Sarah Bryczkowski

JFK Medical Center | JFK · Surgery
18.21 · MD
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Introduction
Robotic General Surgeon at Hackensack Meridian Health, JFK Medical Center in Edison, NJ and RWJ Barnabas Health, Rahway Hospital. Currently working on research in Robotic General Surgery. Previous research on ICU delirium, Minimally Invasive Hernia Repair, breaking bad news in trauma, and physician use of social media.
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JFK Medical Center | JFK
Surgery
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Surgeon
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University of Nebraska at Omaha
Mayo Foundation for Medical Education and Research
Erasmus University Rotterdam
Erasmus MC
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Breaking Bad News in Trauma
Educational Module for Breaking Bad News
Research
Research Items (15)
Background: Traumatic events are sudden, unexpected, and often devastating. The delivery of difficult news to patients and families in the trauma setting has unique challenges that necessitate communication skills that may differ from those used in other clinical environments. Objective: Design and implement a novel curriculum to teach, assess, and provide feedback to trauma residents on the communication skills necessary for delivering difficult news to patients and families in the trauma setting. Methods: This communication curriculum was delivered in three separate phases: (1) didactics using a video education e-module, (2) simulated practice of trauma resuscitation with a high-fidelity mannequin followed by role play of delivering difficult news, (3) an observed skills assessment using standardized patients (SPs). Each phase focused on delivery of difficult news of death and of uncertain/poor prognosis after a resuscitation in the trauma bay. Learners were trauma residents that included postgraduate year (PGY) 1-2 general surgery residents and PGY 1-4 emergency medicine residents at a level 1 trauma center. Outcomes include resident comfort, knowledge, and confidence in delivering difficult news in the trauma setting. Results: Thirty-nine trauma residents participated in the three-phase curriculum. There was an increase in the mean scores of resident-reported comfort, knowledge, and confidence in delivering difficult news for the seriously injured. SPs rated 78% of residents as competent to perform delivery of difficult news in the trauma bay independently. Conclusions: A curriculum to teach and assess trauma residents in the skills necessary to deliver difficult news in the trauma setting is both feasible and effective.
Introduction: Colonic gastrointestinal stromal tumors are rare and never have been reported to present as diverticulitis. Case Description: We describe a case of a 63-year-old female who was treated for a perforated sigmoid diverticulitis which was secondary to a gastrointestinal stromal tumor. Conclusion: While most major guidelines suggest treatment with adjuvant imatinib for immediate or high risk gastrointestinal stromal tumors, there are discrepancies among the guidelines on the management of perforated tumors which warrant further studies to manage these patients.
Communication among patients, colleagues, and staff in healthcare has changed dramatically in the last decade. Digital technology and social media sites have allowed instantaneous access to information. The potential for information technology to improve access to healthcare, enhance the quality, and lower the cost is significant. Text messaging, tweeting, chatting, and blogging are rapidly replacing e-mail as the preferred means of communication in healthcare. This review will highlight how digital technology is changing the way surgeons communicate with colleagues and patients as well as provide some guidance as to how to avoid some of the pitfalls and problems that this form of communication can bring.
Background: The elderly injured have significant palliative care (PC) needs due to increased mortality and poor functional outcomes. We hypothesized the Palliative Performance Scale (PPS) could be predictive of poor outcomes in elderly trauma patients. Methods: Retrospective study of trauma patients 55 years or older admitted to the surgical intensive care unit. Using logistic regression, PPS was assessed as a predictor of mortality, Glasgow Outcome Scale, and discharge destination. Results: Out of 153 patients, 28 died; 28% of the survivors had a Glasgow Outcome Scale 3 or less and 13% were discharged to dependent care. PPS score of 80 or less was an independent predictor of mortality (odds ratio [OR]: 2.97 [1.08 to 8.66]), poor functional outcome (OR: 12.59 [4.81 to 37.07]), and discharge to dependent care (OR: 8.13 [2.64 to 30.09]), yet only 52% of the patients with PPS of 80 or less received PC. Conclusions: Admission PPS can predict mortality and poor functional outcomes in elderly trauma patients, and has potential as a trigger for delivery of PC in this vulnerable population.
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Abstract Introduction Traumatic injury often results in death or significant disability to a previously healthy person, leaving family overwhelmed. Effective communication to support family is therefore important, yet there is little emphasis placed on developing communication skills around death and dying in the trauma setting. Assessment of a resident's communication skills or feedback regarding these skills is rare to nonexistent in emergency medicine and surgery resident training. We designed a curriculum to teach and assess communication skills that address difficult conversations in the trauma bay, which includes this teaching objective structured clinical examination (TOSCE) used to assess communication skills. Methods After a brief introduction and orientation to peer feedback, residents were divided into groups of three to complete two 7-minute TOSCEs, where one resident interacts with a standardized patient (SP) and the other two observe. Communication and overall demeanor are assessed using a checklist format and on a Likert-type scale. The same form was used by the learner, the SP, and the facilitator. SPs assessed residents, and peers/preceptors provided formative feedback. Results Twenty-five residents (nine emergency medicine, 16 surgery) participated in the TOSCE. A majority of participating residents were rated by the standardized patients as competent to perform independently, while a small percentage needed more basic instruction. For the two case scenarios used, SPs rated nearly all residents as competent to perform delivery of poor prognosis and competent or mostly competent to perform delivery of news of death. Mean ratings showed concordance between self-ratings and SP ratings. A majority of residents reported the TOSCE was a valuable learning experience. Discussion In conclusion, a TOSCE is effective in assessing communication skills around the critically injured patient in the trauma bay. A TOSCE is feasible to implement in surgery and emergency medicine residency training, and the format is valued by participants.
Background: Trainees and practicing physicians alike find breaking bad, sad, or difficult news to a patient or family member as one of the most challenging communication tasks they perform. Interpersonal and communication skills are a core competency for resident training. However, in disciplines where technical skills have a major emphasis, such as surgery, the teaching of communication skills may not be a priority. Objective: The objective of our study is to review literature in order to identify best practices and learning modalities used to teach surgery trainees the communication skills regarding delivery of difficult news to patients and family members. Methods: The criteria for inclusion in this literature review were that the study (1) addresses surgeons' training (nontechnical skills) in breaking difficult news to patient and/or families, (2) describes a teaching modality or intervention targeted to teach surgery residents how to deliver difficult news to patient/family, and (3) is published in English. Results: Articles (n = 225) were screened for final eligibility. After discarding duplicates and noneligible studies, and after abstract/full-text review, 18 articles were included in the final analysis. Most studies are single site; address general surgery residents at varying training levels; and include case-specific, outpatient, and intensive care unit (ICU) settings. There is a paucity of studies in the trauma and unexpected death setting. There is a recent trend to use Objective Structured Clinical Examination (OSCE) both to teach and assess communication skills. Variable tools are used to assess this competency as described. Conclusion: Simulation and OSCE format have emerged as modalities of choice both to teach surgery residents how to deliver difficult news and to assess achievement of this competency. There is a gap in the literature regarding teaching and assessing surgery resident communication skills in delivering difficult news after unexpected events in the trauma and operating room settings.
Abstract Traumatic injury can lead to sudden significant permanent disability or unexpected death for patients. The treating practitioner has no prior relationship with these patients or their families. Informing a family of a bad or uncertain outcome or telling a loved one about a patient's death after trauma resuscitation is a unique communication skill for surgeons, emergency medicine physicians, and other providers. Moreover, the chaos and demanding nature of the resuscitation and its emotional toll on the team members contribute additional stress to the provider who must deliver the bad news. Traditional methods for breaking bad news such as SPIKES do not directly translate to this unique environment. Curricula to teach these communication skills in a high-stakes trauma setting are needed, but none exist in the literature. This module was created in an attempt to bridge that gap. It offers a study guide for communication following trauma resuscitation, an ABCDE pocket card, a video didactic, and a pre− and postassessment. This electronic-module was designed to be delivered using online educational platforms. However, this module can also be adapted to the classroom setting: completing assessments and watching video in class. In our institution, 34 residents undergoing the educational module completed a presurvey, and 28 residents (82%) completed a postsurvey. The survey asked about resident perceived knowledge in the skills presented, the value of self-reflection, and the value of the educational experience. While not statistically significant, there was a trend toward improved resident perception of their knowledge in the domains of breaking bad news and death notification. Eighty-four percent found the module valuable as an educational experience.
Background: Adults (age > 50 years) admitted to the surgical intensive care unit (SICU) are at high risk for delirium. Little is known about the role traumatic injury plays in the development of delirium because these patients have often been excluded from studies. Identification of specific risk factors for delirium among older adults following injury would be useful to guide prevention strategies. We attempted to identify modifiable factors that would predict delirium in an older trauma population admitted to the SICU. Methods: Data were collected prospectively from July 2012 to August 2013 at a Level I trauma center on consecutive trauma patients, older than 50 years, admitted to the SICU. Patients who died in the SICU were excluded. Delirium was assessed every 12 hours using the Confusion Assessment Method for the ICU scale. Demographic, injury, social, and clinical variables were reviewed. Bivariate analysis determined significant factors associated with delirium. A multivariate logistic regression model was used to predict delirium risk. After preliminary results, additional analysis compared patients with chest injury (defined as chest Abbreviated Injury Scale [AIS] score ≥ 3) with those without. Results: A total of 115 patients met criteria, with a mean age of 67 years, Injury Severity Score (ISS) of 19, and Glasgow Coma Scale (GCS) score of 14. The incidence of delirium was 61%. Variables present on admission, which were positive predictors of delirium, were as follows: age, ISS greater than 17, GCS score less than 15, substance abuse, and traumatic brain injury (defined as head AIS score ≥ 3). Chest injury (defined as chest AIS score ≥ 3) was a negative predictor of delirium. Significant risk factors influenced by clinical treatment included doses of opioids and propofol, restraint use, and hours deeply sedated (Richmond Agitation Sedation Scale [RASS] score ≤ -3). Clinical treatments with negative predictability were ventilator-free days/30 (vent-free), benzodiazepine-free days/30 (benzo-free), and restraint-free days/30. In a regression model considering age, vent-free days, chest injury, traumatic brain injury, GCS score, benzo-free days, and hours sedated, only age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.01-1.1; p = 0.03) was a predictor of delirium, while vent-free days (OR, 0.79; 95% CI, 0.65-0.96; p = 0.02) and chest injury (OR, 0.3; 95% CI, 0.09-0.83; p = 0.02) were significant negative predictors of delirium. Patients with chest injury had lower delirium incidence (44%) versus those without (75%) (p = 0.002) despite similar GCS score, ISS, and clinical variables. Conclusion: Delirium is common in older trauma patients admitted to the SICU, and for every year for those older than 50 years, the chance of delirium increases by 10%. While higher ISS increases delirium risk, we identified several modifiable treatment variables including days patients were deeply sedated, mechanically ventilated, and physically restrained. Interestingly, patients with chest injury experienced less delirium, despite similar injury severity and clinical variables, perhaps owing to frequent health care provider interactions. Level of evidence: Prognostic/epidemiologic study, level III.
Hospital-acquired delirium is a known risk factor for negative outcomes in patients admitted to the surgical intensive care unit (SICU). Outcomes worsen as the duration of delirium increases. The purpose of this study was to evaluate the efficacy of a delirium prevention program and determine whether it decreased the incidence and duration of hospital-acquired delirium in older adults (age >50 y) admitted to the SICU. A prospective pre- or post-intervention cohort study was done at an academic level I trauma center. Older adults admitted to the SICU were enrolled in a delirium prevention program. Those with traumatic brain injury, dementia, or 0 d of obtainable delirium status were excluded from analysis. The intervention consisted of multidisciplinary education, a pharmacologic protocol to limit medications associated with delirium, and a nonpharmacologic sleep enhancement protocol. Primary outcomes were incidence of delirium and delirium-free days/30. Secondary outcomes were ventilator-free days/30, SICU length of stay (LOS), daily and cumulative doses of opioids (milligram, morphine equivalents) and benzodiazepines (milligram, lorazepam equivalents), and time spent in severe pain (greater than or equal to 6 on a scale of 1 - 10). Delirium was measured using the Confusion Assessment Method for the ICU. Data were analyzed using Chi-squared and Wilcoxon rank sum analysis. Of 624 patients admitted to the SICU, 123 met inclusion criteria: 57 preintervention (3/12-6/12) and 66 postintervention (7/12-3/13). Cohorts were similar in age, gender, ratio of trauma patients, and Injury Severity Score. Postintervention, older adults experienced delirium at the same incidence (pre 47% versus 58%, P = 0.26), but for a significantly decreased duration as indicated by an increase in delirium-free days/30 (pre 24 versus 27, P = 0.002). After intervention, older adults with delirium had more vent-free days (pre 21 versus 25, P = 0.03), shorter SICU LOS (pre 13 [median 12] versus 7 [median 6], P = 0.01) and were less likely to be treated with benzodiazepines (pre 85% versus 63%, P = 0.05) with a lower daily dose when prescribed (pre 5.7 versus 3.6 mg, P = 0.04). After intervention, all older adults spent less time in pain (pre 4.7 versus 3.1 h, P = 0.02), received less total opioids (pre 401 versus 260 mg, P = 0.01), and had shorter SICU LOS (pre 9 [median 5] versus 6 [median 4], P = 0.04). Although delirium prevention continues to be a challenge, this study successfully decreased the duration of delirium for older adults admitted to the SICU. Our simple, cost-effective program led to improved pain and sedation outcomes. Older adults with delirium spent less time on the ventilator and all patients spent less time in the SICU.
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