Karyl J. Burns

Development and evaluation of the advanced trauma operative management course.

BACKGROUND The Advanced Trauma Operative Management (ATOM) course was developed as a model for teaching operative trauma techniques to surgical residents, fellows, and attending surgeons as the number of these cases decreases. METHODS The ATOM course consists of lectures and a porcine operative experience. Comprehensive evaluation of ATOM was designed to assess participant learning in the cognitive, affective, and psychomotor domains. Data on the first 50 participants were prospectively collected and analyzed. RESULTS Participants included 20 expert traumatologists, 9 general surgeons, 9 trauma fellows, 8 general surgery fifth-year residents, and 4 general surgery fourth-year residents. All groups showed improvement in knowledge, with results in the expert and fellow groups reaching statistical significance. Self-efficacy (self-confidence) also improved, with all groups reaching statistical significance. CONCLUSION This course creates life-like situations in a standardized fashion that, along with didactic instruction, improves knowledge and operative confidence for practicing surgeons and surgeons-in-training.

Trauma Death: Views of the Public and Trauma Professionals on Death and Dying From Injuries

OBJECTIVES To determine the values and preferences of the general public and trauma professionals regarding end-of-life care due to injury so as to inform practice guidelines. DESIGN, SETTING, AND PARTICIPANTS Surveys of the general public sampled by random-digit dialing between June 6, 2005, and July 5, 2005, and of a convenience sample of trauma professionals during fall 2005 in the United States were conducted regarding preferences for care in the prehospital, emergency, and critical care settings. MAIN OUTCOME MEASURES Responses to the survey questions. RESULTS Most of the public and trauma professionals would prefer palliative care when doctors determine that aggressive critical care would not be beneficial in saving their lives. During resuscitation of an injured loved one, 51.9% of the public and 62.7% of the professionals would prefer to be in the emergency department treatment room. Most of the public believes that patients should have the right to demand care not recommended by their physicians. Most of both groups trust a doctors decision to withdraw treatment when futility is determined. More of the public (57.4%) than the professionals (19.5%) believe that divine intervention could save a person when physicians believe treatment is futile. Other findings suggest further important insights. CONCLUSIONS The results pose challenges that will require societal discourse to determine the best practice. Resolutions will need to be included in educational curricula and incorporated into practice to ensure that dying trauma victims and their families receive quality end-of-life care.

Predictors of referral to cardiac rehabilitation and cardiac exercise self-efficacy

Cardiac rehabilitation (CR) has known benefits after myocardial infarction (MI) or coronary artery bypass surgery (CABG). Yet, only a small percentage of patients are referred for outpatient CR after hospital discharge. This study investigates patient characteristics related to referral to CR and cardiac exercise self-efficacy, a salient predictor of health behavior change and maintenance. Two hundred nineteen patients enrolled in the study. Of the 185 patients who were CR candidates, 74 were referred to CR. Logistic regression analysis was used to identify variables related to CR referral. Results indicate that patient characteristics of having had fewer MIs or CABGs, having attended CR in the past, and being less physically active during leisure time are related to an increased likelihood of being referred to CR. Multiple regression analysis indicates that leisure physical activity is a predictor of cardiac exercise self-efficacy. Implications for nurses who recruit patients for CR are discussed.

Follow-up survey of participants attending the Advanced Trauma Operative Management (ATOM) Course.

BACKGROUND The ATOM Course was developed to educate surgeons about the surgical management of penetrating injuries. Its goals are to improve knowledge, self-confidence, and technical competence. METHODS ATOM participants completed a 25-item questionnaire to assess self-efficacy (SE) for advanced trauma operative management before and immediately after taking the ATOM course. On follow-up, questionnaires were sent to ATOM participants. One was a 7-item survey to assess the value of the ATOM course to surgical practice. Another was the 25-item questionnaire to assess SE. RESULTS Four items on the survey to assess the value of ATOM had mean scores > or = 4.0 and 3 had mean scores > 3.6. All had modes of 4.0 or greater. For all items, most respondents selected the agree options indicating positive assessments of the ATOM course to their surgical practice. For SE, the pre-ATOM mean SE score was 3.88 and the immediate post ATOM mean SE score was 4.57 (p < 0.05). The follow-up mean SE score was 4.47 indicating maintenance of SE (p > 0.05). CONCLUSIONS Follow-up data from ATOM participants indicate that respondents believe the ATOM course improved their ability to identify and repair traumatic injuries. They report they use the techniques and knowledge learned in ATOM and confidence remains high after the ATOM course. ATOM is well received as an effective teaching strategy for surgical education for the management of penetrating injuries.

A New Paradigm for Surgical Procedural Training

xternal forces continue to exert enormous pressures on surgical care. ational mandates regarding quality, safety, and outcomes of patient care, oupled with concerns about health care costs and demands for greater ransparency, present a host of challenges and exciting opportunities. The ivotal role of education in addressing these imperatives has been rticulated in major reports. Steps are being taken to introduce ignificant changes in existing models of teaching, learning, and assessent; however, more needs to be done to create high-performance earning organizations with a different ethos. This will require fundamenal redesign of education and training models that have borne us in good tead for more than 100 years. Recent advances in the science and ractice of surgical education and training provide a solid foundation on hich new models should be built to positively impact outcomes of urgical care and address the array of national imperatives. This article rovides a synopsis of the challenges and opportunities relating to urgical education and training, outlines the role of simulation, undercores the importance of simulation centers as core facilities through hich new education and training models may be developed and isseminated, and highlights the innovative education and training prorams of the American College of Surgeons (ACS).

Terrorism: a public health threat with a trauma system response.

BACKGROUND The threat of mass casualties and widespread infectious disease caused by terrorism is now a challenge for our government and public health system. Funds have been granted to the states by the Centers for Disease Control and Prevention and the Health Resources and Services Administration to establish bioterrorism preparedness and response capabilities. METHODS Hartford Hospital has been designated as a Center of Excellence for Bioterrorism Preparedness by the Commissioner of the Connecticut Department of Public Health. The Center of Excellence has implemented strategies to prepare for a possible bioterrorist attack. A unique model that combines epidemiology and traumatology is being used to guide the preparedness activities. Although the focus of the grant from the Connecticut Department of Public Health is bioterrorism, the application of the model can apply to preparation for all terrorist events. RESULTS Implementation of strategies indicates that bioterrorism preparedness is well underway. Similar initiatives should be achievable by other trauma systems throughout the country. CONCLUSION A Center of Excellence for Bioterrorism Preparedness in Connecticut is successfully modifying a trauma system to meet the challenge of a new public health threat, terrorism.

The Hartford Consensus: THREAT, A Medical Disaster Preparedness Concept

Mass murder through active shooter and explosive events has been at the forefront of our news. Despite improvements in both law enforcement tactics and emergency trauma care, additional integration of the core functions of the public safety response to these events has the potential to maximize survivability. From the mass casualty shooting at Columbine High School in Littleton, CO, through the shootings at SandyHook Elementary School in Newtown, CT, an examination of events will demonstrate some improvement. However, we must continue to hone our response. Perhaps no incident has changed both law enforcement and fire/rescue/emergencymedical services (EMS) response like the Columbine High School shooting. At that time, traditional law enforcement response doctrine dictated waiting for tactical personnel to arrive to secure the school. During this waiting time, some of the fatalities and some of the morbidity among survivors were due to unchecked hemorrhage and shock. Nearly 8 years later, a clear transition in active shooter response was evident on the campus of Virginia Tech University, where the initial response included 2 tactical medics who provided care, predominantly hemorrhage control and airway management, long before the scene was secured. The mass casualty shooting incident at Foot Hood military base resulted in 13 dead and 31 wounded. An officer was able to stop the shooter, but sustained bilateral thigh wounds with significant hemorrhage from the left lower extremity. An Army medic

Hartford Consensus: A Call to Action for THREAT, a Medical Disaster Preparedness Concept

Received October 23, 2013; Revised December 9, 20 December 10, 2013. From Hartford Hospital, University of Connecticut, Hartfor Burns); Federal Bureau of Investigation (Wade, Fabbri) and t on Tactical Combat Casualty Care, Department of Defense, System (Butler), Washington, DC; Tulane University Depa gery, New Orleans, LA (McSwain); Dallas Police Departme western Medical Center, Dallas, TX (Eastman); and Massach Hospital, Boston, MA (Conn). Correspondence address: Lenworth M Jacobs, MD, MPH, F Hospital, 80 Seymour St, Hartford, CT 06102. email: len hhchealth.org

Advanced Trauma Operative Management Course: Participant Survey

BackgroundThe Advanced Trauma Operative Management (ATOM) course uses standardized porcine simulation to teach the repair of penetrating trauma. It is offered in 26 sites in the United States, Canada, Africa, the Middle East, and Japan. The purpose of the present study was to query ATOM participants regarding their perceptions of the value and influence of the ATOM course on knowledge, confidence, and skill to repair penetrating injuries.MethodsAn anonymous, voluntary survey was posted on the Internet at surveymonkey.com. E-mail notification was sent to all 1,001 ATOM participants through May 2008. Items requested agreement/disagreement on a 5-point Likert scale and space for comments. Agreement indicated positive perceptions of ATOM.ResultsA total of 962 surgeons received the request to complete the survey; 444 ATOM participants from 36 states and 17 countries participated, for a response rate of 46%. Range of agreement with all of the items was 75.4–99.0%. Results include the following: 78.9% (95% CI, 74.7–82.6%) can identify injuries more quickly; 80.7% (95% CI, 76.6–84.3%) have a more organized operative approach; 81.1% (95% CI, 77.0–84.6%) can control bleeding more quickly; 86.1% (95% CI, 82.4–89.2%) can control injuries more effectively; 86.4% (95% CI, 82.7–89.4%) are more competent trauma surgeons; 87.0% are more confident (95% CI, 83.4–89.9%), and 89.2% are more knowledgeable (95% CI, 85.8–91.8%) about repairing penetrating injuries; 99% (95% CI, 97.4–99.7%) said ATOM is worthwhile. Overall, 87.4% of the comments were positive.ConclusionsParticipants worldwide perceive that ATOM is worthwhile and helps surgeons improve knowledge, confidence, and skill in repairing penetrating injuries.

Prehospital HMG Co-A Reductase Inhibitor Use and Reduced Mortality in Ruptured Abdominal Aortic Aneurysm

BACKGROUND The compounds 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (HMG Co-A reductase inhibitors, statins) are popular medications for the control of elevated serum cholesterol. Recent evidence has demonstrated a survival benefit to patients who take statins in the premorbid period with severe sepsis, septic shock, or severe trauma. We hypothesized that a similar benefit would be seen in patients with ruptured abdominal aortic aneurysm. STUDY DESIGN We completed a retrospective review of patients with ruptured abdominal aortic aneurysm in our institution from January 2000 to December 2008. We compared age, gender, mortality rates, and Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) scores for all patients who met inclusion and exclusion criteria. We compared hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient between survivor groups with and without prehospital statin use. We compared mortality, cardiac morbidity, and gender using the Pearson chi-square test, Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores and age using the Students t-test and lengths of stay using the Mann Whitney-U test. RESULTS Mortality in the group without prehospital statin use was 63.8%, and in the group with prehospital statin use was 34.8% (p=0.018, odds ratio 0.30 to 0.11). Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores were similar between survivor groups with and without statin use and nonsurvivor groups with and without statin use. Hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient were not statistically different among survivors. CONCLUSIONS Prehospital statin use appears to be associated with a significant survival benefit in the ruptured abdominal aortic aneurysm population.