Darrell Boone

Trauma education and assessment.

Trauma education has evolved over the past 30 years from an unstructured preceptorship to standardised courses offered worldwide. The Advanced Trauma Life Support (ATLS) course has formed the backbone of trauma management philosophy and has spawned a series of courses aimed at specific patient populations and health care groups. Trauma education and assessment for advanced trainees has taken the form of formal clinical fellowships. In addition to clinical experience, a number of tools have been validated in aiding trauma education including use of videotape review and simulation technology. Future emphasis on development and validation of teaching and assessment techniques could improve trauma education and secondarily impact trauma outcomes worldwide.

Use of Human Patient Simulation and Validation of the Team Situation Awareness Global Assessment Technique (TSAGAT): A Multidisciplinary Team Assessment Tool in Trauma Education

OBJECTIVE Situation awareness (SA) is a vital construct for decision making in intense, dynamic environments such as trauma resuscitation. Human patient simulation (HPS) allows for a safe environment where individuals can develop these skills. Trauma resuscitation is performed by multidisciplinary teams that are traditionally difficult to globally assess. Our objective was to create and validate a novel tool to measure SA in multidisciplinary trauma teams using a HPS--the Team Situation Awareness Global Assessment Technique (TSAGAT). SETTING Memorial University Simulation Centre. DESIGN/PARTICIPANTS Using HPS, 4 trauma teams completed 2 separate trauma scenarios. Student, junior resident, senior resident, and attending staff teams each had 3 members (trauma team leader, nurse, and airway manager). Individual SAGATs were developed by experts in each respective field and contained shared and complimentary knowledge questions. Teams were assessed with SAGAT in real time and with traditional checklists using video review. TSAGAT was calculated as the sum of individual SAGAT scores and was compared with the traditional checklist scores. RESULTS Shared, complimentary, and TSAGAT scores improved with increasing team experience. Differences between teams for TSAGAT and complimentary knowledge were statistically significant (p < 0.05). Mean checklist differences between teams also reached statistical significance (p < 0.05). TSAGAT scores correlated strongly with traditional checklist scores (Pearson correlation r = 0.996). Interrater reliability for the checklist tool was high (Pearson correlation r = 0.937). CONCLUSION TSAGAT is the first valid and reliable assessment tool incorporating SA and HPS for multidisciplinary team performance in trauma resuscitation. TSAGAT could compliment or improve on current assessment methods and curricula in trauma and critical care and provides a template for team assessment in other areas of surgical education.

TEAM: A Low-Cost Alternative to ATLS for Providing Trauma Care Teaching in Haiti

OBJECTIVE Trauma resuscitation protocols have unified the care of trauma patients and significantly improved outcomes. However, the success of the Advanced Trauma Life Support course is difficult to reproduce in developing countries due to set-up costs, limitations of resources, and variations of practice. The objective of this study is to assess the Trauma Evaluation and Management (TEAM) course as a low-cost alternative for trauma resuscitation teaching in Low and Middle Income Countries (LMIC). DESIGN As part of the Team Broken Earth initiative, TEAM course was provided to the health care professionals in Haiti. At its conclusion, participants were asked to complete a survey evaluating the course. Qualitative and quantitative data were analyzed to evaluate the perception of the course. SETTING The course was provided in Port-au-Prince, Haiti. PARTICIPANTS A total of 80 health care professionals participated in the course. Response was obtained from 69 participants, which comprised of 32 physicians, 10 Emergency Medical Technicians (EMT), 22 nurses, and 5 medical trainees. RESULTS The course was well received by physicians, nurses, and EMT with an average score of 90.6%. Question analysis revealed a lower satisfaction of physicians for the course manual and teaching materials, and information related to decisions for transfer of patients. EMT consistently felt that the course was not tailored to their learning and practice needs. Written feedback demonstrated several areas of weaknesses including need for improvements in translations, hands-on practice, and educational materials. CONCLUSIONS Overall, the TEAM course was well received. Analysis demonstrated a need for adjustments specific to LMIC including a focus on prehospital assessment, increased nursing responsibilities, and unavailability of specialists referrals. Team Broken Earth intends to take these findings into consideration and continue to provide the TEAM course to other LMIC.

Pre-operative and post-operative changes in CRP and other biomarkers sensitive to inflammatory status in patients with severe obesity undergoing laparoscopic sleeve gastrectomy

INTRODUCTION C-reactive protein (CRP) is often elevated in patients living with severe obesity (BMI≥35kg/m2). However, there is limited information on how CRP, and other inflammation responsive biomarkers, change in response to weight loss following laparoscopic sleeve gastrectomy (LSG). We studied how CRP, ferritin and albumin change following LSG surgery in relation to obesity, metabolic syndrome (MetS) ATPIII risk components and diabetes mellitus (DM). METHODS Laboratory parameters (including CRP) were examined in 197 patients prior to LSG, and at 6, 12, 18 and 24months. Changes in laboratory parameters, and laboratory investigations, were also examined in a 125 patient subgroup at both pre-LSG and at the 12month follow-up visit. RESULTS All patients had BMI≥35kg/m2. CRP levels positively correlated with BMI (r=0.171, p=0.016) and alkaline phosphatase (ALP; r=0.309; P<0.001), but negatively correlated with alanine aminotransferase (ALT; r=-0.260; P<0.001) and albumin (r=-0.358; P<0.001). LSG significantly reduced CRP and ferritin, which were maintained for at least 24months. At 12months post-LSG there was a significant decrease in weight (kgs) (p<0.001), CRP (p<0.001), ferritin (p=0.004), and various MetS risk components (p<0.001) but not albumin (p=0.057). Changes in CRP also correlated with changes in weight (r=0.233, p=0.018) and ALP (r=0.208, p=0.034) but not albumin (r=-0.186, p=0.058) or ferritin (r=0.160, p=0.113) after LSG. CONCLUSION The negative correlation between CRP and albumin levels in obesity may indicate a low grade inflammatory process affecting both. LSG related weight loss decreased CRP and ferritin, likely explained by improvement in inflammatory status.

The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks

Background Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure’s morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. Methods We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. Results Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was

Effect of Colonoscopy Volume on Quality Indicators.

35 000. Conclusion The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.

Use of human patient simulation and the situation awareness global assessment technique in practical trauma skills assessment.

Background. The purpose of this study is to determine if colonoscopy quality is associated with the annual case volume of endoscopists. Methods. A retrospective cohort study was performed on 3235 patients who underwent colonoscopy in the city of St. Johns, NL, between January and June 2012. Data collected included completion of colonoscopy (CCR) and adenoma detection rates (ADR). Endoscopists were divided into quintiles based on annual case volume. To account for potential confounding variables, univariate analyses followed by multivariable logistic regression were used to identify variables independently associated with CCR and ADR. Results. A total of 13 surgeons and 8 gastroenterologists were studied. There was a significant difference in CCR (p < 0.001) and ADR (p < 0.001) based on annual volume. Following multivariable regression, predictors of successful colonoscopy completion included annual colonoscopy volume, lower age, male sex, an indication of screening or surveillance, and a low ASA score. Predictors of adenoma detection included older age, male sex, an indication of screening or surveillance, and gastroenterology specialty. Conclusion. Higher annual case volume is associated with better quality of colonoscopy in terms of completion. However, gastroenterology specialty appears to be a better predictor of ADR than annual case volume.