Graduate medical education: issues for the 21st century.
Explore the source record for details and available documents.
Education, Medical, Graduate↗
Biomedical subjects
G F Sheldon
Publications and source records attributed to G F Sheldon.
A comparison of intensive care unit care of surgical patients in teaching and nonteaching hospitals.
Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.
Attitude of Health Personnel↗
Surgery in the aged.
Coincident with improvement in medical care and life-styles, the longevity of the population of the United States is increasing. As the population ages, more surgical procedures will be performed in elderly patients. The effects of the aging process on organ systems generally does not compromise function under normal conditions. However, the elderly patient may not be able to meet the metabolic demands of a hypermetabolic state. Operative outcome for the most part is related more to the urgency of the procedure than to the age of the patient. With the proper preoperative evaluation and postoperative care, the elderly patient at risk for perioperative morbidity and mortality can be identified and outcome approved. In most cases age in and of itself is not a contraindication to surgical intervention. Surgical problems in the aged patient can and should be safely managed with early elective management prior to the development of emergent situations.
Aged↗
Vascular surgery--a specialty of surgery.
Explore the source record for details and available documents.
Accreditation↗
ABGs and arterial lines: the relationship to unnecessarily drawn arterial blood gas samples.
Arterial blood gas measurements (ABGs) are the most common tests ordered in an ICU. ABG utilization in a surgical ICU over a 1-year period (September 1, 1987-October 31, 1988) was evaluated to identify factors that might help reduce overutilization. A total of 842 admissions comprising 2,381 patient days were reviewed. ABGs were the most commonly ordered test (mean of 4.8/patient/day). Patients with arterial lines (A-lines) had more ABGs drawn than those who did not regardless of the value of PaO2 (p less than 0.01), PaCO2 (p less than 0.01 except for PaCO2 greater than 55), APACHE II score (p less than 0.01), use of ventilators (p less than 0.01), pulse oximeters (p less than 0.01), or a combination of the last two (p less than 0.01). Multivariate analysis demonstrated that the presence of an A-line was the most powerful predictor of the number of ABGs drawn per patient (p less than 0.0001) independent of all other measures of the patient's clinical status such as the use of ventilators, oximeters, and values of PaO2, PaCO2, or the APACHE II score. This suggests that ABGs are being drawn unnecessarily simply because of the presence of an A-line. To reduce the number of ABGs drawn, a policy for specific indications for placement of A-lines and ABG analysis should be adopted.
Blood Gas Analysis↗
Hepatic trauma.
Hepatic trauma is a common form of abdominal injury. Although the majority of hepatic injuries are minor and require little or no treatment, many hepatic injuries are major and lethal if not managed appropriately. Good management of these patients requires a thorough understanding of hepatic anatomy and of the options available for surgical management of hepatic injuries. These options include simple suture, hepatotomy to expose the bleeding vessels and ligation, hepatic artery ligation, packing of hepatic injuries, and, rarely, formal anatomic lobectomy and atriocaval shunting. The trauma surgeon must be familiar with these types of management and be able to apply them in appropriate situations. Nonoperative management is now being reported more commonly and it may be appropriate in a selected group of patients. While the most common cause of death after hepatic injury is from exsanguination occurring early after injury, patients with major hepatic injury remain at risk for a variety of complications after the initial injury. These include hepatic abscess, hemobilia, pseudoaneurysm, and arteriovenous malformations that lead to bleeding. All of these are best treated by CT scan and interventional radiologic techniques. A determined and committed approach to these injured patients can significantly decrease the mortality of these injuries.
Hepatectomy↗
Critical care education in general surgery residencies.
Surgical critical care (SCC) was recently identified as an essential component of general surgery by the American Board of Surgery (ABS). Previous studies have found limited attention to critical care education in general surgery programs. This survey was developed to determine the changes in critical care education, following the emphasis by the ABS. The survey determined the format for SCC education, the time and resources committed, and the views of the program directors toward SCC. Program directors of all 296 approved general surgery residencies were surveyed, with a 79% response. Most program directors (91%) agree that SCC is an essential component of general surgery, and 72% believe a separate intensive care unit (ICU) rotation should be used in SCC education. Education in SCC was provided by a separate ICU service in 110 (47%) of the programs. The remaining 53% used care of patients in the ICU during traditional services as their educational experience. The average ICU rotation for surgery residents was 9 weeks and usually occurred in the second year of training. In 97% of the 110 programs with an ICU service, lectures and conferences were conducted regularly. Seventeen programs sponsored critical care fellowships, and 25 additional programs were considering them. Ninety percent of surgical ICU services had faculty that consisted exclusively of surgeons or surgeons and other specialists. Only 53% of surgeons attending on an ICU service had a reduction in their other responsibilities. Despite overwhelming agreement that critical care is an essential component of general surgery, less than half of the training programs have an ICU service to coordinate resident education in SCC. If surgeons are to continue to provide total care to their patients, there needs to be increased commitment to SCC education.
Critical Care↗
Biliary secretory IgA levels in rats with protein-calorie malnutrition.
Malnutrition is a recognized cause of failure of host defense mechanisms. In the past 5 years, it has been demonstrated that the gut, long known to have significant morphologic changes with protein calorie malnutrition (PCM), is an immune organ affected by malnutrition. To assess the role of biliary immunoglobulin A (S-IgA), part of the barrier to bacterial invasion from the gastrointestinal tract, the following study was performed. Seventy-eight Fisher female inbred rats weighing 110-130 g were randomly separated into two groups. The control rats were fed standard rat chow. The experimental rats were fed a 2% agar protein depletion (PCM) diet (USP XV). The biliary tract of the rat was cannulated with Silastic tubing and bile flow and rat secretory immunoglobulin A (S-IgA) was sampled at intervals. S-IgA was measured by the Elisa method. Total bile protein was measured by micro-Kjeldahl. Bile was collected from the rats on day 0, 7, 14, 21, 29, 36, 42, and 49. During the study, the weight of rats fed the PCM diet decreased from 127.4 +/- 14.5 g at day 0 to 83 +/- 2.6 g on day 37. Control rats gained weight from 124.4 +/- 14.5 g at day 0 to 153.6 +/- 3.8 g at day 37. Total biliary protein at day 0 was 2.52 +/- .05 mg/ml and at day 36 was 2.51 +/- 11 mg/ml for PCM rats and 2.57 +/- 10 mg/ml for control rats. Normal rats and control rats both had an initial increase of S-IgA from 2.74 +/- 73 mg/ml on day 0 to 5.75 +/- 1.75 mg/ml on day 37. Both PCM and control rats demonstrated an increase in S-IgA levels despite significant loss of weight in the experimental group. Similarly, total biliary protein was not decreased in either group. The results suggest that gut immune system is preserved despite significant protein calorie malnutrition.
Animals↗
Editorial review on "A future for surgical critical care?".
Explore the source record for details and available documents.
Certification↗
Hereditary spherocytosis. Recent experience and current concepts of pathophysiology.
Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. A deficiency of spectrin, the largest and most abundant structural protein of the erythrocyte membrane skeleton, results in the formation of spherocytes which lack the strength, durability, and flexibility to withstand the stresses of the circulation. Clinical manifestations of the disease are primarily dependent on the severity of hemolysis, which additionally results in an increased incidence of pigment gallstones. The likelihood of cholelithiasis is directly related to patient age and is uncommon before 10 years of age. Splenectomy is indicated in virtually every patient. When the disease is diagnosed in early childhood, the risk of overwhelming postsplenectomy sepsis makes it advisable to delay splenectomy until after 6 years of age if possible. At the time of splenectomy, it is important to identify and remove any accessory spleens. If gallstones are present, cholecystectomy should be performed. Although spherocytosis persists following splenectomy, hemolysis is alleviated and clinical cure of the anemia is achieved for most patients. Patients with recessively inherited spherocytosis are exceptions. Although they are significantly benefited by splenectomy, their anemia is not completely corrected. Splenectomy reduces hemolysis in all patients and thereby decreases the risk for development of pigment gallstones. Excision of an enlarged spleen removes the danger of traumatic rupture.
Adolescent↗
Massive transfusion.
Massive transfusion is a potentially serious problem associated with a number of complications, including changes in coagulation factor and platelet concentration, nonmechanical bleeding, hypothermia, pulmonary dysfunction, hypokalemia and hyperkalemia, hypocalcemia, hypomagnesemia, acidosis and alkalosis, immune suppression, blood transfusion reactions, and transmission of infectious diseases. The pathophysiology and management of massive transfusion are reviewed in this article.
Blood Coagulation Disorders↗
Management of injuries to the porta hepatis.
The management of injuries to the porta hepatis is challenging and controversial. Although definitive, anatomic reconstruction of injured ductal or vascular structures is optimal, porta hepatis injuries are universally accompanied by injuries to other organs (3.6 in this series), which often precludes initial repair. Moreover, frequent injury to the inferior vena cava, aorta, or other major blood vessels in addition to the structures of the porta hepatis results in these injuries being treated in conjunction with exsanguinating hemorrhage. For that reason, control of hemorrhage is the initial management priority, with the initial operation requiring expeditious, if less than anatomically exact, operations. Eighteen of 31 patients survived porta hepatis injury. Hepatic artery injuries were treated by ligation. Complex injuries to bile ducts frequently required enteric-ductal anastomoses as secondary procedures. Of 29 patients with portal vein injuries, six were treated by ligation, 22 by lateral repair, and one with splenic vein interposition graft. As in earlier reports, the structure of the porta hepatis associated with the highest morbidity and mortality rates when injured was the portal vein.
Abdominal Injuries↗
The effect of parenteral nutrition on gastrointestinal immunity. The importance of enteral stimulation.
Secretory IgA (S-IgA), an immunoglobulin present in secretions, prevents the adherence of bacteria to mucosal cells and is the principle component of the gut mucosal defense system. The purpose of this study was to determine whether the route of nutrient administration affects S-IgA. Twenty-five female Fisher rats were randomized into three groups. Groups I and II were fed an isonitrogenous, isocaloric standard hyperalimentation solution, Group I intravenously and Group II via a gastrostomy. Group III (control) was fed rat chow and water ad lib. Since bile is one of the principle sources of S-IgA, animals had biliary T-tubes placed for sampling of bile every 4 days. At day 16, Group I animals were fed rat chow and water for an additional 8 days. S-IgA was measured by the ELISA immunoassay. Results indicated at day 16 that the S-IgA level in mg/ml of Group I was 1.1 +/- 0.2, while the S-IgA in Groups II and III was 2.2 +/- 0.6 and 2.2 +/- 0.26, respectively. Furthermore, the S-IgA level in Group I after 8 days of enteral feeding rose to 1.8 +/- 0.4. The difference in S-IgA levels between enterally and parenterally fed rats suggests that an important defense barrier is compromised during parenteral hyperalimentation. Rats fed the same nutrients by gastrostomy maintained S-IgA levels better than rats fed the same nutrients intravenously. The rapid return to normal levels after resumption of enteral feeding suggests that the intraluminal presence of foodstuffs is essential for maintenance of S-IgA.
Animals↗
1984 A.A.S.T. presidential address: medical education and the trauma surgeon--the role of the A.A.S.T.
Explore the source record for details and available documents.
Certification↗
Effect of abdominal operations on survival after septic challenge in normal rats.
We evaluated the effect of 60% small-bowel enterectomy that removed 75% of Peyer's patches, and the effects of lesser abdominal operations, on the survival of rats following inducement of peritonitis. We divided 286 female Fischer rats weighing 140 to 200 g into four experimental and two control groups. Following enterectomy, rats recovered for ten to 14 days before peritonitis was induced by intraperitoneal injection of 0.7 mL/100 g of body weight of a solution of 4% hemoglobin and Escherichia coli (10(9)/mL). At 48 hours after enterectomy, the survival rate was better than that in rats not operated on or anesthetized. Survival rates for rats having lesser intra-abdominal operations were significantly greater after peritonitis than the rates for controls, but were similar to rates for rats having enterectomies. Our results suggest that intra-abdominal operation of minimal or large magnitude is associated with improved survival from hemoglobin-E coli adjuvant peritonitis.
Anesthesia↗
Management of foreign body ingestion.
Management of ingested foreign bodies (FB) is a common clinical problem. A 10-year experience of 101 foreign body ingestions is reported. The experience suggests that endoscopic removal of foreign bodies is curative for objects located in the cricopharynx or upper esophagus. Foreign bodies which pass into the stomach can be observed for development of symptoms, as 80% of FB which reach the stomach spontaneously pass. Only 12% of patients required operation, which was done without mortality.
Adolescent↗
Mortality in retroperitoneal hematoma.
Eighty-one patients sustained retroperitoneal hematoma (RH) from blunt (70%) and penetrating (30%) trauma. Retroperitoneal hematomas were classified into 10 centro-medial Zone I, 25 lateral Zone II, and 46 pelvic Zone III hematomas. The mean injury Severity Score (ISS) for the entire series was 26.4 +/- 14. The mean ISS of nonsurvivors was 37.6 +/- 12. Overall mortality was 20%; if head injury deaths are excluded (six), mortality was 13%. Retroperitoneal hematoma associated with pelvic fracture had a mortality of 19%. Incidence of respiratory failure for entire series, excluding head trauma, was 29%. Respiratory failure occurred in 37% of patients with Zone III injuries. A requirement for ventilatory support greater than 48 hours was associated with a mortality of 35%. PaO2/FIO2 at 48 hours in intubated patients was significantly decreased in nonsurvivors compared to survivors, whereas the mean ISS of this subset of patients did not differentiate between survivors and nonsurvivors.
Abdominal Injuries↗
Duodenal trauma: experience of a trauma center.
In the past decade 93 patients with duodenal injury were treated at a trauma center. By chart review, the age, sex, mechanism of injury, time to initial exploration (and the reason for delay), laboratory results, associated injury, extent of duodenal injury, operative repair, use of drains and tube decompression, morbidity, and cause of death were tabulated in order to improve management of these injuries. Of 87 patients surviving until the time of operative repair 73% required no repair (four) or primary closure (59). The remainder had either resection with primary anastomosis (ten), diverticulization (12), or pancreaticoduodenectomy (two). All patients with penetrating trauma were immediately explored. Patients with blunt trauma were explored on the basis of the judgment of house staff and faculty. Overall mortality was 18%. Significant morbidity occurred in 49% of survivors. This urban experience was heavily weighted toward penetrating injury. In this group early death usually resulted from associated vascular injuries. Blunt duodenal injury was less frequently associated with immediate exsanguination. Mortality associated with blunt duodenal injury was usually the result of delayed diagnosis. In blunt duodenal trauma peritoneal lavage is not diagnostic and may often be misleading; in this series 50% of lavages were false negatives. Blunt duodenal trauma, particularly when combined with pancreatic injury or delayed repair, was a lethal combination. A high index of suspicion and aggressive diagnostic evaluation (CT contrast study/amylase) in the emergency department is required in equivocal cases to avoid morbidity and mortality.
Adolescent↗