Lenworth M. Jacobs

New directions in simulation-based surgical education and training: Validation and transfer of surgical skills, use of nonsurgeons as faculty, use of simulation to screen and select surgery residents, and long-term follow-up of learners

The Consortium of American College of Surgeons-Accredited Education Institutes was created to explore new opportunities in simulation-based surgical education and training beyond the scope of individual accredited institutes. During the Third Annual Meeting of the Consortium of American College of Surgeons-Accredited Education Institutes Consortium, 4 work groups addressed the validation and transfer of surgical skills, the use of nonsurgeons as faculty, the use of simulation to screen and select surgery residents, and long-term follow-up of learners. The key elements from the deliberations and conclusions are summarized in this manuscript.

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.

Successful Nonoperative Management of the Most Severe Blunt Renal Injuries: A Multicenter Study of the Research Consortium of New England Centers for Trauma

IMPORTANCE Severe renal injuries after blunt trauma cause diagnostic and therapeutic challenges for the treating clinicians. The need for an operative vs a nonoperative approach is debated. OBJECTIVE To determine the rate, causes, predictors, and consequences of failure of nonoperative management (NOM) in grade IV and grade V blunt renal injuries (BRIs). DESIGN Retrospective case series. SETTING Twelve level I and II trauma centers in New England. PARTICIPANTS A total of 206 adult patients with a grade IV or V BRI who were admitted between January 1, 2000, and December 31, 2011. MAIN OUTCOMES AND MEASURES Failure of NOM, defined as the need for a delayed operation or death due to renal-related complications during NOM. RESULTS Of 206 patients, 52 (25.2%) were operated on immediately, and 154 (74.8%) were managed nonoperatively (with the assistance of angiographic embolization for 25 patients). Nonoperative management failed for 12 of the 154 patients (7.8%) and was related to kidney injury in 10 (6.5%). None of these 10 patients had complications because of the delay in BRI management. The mean (SD) time from admission to failure was 17.6 (27.4) hours (median time, 7.5 hours; range, 4.5-102 hours), and the cause was hemodynamic instability in 10 of the 12 patients (83.3%). Multivariate analysis identified 2 independent predictors of NOM failure: older than 55 years of age and a road traffic crash as the mechanism of injury. When both risk factors were present, NOM failure occurred for 27.3% of the patients; when both were absent, there were no NOM failures. Of the 142 patients successfully managed nonoperatively, 46 (32.4%) developed renal-related complications, including hematuria (24 patients), urinoma (15 patients), urinary tract infection (8 patients), renal failure (7 patients), and abscess (2 patients). These patients were managed successfully with no loss of renal units (ie, kidneys). The renal salvage rate was 76.2% for the entire population and 90.3% among patients selected for NOM. CONCLUSIONS AND RELEVANCE Hemodynamically stable patients with a grade IV or V BRI were safely managed nonoperatively. Nonoperative management failed for only 6.5% of patients owing to renal-related injuries, and three-fourths of the entire population retained their kidneys.

A 12-year experience with prehospital cricothyrotomies

INTRODUCTION Maintaining cricothyrotomy skills is difficult for air medical crewmembers because the procedure is performed infrequently. The purposes of this study were to review our programs experience with cricothyrotomies and use this pilot study to guide an industry-wide study. METHODS We conducted a retrospective review of all cricothyrotomies performed by our flight crew during the past 12 years. The flight logs were reviewed for patient demographics, scene information, clinical data, and procedure data. RESULTS During this period, 8833 patients were transported: 1589 required intubation (18%), and eight of the 1589 required a cricothyrotomy (0.5%). Five nurses (14% of the total employed during the study) and one physician attempted this procedure. All patients had at least one intubation attempt before the cricothyrotomy (average 3.6, range 1-6 attempts). Six (75%) patients had airway edema, four (50%) had an unstable trachea, and one patient (12.5%) had an airway obstruction. Five (62.5%) of the cricothyrotomy attempts were successful. The remaining three patients were managed with bag-valve mask ventilation. Three patients arrived at the receiving hospital with a perfusing rhythm. CONCLUSION Cricothyrotomy, rarely performed by our flight crews, is successful in 62.5% of cases. These preliminary data suggest current training practices should be re-evaluated. An industrywide survey is planned to determine the optimal training program.

Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients.

INTRODUCTION Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B). METHODS A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared. RESULTS Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P < .05). A difference was demonstrated between groups A and B in pH and HCO3 measurements (P < .05), with Group B presenting in a more acidotic state on admission to the hospital. CONCLUSION Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type of assess benefit of prehospital utilization of blood products is warranted.

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).

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

Trauma 24-Hour Observation Critical Path

BACKGROUND The 24-hour observation critical pathway for trauma is a clinical tool developed to expedite health care delivery to minimally injured patients. The use of patient care, BS, guidelines and physician-approved standing orders was implemented in a Level I trauma center. METHODS A retrospective chart review was performed of 122 patients admitted via the emergency department between December 1, 1993, and May 31, 1994. All patients were evaluated in the emergency department by emergency medicine and trauma physicians and deemed appropriate for 24-hour observation. The information collected included patient demographics, hospital charges, injuries, length of stay, diagnostic tests, consultations, and variances from the critical pathway. RESULTS During the 6-month study period, there were 600 trauma admissions. Of those admissions, 122 patients (20%) were evaluated in the emergency department and deemed appropriate for enrollment in the 24-hour observation pathway. The charts of these patients were reviewed. Fourteen admissions were determined inappropriate for the critical pathway because of the severity of injuries or discharge against medical advice. One hundred eight charts were evaluated further. Eighty-nine patients (80%) completed the critical pathway with a length of stay of 24 hours. CONCLUSION The 24-hour observation critical pathway was designed and used appropriately as exemplified by an overall 80% completion rate. The critical pathway offers a mechanism to streamline care of the minimally injured trauma patient. It also serves as a quality-improvement tool for increasing efficiency, decreasing utilization of resources, and decreasing length of stay.

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.