Anastasia Kunac

A Review of Endoscopic Simulation: Current Evidence on Simulators and Curricula.

Upper and lower endoscopy is an important tool that is being utilized more frequently by general surgeons. Training in therapeutic endoscopic techniques has become a mandatory requirement for general surgery residency programs in the United States. The Fundamentals of Endoscopic Surgery has been developed to train and assess competency in these advanced techniques. Simulation has been shown to increase the skill and learning curve of trainees in other surgical disciplines. Several types of endoscopy simulators are commercially available; mechanical trainers, animal based, and virtual reality or computer-based simulators all have their benefits and limitations. However they have all been shown to improve trainees endoscopic skills. Endoscopic simulators will play a critical role as part of a comprehensive curriculum designed to train the next generation of surgeons. We reviewed recent literature related to the various types of endoscopic simulators and their use in an educational curriculum, and discuss the relevant findings.

Ethics in Geriatric Trauma

Ethical principles that underlie contemporary surgical care of the elderly are founded on principles of medicine originating with the Hippocratic Oath: non-maleficence, beneficence, autonomy, and justice. Caring for the geriatric trauma patient may be particularly challenging as this is a vulnerable and sometimes frail patient population often with limited decision-making capacity. This chapter explores the ethical principles that form the cornerstones of geriatric trauma care, outlines the consent process and determination of decision-making capacity, and discusses the concept of DNR and medical futility.

The Role of High-Fidelity Team-Based Simulation in Acute Care Settings: A Systematic Review

Introduction  High-fidelity team-based simulation has been identified as an effective way of teaching and evaluating both technical and nontechnical skills. Several studies have described the benefits of this modality in a variety of acute care settings, but a lack of standardized methodologies has resulted in heterogeneous findings. Few studies have characterized high fidelity simulation across a broad range of acute care settings and integrated the latest evidence on its educational and patient impact. Methods  The MEDLINE, EMBASE, Cochrane Library, and PsycINFO databases were searched for empirical studies from the last 10 years, investigating high fidelity team-based simulation in surgical, trauma, and critical care training curricula. Results  Seventeen studies were included. Interventions and evaluations were comprehensively characterized for each study and were discussed in the context of four overarching acute care settings: the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams. Conclusions  The use of high-fidelity team-based simulation has expanded in acute care and is feasible and effective in a wide variety of specialized acute settings, including the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams. Training programs have evolved to emphasize team-based, multidisciplinary education models and are often conducted in situ to maximize authenticity. In situ simulations have also provided the opportunity for system-level improvement and discussions of complex topics such as social hierarchy. There is limited evidence supporting the impact of simulation on patient outcomes, sustainability of simulation efforts, or cost-effectiveness of training programs. These areas warrant further research now that the scope of utilization across acute care settings has been characterized.

Short-term surgical missions in resource-limited environments: Five years of early surgical outcomes

Outcomes of short-term surgical missions (STSMs) hosted in developing countries are underreported, raising quality concerns. This study aims to analyze early outcomes of one humanitarian surgical organization to show that safe essential general surgery can be provided in the context of STSMs. Records from 6 STSMs to Sierra Leone and Ghana were reviewed for early complications and analysis performed to identify associated factors. Missions performed elective, general surgery on low risk patients, with adherence to patient safety protocols. No perioperative mortality occurred from 372 procedures, most frequently inguinal hernia repair (54%). Seventeen surgical (5%), 3 infectious (1.2%), and 6 anesthesia (2%) complications were reported. Only younger age was significantly associated with complications. Essential general surgery can be performed safely on STSM assuming careful patient selection, avoidance of high-risk cases, and adherence to patient safety protocols. Data collection is feasible and should be undertaken to improve the quality of care.

First rib fracture: A harbinger of severe trauma?

BACKGROUND Prior to routine CT scanning, first rib fractures (FRFs) were considered a harbinger of great vessel injuries. We hypothesized FRFs identified on screening CXR have significant associated injuries, while those identified on CT alone do not. METHODS We reviewed adult blunt thoracic trauma patients 2014-2015 to identify all FRFs and then tabulated demographics, injury characteristics, and outcomes. RESULTS Of 429 patients with chest trauma, 56 had a FRF. CXR diagnosed 20% and CT 80%. Those diagnosed on CXR were older (61 vs 48 p = 0.03), had more severe chest trauma (45% vs 13% chest AIS>3, p = 0.029), longer ICU stays (10 vs 4 days, p = 0.046), and risk for intubation (73% vs 27%, p = 0.011). There was only one major vascular injury in each group. Most FRF patients had associated injuries, including 82% with pelvic fractures. CONCLUSIONS Widespread use of CT scanning has resulted in a 5-fold increase in FRF diagnoses. While vascular injuries are not common, especially when identified on initial CXR, FRFs correlate with morbidity and associated injuries.

Complications Status Post Damage Control for the General Surgeon

Damage control laparotomy is widely practiced as a temporizing measure to salvage surgical patients whose physiologic derangements do not permit the completion of an intended operation. The more complete description of the development and evaluation of damage control laparotomy following severe trauma is outlined in Chaps. 1 and 2. However, it is worth briefly reviewing the genesis of the procedure in light of developing of early and late complications. The technique was popularized in the early 1980s by Stone and associates for surgical treatment of coagulopathic trauma patients. Stone described the technique of packing, control of hemorrhage, bowel resection without anastomosis or stoma formation to control contamination, and biliary or pancreatic drainage if necessary. Patients returned to the operating room for definitive operative repair of injuries following correction of coagulopathy. As the widespread use of non-warfarin anticoagulants, many with no or complicated reversal agents, is increasingly encountered in patients with emergent surgical conditions, the need for damage control for uncontrolled coagulopathy will not be an uncommon event.

Endovascular coil embolisation of a giant pulmonary artery pseudoaneurysm from a gunshot wound

A 38-year-old female was brought to the trauma emergency room after sustaining multiple gunshot wounds to the right chest and abdomen. She had pulmonary contusions involving the right lung and a haemopneumothorax initially managed with chest tube placement. A few weeks into her hospitalisation, she was found to have a giant right pulmonary artery pseudoaneurysm, which corresponded to a bullet tract. The pseudoaneurysm was causing a steal phenomenon and impaired perfusion of the right middle lobe and right lower lobe. Endovascular coil embolisation of the pseudoaneurysm was performed with restoration of perfusion to the right lung.