11), e-mail (n = 9), or text message (n = 2). Handoff duration varied from 10 to 120 minutes for 5 to 42 patients. Five of 30 respondents had undergone formal training in how to conduct handoffs.

Conclusions: A national sample of academic intensivists identified common ideal attributes of attending handoffs, yet their reported handoff practices varied widely. Ideal handoff practices may form the basis of future interventions to improve communication between intensivists.
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http://dx.doi.org/10.1513/AnnalsATS.201306-151OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4028740PMC
March 2014

High-frequency oscillatory ventilation.

Curr Probl Surg 2013 Oct;50(10):471-8

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http://dx.doi.org/10.1067/j.cpsurg.2013.08.011DOI Listing
October 2013

A checklist for trauma and emergency anesthesia.

Anesth Analg 2013 Nov;117(5):1178-84

From the *Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; †Department of Anesthesiology and Pain Medicine, Harborview Medical Center/University of Washington, Seattle, WA; ‡Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA; §Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, AL; ‖Department of Anesthesiology, Case Western Reserve University/MetroHealth Medical Center, Cleveland, OH; ¶Department of Anesthesiology, Ryder Trauma Center/University of Miami Miller School of Medicine, Miami, FL; and #Department of Anesthesiology, Mayo Clinic College of Medicine, Phoenix, AZ.

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http://dx.doi.org/10.1213/ANE.0b013e3182a44d3eDOI Listing
November 2013

Analysis of field reports from anaesthesia volunteers in low- to middle-income countries.

Med Educ 2013 Oct;47(10):1029-36

Department of Anaesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objectives: The objective of this study was to identify key experiences and common motifs of volunteer doctors who have participated in anaesthesia-related volunteer experiences abroad through the Health Volunteers Overseas (HVO) programme. An additional goal was to understand the effects of medical volunteerism in developing countries on the volunteers themselves.

Methods: After a medical mission with HVO, anaesthesia volunteers submit a post-experience report. Twenty-five reports were randomly selected from the 58 available trip reports, including five from each of the five countries collaborating with HVO. Data in the reports were analysed using a modified grounded theory and constant comparative technique until thematic saturation was achieved.

Results: Three major discoveries emerged from the analysis of post-experience reports: (i) anaesthesia residents and attending physicians find their volunteer experiences in the developing world to be personally rewarding and positive; (ii) most participants feel their educational interventions have a positive impact on local students and anaesthesia providers, and (iii) global volunteerism poses challenges, primarily caused by lack of resource availability and communication issues.

Conclusions: Our results give new insight into the experiences of and challenges faced by a cohort of HVO-sponsored anaesthesia volunteers while abroad and validates the positive effects these global health experiences have on the volunteers themselves. This group of anaesthesia volunteers was able to further their personal and professional growth, sharpen their physical diagnosis and clinical reasoning skills in resource-poor environments and, most importantly, provide education and promote an exchange of ideas and information.
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http://dx.doi.org/10.1111/medu.12262DOI Listing
October 2013

A basic needs assessment of Kenyan health care practitioners' training and ability in providing resuscitation management for patients in Mbagathi Hospital, Nairobi.

J Clin Anesth 2013 Aug 17;25(5):388-392. Epub 2013 Aug 17.

Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA. Electronic address:

Study Objective: To determine if health care providers at one district hospital in Nairobi, Kenya, possess the training and confidence necessary to attend to basic needs for patient resuscitation.

Design: Prospective cohort study.

Setting: Mbagathi District Hospital, Nairobi, Kenya, a 300-bed, government district-level health care facility serving over one million Kenyans.

Subjects: 21 medical officers, clinical officers, medical officer and clinical officer interns, and nurses.

Measurements: An investigator-designed survey, the Self Assessment of Clinical Skills, designed to assess training and level of confidence in addressing basic resuscitation, was administered.

Main Results: 80% of respondents have been taught how to maintain a patent airway, but 22% felt less than confident in their ability. Nearly two thirds (62%) of respondents had not been trained to use a pulse oximeter. 100% of respondents felt they would benefit from additional training in airway and pulse oximetry assessment. While 90% reported that they had been taught to treat hypotension and 76% had experience treating hypotension, only 62% felt confident in their ability to treat hypotension. 95% desired additional training in hypotension management. 85% wanted additional training in measuring blood pressure, and every respondent desired additional training in the other circulatory monitoring skills listed on the survey.

Conclusions: Providers of the Mbagathi District Hospital, Nairobi, report a lack of confidence in recognizing basic resuscitation needs, and they desire additional training.
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http://dx.doi.org/10.1016/j.jclinane.2013.02.005DOI Listing
August 2013

Advances in the management of the critically injured patient in the operating room.

Anesthesiol Clin 2013 Mar 14;31(1):67-83. Epub 2012 Dec 14.

Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA.

Care of trauma patients continues to improve through better understanding of optimal timing of operating room (OR) interventions, improved monitoring for patients with head injury and hemodynamic compromise, optimization of volume status, and use of appropriate vasoactive agents. Investigation of the pathophysiology of trauma patients as they progress to the chronic phase continues to advance interventions in the ICU and the OR. This article is an evidence-based update of anesthetic considerations for these patients, including management of intracranial pressure, cardiac monitoring, management of the damage control abdomen, fluid and hemodynamic management, and control of coagulopathies.
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http://dx.doi.org/10.1016/j.anclin.2012.11.001DOI Listing
March 2013

Emergency tracheal intubation immediately following traumatic injury: an Eastern Association for the Surgery of Trauma practice management guideline.

J Trauma Acute Care Surg 2012 Nov;73(5 Suppl 4):S333-40

Virginia Commonwealth University Medical Center, Richmond, Virginia, USA.

Background: The ABCs of trauma resuscitation begin with the airway evaluation, and effective airway management is imperative in the care of a patient with critical injury. The Eastern Association for the Surgery of Trauma Practice Management Guidelines committee aimed to update the guidelines for emergency tracheal intubation (ETI) published in 2002. These guidelines were made to assist clinicians with decisions regarding airway management for patients immediately following traumatic injury. The goals of the work group were to develop evidence-based guidelines to (1) characterize patients in need of ETI and (2) delineate the most appropriate procedure for patients undergoing ETI.

Methods: A search of the National Library of Medicine and the National Institutes of Health MEDLINE database was performed using PubMed (www.pubmed.gov).

Results: The search retrieved English-language articles published from 2000 to 2012 involving patients who had sustained blunt trauma, penetrating trauma, or heat-related injury and had developed respiratory system insufficiency or required ETI in the immediate period after injury (first 2 hours after injury). Sixty-nine articles were used to construct this set of practice management guidelines.

Conclusion: The data supported the formation of six Level 1 recommendations, four Level 2 recommendations, and two Level 3 recommendations. In summary, the decision to intubate a patient following traumatic injury is based on multiple factors, including the need for oxygenation and ventilation, the extent and mechanism of injury, predicted operative need, or progression of disease. Rapid sequence intubation with direct laryngoscopy continues to be the recommended method for ETI, although the use of airway adjuncts such as blind insertion supraglottic devices and video laryngoscopy may be useful in facilitating successful ETI and may be preferred in certain patient populations. There is no pharmacologic induction agent of choice for ETI; however, succinylcholine is the neuromuscular blockade agent recommended for rapid sequence intubation.
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http://dx.doi.org/10.1097/TA.0b013e31827018a5DOI Listing
November 2012

Care of the injured worldwide: trauma still the neglected disease of modern society.

Scand J Trauma Resusc Emerg Med 2012 Sep 15;20:64. Epub 2012 Sep 15.

Department of Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street (MSC 613/CSB 420), Charleston, SC 29425-6130, USA.

Traditionally, surgical diseases including emergency and injury care have garnered less attention and support internationally when compared to other medical specialties. Over the past decade however, healthcare professionals have increasingly advocated for the need to address the global burden of non-communicable diseases. Surgical disease, including traumatic injury, is among the top causes of death and disability worldwide and the subsequent economic burden is substantial, falling disproportionately on low- and middle-income countries (LMICs). The future of global health in these regions depends on a redirection of attention to diseases managed within surgical, anesthesia and emergency specialties. Increasing awareness of these disparities, as well as increasing focus in the realms of policy and advocacy, is crucial. While the barriers to providing quality trauma and emergency care worldwide are not insurmountable, we must work together across disciplines and across boundaries in order to negotiate change and reduce the global burden of surgical disease.
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http://dx.doi.org/10.1186/1757-7241-20-64DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518175PMC
September 2012

Team composition and perceived roles of team members in the trauma bay.

J Trauma Nurs 2012 Jul-Sep;19(3):133-8

Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, USA.

Perceptions of trauma team members and their roles may impact team performance, requiring intervention. Participant observation and semistructured interviews were performed with trauma team members: attendings, nurses, fellows, residents, and medical students. Some team members do not include nurses as members of the team. A greater proportion of male than female team leaders perceived their role as teacher or educator. Nurses, attendings, and fellows, provided parallel descriptions of good leaders, whereas medical students and residents stressed other qualities. Inconsistencies in trauma team role definition and membership should be addressed, toward the goal of improving team communication and patient outcomes.
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http://dx.doi.org/10.1097/JTN.0b013e318261d273DOI Listing
February 2013

Acute lung injury and the acute respiratory distress syndrome in the injured patient.

Scand J Trauma Resusc Emerg Med 2012 Aug 10;20:54. Epub 2012 Aug 10.

Department of Anesthesiology & Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.

Acute lung injury and acute respiratory distress syndrome are clinical entities of multi-factorial origin frequently seen in traumatically injured patients requiring intensive care. We performed an unsystematic search using PubMed and the Cochrane Database of Systematic Reviews up to January 2012. The purpose of this article is to review recent evidence for the pathophysiology and the management of acute lung injury/acute respiratory distress syndrome in the critically injured patient. Lung protective ventilation remains the most beneficial therapy. Future trials should compare intervention groups to controls receiving lung protective ventilation, and focus on relevant outcome measures such as duration of mechanical ventilation, length of intensive care unit stay, and mortality.
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http://dx.doi.org/10.1186/1757-7241-20-54DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3518173PMC
August 2012
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