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Managing Critically Ill Surgery Patients

Managing Critically Ill Surgery Patients

Staff shortages for sur­geons and intensivists can make it challenging for hospitals to optimize the care of critically ill and injured surgical patients. “Although critical care and surgery have made tremendous advances during the past 50 years, these advances have led to greater subspecialization,” says Samuel A. Tisherman, MD. “This has discouraged many surgeons from including critical care as a principal component of their practice.” Broadening Training In a white paper published in JAMA Surgery, Dr. Tisherman and colleagues presented recommendations for broadening multidisciplinary training and practice opportunities in surgical critical care for intensivists. The article also offered guidance for maintaining a 24/7 intensivist model. In this model, all intensivists—regardless of their base specialty—must be appropriately trained, credentialed, and dedicated to critical care and give undivided attention to critically ill patients. Dr. Tisherman and colleagues encouraged several approaches to assure adequate staffing in order to provide intensivist coverage of critically ill or injured surgical patients: – Mechanisms should be in place for physicians from multiple disciplines to be educated in surgical critical care, to enroll in accredited surgical critical care fellowship programs, and to receive full certification. – Organizational support is needed to develop common critical care training programs and credentialing with other specialties that offer these certifications. – Hospitals and surgical departments should recognize that intensivists whose primary specialty is not surgery are necessary to provide patients with high-level surgical critical care. – All intensivists should dedicate time to the ICU without other concurrent obligations. The amount of time devoted to surgical critical care within training programs should not be shortened or diluted. Critical care coverage must be...
Medical Simulation in Interventional Cardiology

Medical Simulation in Interventional Cardiology

Use of medical simulation has grown considerably over the past decade because it helps physicians overcome many training challenges, such as work-hour restrictions and the pace at which technology is evolving. According to John C. Messenger, MD, FSCAI, interventional cardiology is particularly well-suited for simulation. “These procedures are often complex,” he says. “The learning curves can be steep, and complications can be life-threatening. Simulation provides a safe arena to develop and refine skills that improve overall patient care. It’s especially helpful in interventional cardiology because of the field’s ever-changing technological and procedural environment.” A Call to Action In Catheterization and Cardiovascular Interventions, the Society for Cardiovascular Angiography and Interventions (SCAI) examined the current state of medical simulation in interventional cardiology. SCAI also issued recommendations for expanding and standardizing the use of this training technology by interventional cardiologists and fellows-in-training. “We need to increase use of medical simulation and accessibility to this training for highly complex procedures, such as structural heart interventions,” says Dr. Messenger, who chairs SCAI’s Simulation Committee. “Simulation can also improve training in areas where procedural volumes are low.” A key recommendation from SCAI is to integrate formal simulation programs into annual meetings and other training programs for fellows and practicing physicians. However, one of the major issues with integrating simulation is the high cost of simulators. “The key is for clinicians and simulation vendors to collaborate and find ways to alleviate the financial burden associated with simulation,” says Dr. Messenger. “Using simulation at annual meetings and establishing regional or central simulation centers could ease this burden.”   The key is for clinicians and simulation vendors to...
Reducing Postoperative Pulmonary Complications

Reducing Postoperative Pulmonary Complications

Pulmonary complications after surgery are relatively common, occurring in roughly 3% of patients who undergo non-cardiac operations. When compared with other adverse postoperative outcomes, pulmonary complications are also among the most costly. Some analyses have shown that these complications can increase hospital length of stay by as many as 14 days when compared with a lack of these complications. “Clinicians have little guidance on how to prevent pulmonary complications after operations,” says David McAneny, MD. “Efforts to standardize care may reduce the incidence of adverse pulmonary outcomes.” Testing an Intervention In a study published in JAMA Surgery, Dr. McAneny and colleagues tested an intervention designed to reduce the incidence of postoperative pulmonary complications. “Our goal was to create a simple, inexpensive pulmonary care program that was easily understood and remembered by patients, their families, and our staff,” says Dr. McAneny. “We included lung expansion exercises, early and frequent patient mobilization, oral hygiene, and education as key components of our strategy.” In order to facilitate recall of the intervention, the acronym “I COUGH” was developed. I COUGH components included: Incentive spirometry. Coughing and deep breathing. Oral care (brushing teeth and using mouthwash twice daily). Understanding (patient and family education). Getting out of bed frequently (at least three times daily). Head-of-bed elevation. “A critical component of I COUGH is patient education, a process that begins in clinics and continues during preoperative assessments,” explains Dr. McAneny. “Brochures, a video in various languages, and posters with instructions that describe the importance of postoperative pulmonary care were developed.” The multidisciplinary program taught and reinforced principles of the I COUGH interventions. Elements of I COUGH...
Sexual Assault Training for ED Residents

Sexual Assault Training for ED Residents

According to recent estimates, more than 125,000 sexual assaults occur each year in the United States. “Emergency physicians (EPs) work closely with law enforcement in sexual assault cases because these victims often present to EDs for evaluation,” says Margaret K. Sande, MD, MS. “Documentation and testimony in sexual assault cases from EPs is valuable for the prosecution of offenders.” She adds that studies demonstrate that accurate and thorough documentation of sexual assault injuries correlates with higher rates of charges filed and successful convictions of perpetrators. The American Board of Emergency Medicine’s Model of Clinical Practice of Emergency Medicine includes the assessment of sexual assault and completion of examinations for these events as integral topics and skills during the training of emergency medicine (EM) residents. However, Dr. Sande says there are no nationally recognized recommendations on the number of hours or content that should be dedicated to training. She notes that some EM residents may not feel properly prepared to perform the complex forensic examinations often required for sexual assault patients. Assessing Training Over the last 35 years, sexual assault nurse examiner (SANE) programs have been established to improve the quality of care for sexual assault victims. Throughout the country, these programs have quickly become the model of care for assault victims, but few analyses have explored how they impact EM resident training. In a study published in the Western Journal of Emergency Medicine, Dr. Sande and colleagues gathered information from program directors of EM residency programs in the U.S. to assess current training for the care of sexual assault. They also surveyed program directors on their views of the...
Career Plans Among Internal Medicine Residents

Career Plans Among Internal Medicine Residents

General internists are expected to play a pivotal role in providing healthcare as the population ages, the burden of chronic disease grows, and healthcare reform tries to improve coverage for millions of currently uninsured patients. Studies suggest that only 20% to 25% of internal medicine (IM) residency grad­uates pursue general medical careers. Complicating the problem is that fewer medical students appear to be interested in general medicine and primary care. Career Plans Among Internal Medicine Residents It’s unclear to what degree primary care training program graduates favor general IM careers, and few studies have explored how career plans may differ across sociodemographic factors. In JAMA, Denise M. Dupras, MD, PhD, and I had a study published that looked at the career plans of IM residents by training program, sex, and medical school location. We also looked at how career plans evolved during training. According to our results, graduates of primary care IM training programs, women, and medical school graduates were more likely than their counterparts to report generalist career plans. These residents were also more likely to remain interested in generalist careers over the course of their training. However, general medicine career plans were less common than subspecialty career plans in each of these groups. The small number of IM residents reporting plans for generalist careers means that only a limited number of generalists can be expected to enter practice each year. Serious Implications on General Internal Medicine Overall, only one in five IM graduates planned a career in general internal medicine. Even in primary care IM residency programs that are dedicated to generalist and primary care training, most graduates still...
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