Barbara J. Pettitt

Validation of Surgeon-Performed Emergency Abdominal Ultrasonography in Pediatric Trauma Patients

BACKGROUND/PURPOSE The focused assessment for the sonographic evaluation of trauma patients (FAST) in adults is effective in detecting intraperitoneal and intrapericardial fluid and can be performed quickly by surgeons in the emergency department (ED). The authors sought to validate the accuracy of FAST performed by surgeons during ED resuscitation of pediatric trauma patients. METHODS Patients were assigned to one of three groups based on standard clinical criteria: immediate surgery, abdominal computed tomography (CT), or observation alone. FAST was then performed in the ED by a surgery resident (postgraduate year 3 or higher) or an attending trauma surgeon. Four views were used to assess the possible presence of fluid in the pericardial, subphrenic, subhepatic, and pelvic spaces. Time needed to conduct FAST was noted. Presence of peritoneal or pericardial fluid by FAST was compared with that determined by CT or surgery. Sensitivity, specificity, and predictive values were calculated. For those who did not undergo CT or surgery, FAST findings were compared with the clinical course. RESULTS Technically adequate studies could be performed on 192 of 196 eligible children. Their ages ranged from 3 months to 14 years (mean, 6.9 years); 119 were boys (62%), and 188 (98%) had sustained a blunt injury. FAST was performed in a mean time of 3.9 minutes (range, 1-17 minutes). All FAST examinations were reviewed by our senior surgeon-sonographer (GSR). Interrater agreement between the performing and reviewing surgeon-sonographer was 100%. Sixty (31%) patients underwent either abdominal CT (n = 56; mean Injury Severity Score (ISS), 9.6) or immediate operation (n = 4; mean ISS, 18.8). Of the 10 patients with verified presence of intraperitoneal fluid, eight had positive and two had false-negative FAST examination results. Of the 50 patients with verified absence of intraperitoneal fluid, none had a positive FAST (ie, no false-positives); sensitivity was 80%; specificity, 100%; predictive value positive, 100%; predictive value negative, 96%. None of the 132 patients followed up clinically without CT or surgery (mean ISS, 4.5) had fluid documented by FAST, and all did well. CONCLUSIONS The focused assessment for the sonographic evaluation of pediatric blunt trauma patients performed by surgical residents and attendings in the ED rapidly and accurately predicted the presence or absence of intraperitoneal fluid. The FAST is a potentially valuable tool to rapidly prioritize the need for laparotomy in the child with multiple injuries and extraabdominal sources of bleeding.

Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills.

BackgroundVideo game experience (VGE) has been identified as a possible predictive factor for surgical skill. We hypothesized that surgical novices with previous VGE would acquire new surgical skills faster than those without.MethodsFourth-year medical students (M4) and first-year surgical residents (PG-1) completed a survey asking about standard demographic data and previous VGE. Gamers had high VGE, defined as more than 3 h per week of videogame playing. Nongamers had little or no VGE. Both groups trained to proficiency on two tasks (AcquirePlace and Traversal) of the MIST-VR simulator, with proficiency defined as meeting previously validated criteria on two consecutive trials. The number of trials required to achieve proficiency for each task was recorded.ResultsThe 26 participants included 11 M4s and 15 PG-1s: 17 males (8 gamers/9 nongamers) and 9 females (3 gamers/6 nongamers), mean age 27.8 years. There were no differences in time to proficiency between the M4 and PG-1 residents, and there were no significant differences in the relative number of gamers per gender. All participants eventually met proficiency criteria. The 11 gamers reached proficiency more quickly than the 15 nongamers (median 0 trials versus 6 trials, p = 0.01). Gamers scored lower than nongamers on their initial attempts. Women overall took longer to reach proficiency than did men (median 10 trials versus 0 trials, p = 0.002). When stratified according to VGE, female nongamers took longer to reach proficiency than male nongamers (median 11 trials versus 1 trial, p = 0.006) but among gamers, there was no difference between females and males (median 0 trials versus 0.5 trials, NS).ConclusionPrevious VGE shortens time to achieve proficiency on two tasks on a validated surgical simulator. The possibility that VGE may ameliorate gender differences in length of time required to acquire surgical skills should be explored further.

A prospective study for the detection of vascular injury in adult and pediatric patients with cervicothoracic seat belt signs.

BACKGROUND A delayed diagnosis of injury to cervicothoracic vessels from blunt trauma may cause significant adverse sequelae. The association of a cervicothoracic seat belt sign with such an injury is unknown. METHODS Algorithms were prospectively studied for the detection of occult vascular injury in patients with cervicothoracic seat belt signs. Patients with neck seat belt signs underwent arteriography or computed tomographic angiography (CTA). Those with thoracic seat belt signs underwent aortography/arteriography if a ruptured thoracic aorta or injury to a great vessel was suspected or a neurovascular abnormality was present. RESULTS During a 17-month period, 797 patients were admitted to the trauma service secondary to motor vehicle crashes. One hundred thirty-one (16.4%) had cervical or thoracic seat belt signs. Four (3%) of the patients had carotid artery injuries, the presence of which was strongly associated with a Glasgow Coma Scale score < 14, an Injury Severity Score > 16 (p < 0.0001), and the presence of a clavicle and/or first rib fracture (p < 0.0037). Of the remaining patients, 17 had thoracic trauma. There were no vascular injuries in the children and only one had thoracic trauma. CONCLUSION The algorithms are safe and accurate for the detection of cervicothoracic vascular injury in adult and pediatric patients with seat belt signs. The cervicothoracic seat belt mark and an abnormal physical examination are an effective combination in screening for cervicothoracic vascular injury.

Designing an ethics curriculum to support global health experiences in surgery.

BACKGROUND The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery. MATERIALS AND METHODS Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships. RESULTS Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon-patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change. CONCLUSIONS Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.

Medical students impact laparoscopic surgery case time.

BACKGROUND Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

Do Medical Students in the Operating Room Affect Patient Care? An Analysis of One Institution’s Experience Over the Past Five Years

BACKGROUND Medical students are active learners in operating rooms during medical school. This observational study seeks to investigate the effect of medical students on operative time and complications. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to operative records for nonemergent, inpatient general surgery cases at our institution from 1 January 2009 to 1 January 2013. Cases were grouped into 13 distinct procedure groups. Hospital records provided information on the presence of medical students. Demographics, comorbidities, intraoperative variables, and postoperative complications were analyzed. RESULTS Overall, 2481 cases were included. Controlling for wound class, procedure group, and surgeon, medical students were associated with an additional 14 minutes of operative time. No association between medical students and postoperative complications was observed. CONCLUSIONS The educational benefits gained by the presence of medical students do not appear to jeopardize the quality of patient care.