Impacto de COVID-19 en la formación de los alumnos de la Carrera de Posgrado de Cirugía General en un Hospital COVID / Impact of COVID-19 pandemic on trainees' education in the Postgraduate Program in General Surgery in a COVID-19-dedicated hospital

RESUMEN Antecedentes: El Hospital Eva Perón de la ciudad de Granadero Baigorria se destinó a la atención casi exclusiva de pacientes afectados por COVID-19, lo que implicó modificar las actividades que allí se desarrollan. Allí se realizan actividades correspondientes al Posgrado de Cirugía General de la Facultad de Ciencias Médicas de la Universidad Nacional de Rosario. El objetivo es describir los cambios y el funcionamiento del posgrado de Cirugía General en el HEEP durante la pandemia por COVID-19, y el impacto que esta tuvo sobre la formación de los alumnos. Material y métodos: se realizó un trabajo descriptivo, comparativo. Período 20 de marzo de 2020 al 30 de septiembre de 2020 y el mismo período del año 2019. Variables analizadas: número de cirugías, horas en el hospital, número de guardias, actividad en consultorio y pacientes evaluados, seminarios teóricos, cursado de la carrera de posgrado. Resultados: las cirugías totales se redujeron un 74,88%. Las cirugías programadas se redujeron un 85,59%. Las cirugías de guardia se redujeron un 63,19%. Las guardias de R1, R2 y R3 se vieron disminuidas, al contrario de R4. Las horas en el hospital se redujeron en todos los alumnos. Los pacientes ingresados disminuyeron el 74,06%. La atención en todos los consultorios se vio reducida. Las actividades académicas se incrementaron, de forma no presencial. Conclusión: la pandemia por COVID-19 afectó significativamente la formación de los alumnos del posgrado de Cirugía General del HEEP. Se recurrió a métodos no tradicionales de enseñanza para realizar actualizaciones y discutir trabajos científicos.

ABSTRACT Background: Hospital Eva Perón in the city of Granadero Baigorria was almost exclusively dedicated to the care of COVID-19 patients; thereby, it was necessary to modify its activities, as those of the postgraduate program in General Surgery of Facultad de Ciencias Médicas, Universidad Nacional de Rosario, which take place in this hospital. The aim of this study is to describe the changes made and the performance of the postgraduate program in general surgery at HEEP during the COVID-19 pandemic, and its impact on trainees' education. Material and methods: We conducted a descriptive study comparing the period between March 20, 2020, and September 30, 2020, with the same period in 2019. The variables analyzed included number of surgeries, hours spent in hospital, number of in-house call shifts, activities in the outpatient clinic and evaluation of patients, theoretical seminars, attendance to classes of the postgraduate programs and research work. Results: The total number of surgeries decreased by 74.88%, scheduled surgeries by 85.59% and emergency surgeries by 63.19%. The numbers of in-house call shifts of PGY-1, PGY-2 and PGY-3 residents decreased but not those of PGY-4 residents. The hours spent in hospital decreased in all the trainees. The number of patients hospitalized decreased by 74.06% and there was a reduction in all the activities of the outpatient clinics. The academic activities, performed non-face-to-face, increased. Conclusion: The COVID-19 pandemic significantly affected trainees' education in the postgraduate program in General Surgery at HEEP. Non-traditional teaching methods were used for updating and discussing scientific papers.

Sesgos en investigación quirúrgica / Biases in surgical research

Resumen Los resultados de diversos hallazgos de investigación han sido objeto de crítica, en especial en los últimos años, debido a presencia de errores sistemáticos (sesgos), los que ponen en duda la validez interna de los resultados obtenidos. Estos sesgos pueden ocurrir en cualquier etapa del curso de una investigación, es decir, desde la planificación del estudio hasta la presentación y publicación de sus resultados. Los sesgos se han clasificado de diferentes formas, intentado agruparlos bajo dimensiones conceptuales, objeto de organizar de mejor forma la información existente, que además es considerable. Los sesgos pueden ocurrir por diversos motivos, pero en general, los más frecuentes son aquellos originados por el observador (él o los que miden), por lo que es observado (sujeto en estudio); y aquello con lo que se observa (instrumento de medición). Por otra parte, varios de los múltiples sesgos existentes, se pueden agrupar en: sesgos de selección, de medición o información, y de confusión. El objetivo de este manuscrito fue comentar la importancia de los sesgos más comunes en la investigación quirúrgica, y su relación con algunos diseños de investigación; así como, conocer las estrategias existentes para minimizar su ocurrencia.

The results of many research findings have come under scrutiny in recent years due to the introduction of systematic errors (biases), which can occur at any stage during an investigation, from planning to presentation of results and their presentation and further publication. Biases have been classified in different ways, trying to group them under conceptual dimensions to better organize the existing information, which is considerable. Biases can occur for various reasons, but in general, the most frequent are those originated by the observer, what is observed; and what is observed with. I.e., the subject that is measured, who measures it and with what it measures it. On the other hand, several of the multiple biases can be grouped into selection, measurement or information, and confounding biases. The aim of this manuscript was to comment on the importance of the most common biases in surgical research, and their relationship with some research designs; as well as know the existing strategies to reduce its occurrence.

Características sociodemográficas en cuidadores principales de pacientes operados de cáncer de cerebro / Socio-demographic characteristics in primary caregivers of patients with brain cancer surgery

RESUMEN Introducción: la atención al enfermo es llevada a cabo por una secuencia específica de la familia, por lo que esta es considerada un cuidador principal. Objetivo: describir las características sociodemográficas en cuidadores principales de pacientes operados de cáncer de cerebro. Materiales y métodos : se realizó un estudio descriptivo, retrospectivo, en un universo de 128 cuidadores principales de pacientes operados de cáncer de cerebro en el Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández, de Matanzas, entre 2016 y 2018. Criterio de inclusión: cuidadores que residían en la provincia y aceptación del consentimiento informado. Se excluyeron familiares de pacientes que fallecieron durante la investigación. Se aplicaron cuestionarios y entrevistas para caracterizar los resultados. Los mismos se analizaron en frecuencias absolutas, relativas, porcentual, en paquete estadístico de SPSS versión 20.0 en Windows. Resultados : predominó el sexo femenino (79,68 %). El 100 % de los cuidadores principales residían en casa del enfermo. Prevaleció el nivel de escolaridad de técnico medio (35,93 %); 88,28 % de los cuidadores mantenían vínculo laboral, y 41,40 % eran hermanas de los enfermos. Dentro de las necesidades de aprendizaje del cuidador, el déficit de conocimientos sobre la enfermedad constituyó el 73,43 %. Conclusiones: imperó el género femenino en los cuidadores con vínculo laboral, y con mayor incidencia las hermanas. Se evidenció la complejidad del cuidado en el hogar de los pacientes con secuelas, minusvalía progresiva producidas por la enfermedad, y que generalmente la mujer asume con más facilidad (AU).

ABSTRACT Introduction: the care of the patient is carried out by a specific sequence of the family, catalogued as a main caregiver. Objective: to describe the socio-demographic characteristics in main caregivers of patients who underwent a brain cancer surgery. Materials and methods: a retrospective, descriptive study was carried out in a universe of 128 main caregivers of patients who underwent brain cancer surgery in the University Hospital Faustino Perez Hernandez, of Matanzas, from 2016 until 2018. Inclusion criteria: caregivers living in the province of Matanzas and giving the informed consent. The relatives of patients who died during the research were excluded. Interviews were made and questionnaires applied to characterize the results. They were analyzed in absolute, relative, and percentage frequencies in statistical packet Windows SPSS, 20.0. Results: female sex predominated (79.68%). 100% of main caregivers lived in the house of the patient. The technician scholarship predominated (35.93%); 88.28% of the caregivers kept their employment bonds, and 41.40% were patients' sisters. The deficit of knowledge on the disease was 73.43% of the caregiver learning necessities. Conclusions: female genre prevailed in caregivers with employment bonds, with higher incidence of sisters. It was evidenced the complexity of home care of the patients with sequels, progressive disabilities caused by the disease, generally assumed more easily by women (AU).

Reducción de la exposición en residentes de Cirugía frente al brote de COVID-19 / Reduction of exposure in residents of Surgery in face of the outbreak of COVID-19

El brote mundial de COVID-19 durante el primer trimestre de 2020 constituye un desafío sin precedentes para el sistema de salud. El objetivo es describir las estrategias adoptadas por los residentes de Cirugía General de un Hospital Universitario de la Argentina, para salvaguardar la salud de los residentes, reducir el riesgo de exposición de los pacientes quirúrgicos, mantener la formación académica continua y fomentar el trabajo en equipo. Minimizar la exposición de los residentes dividiendo el personal total en dos equipos que trabajan por quincenas; dividir las actividades, las horas dentro del hospital y los turnos por igual entre los residentes; usar telemedicina para controles posoperatorios/ ambulatorios; suspender la actividad de consultorio; organizar clases diarias en línea y revisiones de artículos publicados. En el contexto de la pandemia de COVID-19 se deben utilizar todos los medios para minimizar el riesgo de exposición para así optimizar los recursos humanos. A pesar de que estas estrategias pueden aplicarse fácilmente a otras residencias, se necesita más investigación para evaluar su impacto en la transmisión de enfermedades, y en la salud física y emocional de los profesionales de la salud.

The worldwide outbreak of COVID-19 during the first quarter of 2020 constitutes an unprecedented challenge for the health system. The aim is to describe the strategies adopted by residents of General Surgery of a university hospital of Argentina, to safeguard the health of residents, reduce the risk of exposure of surgical patients, maintain continuous academic training and promote teamwork. Minimize resident exposure by dividing the group into two teams that work by fortnights; divide activities, hours within hospital, and shifts equally among residents; use telemedicine for postoperative / ambulatory controls; suspend office activity; organize daily online classes and reviews of published articles. In the context of the COVID-19 pandemic, all means should be used to minimize the risk of exposure in order to optimize human resources. Although these strategies can easily be applied to other residencies, more research is needed to assess their impact on disease transmission, and on the physical and emotional health of health professionals.

Cambios en el Programa de Formación Quirúrgica en la era COVID-19 / Changes in the Surgical Training Program in the COVID-19 era

La aparición de esta nueva enfermedad por coronavirus 2019 (COVID-19) ha generado un gran impacto dentro de los equipos de salud, obligando a realizar cambios profundos en la actividad diaria. Estas modificaciones están orientadas a promover un ambiente de trabajo seguro para el personal médico y no médico. Sin embargo, algunos de esos cambios pueden tener consecuencias sobre el proceso de aprendizaje de los médicos en formación. El desafío que enfrenta un Servicio de Cirugía de un Hospital Universitario es mantener la continuidad de los programas formativos asegurando a la vez la seguridad de los médicos residentes. En este comunicado se describen los cambios realizados en el Programa de la Residencia de Cirugía General en un Hospital Universitario, orientados a brindar la misma calidad educativa, en un entorno seguro durante el transcurso de esta pandemia.

The appearance of this new coronavirus 2019 disease (COVID-19) has generated a great impact within health teams, forcing profound changes in the daily activity. These modifications are aimed at promoting a safe work environment for medical and non-medical personnel. However, some of these changes may have consequences on the learning process of doctors in training. The challenge faced by a Surgery Service of a University Hospital is to maintain the continuity of the training programs while ensuring the safety of Residents. This report describes the changes made to the General Surgery Residency Program at a university hospital, aimed at providing the same educational quality, in a safe environment during the course of this pandemic.

Evaluación de las habilidades no técnicas en cirugía / Assessment of non-technical skills in surgery

Resumen Tradicionalmente, se ha asociado a la falta de habilidades y competencias técnicas con los eventos adversos en el área quirúrgica. Sin embargo, se ha visto que un gran porcentaje de estos eventos se relacionan directamente con déficits en las habilidades no técnicas (HNT) del equipo quirúrgico. Por lo tanto, la evaluación de éstas se ha vuelto un tópico relevante para minimizar errores y fortalecer el desempeño en el escenario operatorio. Múltiples instrumentos han sido desarrollados con este fin, tanto para analizar el funcionamiento del equipo completo, como de cada subgrupo que lo conforma. El presente trabajo pretende resumir los principales aspectos de los distintos métodos que han sido desarrollados en los últimos años para la evaluación de HNT en el área quirúrgica.

Traditionally, the lack of skills and technical competencies has been associated with adverse events in the surgical area. However, it has been seen that a large percentage of these events are directly related to deficits in the non-technical skills (NTS) of the surgical team. Therefore, the evaluation of these has become a relevant topic to minimize errors and strengthen performance in the operating room. Multiple instruments have been developed for this purpose, both to analyze the operation of the complete equipment, and of each subgroup that comprises it. This article aims to summarize the key aspects of the methods that have been developed in recent years for the evaluation of NTS in the surgical area.

Demanda de información y conocimiento de los pacientes de su derecho a decidir o rechazar una cirugía. Experiencia en dos servicios quirúrgicos / Patients' demand for information and awareness of their right to decide on undergoing or refusing surgery. Experience in two surgical departments / Demanda de informação e de conhecimento dos pacientes sobre seu direito a decidir ou rejeitar uma cirurgia. Experiência em dois serviços cirúrgicos

El consentimiento informado como deber del médico y derecho de los pacientes está expresamente reconocido en la legislación nacional con especial énfasis a partir de la aprobación de la Ley N° 18.335 en el año 2008. Sin embargo, se han evidenciado dificultades en el proceso de información y obtención del consentimiento. Mediante un cuestionario cerrado, anónimo y autoadministrado se consultó a pacientes operados sobre qué aspectos de la información consideraban relevantes conocer y qué conocimiento tenían sobre el derecho a ser informados. Más del 80% de los entrevistados manifestó el interés en contar con información sobre alternativas terapéuticas y sobre las complicaciones más frecuentes de la intervención. Asimismo, creyeron pertinente contar con la descripción del procedimiento al que serán sometidos y las opciones de modificar el tipo de cirugía durante la operación. Menos del 10% explicitó el interés en ser informado sobre el riesgo de muerte, la posibilidad de reintervenciones y en recibir información mediante figuras e imágenes ilustrativas del procedimiento. Se destaca que nueve de cada diez entrevistados admitieron conocer su derecho a ser informados sobre diferentes aspectos del acto quirúrgico y que casi la mitad (48%) consideró que debe confiar en las decisiones del médico sin importar la cantidad de información recibida.

Informed consent as the physician´s obligation and the patient's right is expressly recognized by the national law, mainly as from 2008, when Act Number 18335 was passed. However, certain difficulties have been seen in the information process and in connection with obtaining consent. Patients who underwent surgery were consulted by means of a closed, anonymous and self-administered survey as to the specific aspects they considered relevant to know and how familiar they were with their right to be informed. Over 80% of the patients in the survey stated they were interested in learning about treatment alternatives and the most frequent complications arising from treatment. Likewise, they thought it would be appropriate to know about the procedure they would undergo and the options available to modify the kind of surgery once it had started. Under 105 of patients stated they were interested in learning about life-threatening risks, the chance of a needing to operate again and receiving information through pictures and illustrations showing the procedure. The study points out 9 out of ten patients admitted they knew about their right to be informed about different aspect of the surgery and that almost half of them (48%) stated they needed to trust the decisions made by physicians, regardless of the quality of the information received.

Ele informou o dever do médico e paciente lei consentimento é expressamente reconhecido pela legislação nacional, com ênfase especial a partir da adoção da Lei nº 18.335, em 2008. No entanto, eles têm demonstrado dificuldades no processo de informação e obter consentimento. Através de um questionário fechado, anônimo e autoadministrado, os pacientes operavam quais aspectos da informação que consideravam relevantes para conhecer e quais os conhecimentos que tinham sobre o direito de serem informados. Mais de 80% dos entrevistados manifestaram interesse em ter informações sobre alternativas terapêuticas e sobre as complicações mais frequentes da intervenção. Da mesma forma, consideraram pertinente a descrição do procedimento a que serão submetidas e as opções para modificar o tipo de cirurgia durante a operação. Menos de 10% manifestaram interesse em ser informado sobre o risco de morte, possibilidade de reintervenções e recebimento de informações através de figuras e imagens que ilustram o procedimento. Ele destaca que nove em cada dez inquiridos admitiram a conhecer o seu direito de ser informado sobre os diferentes aspectos da cirurgia e quase metade (48%) considerou deve confiar nas decisões do médico, independentemente da quantidade de informações recebidas.

The critical view of safety prevents the appearance of biliary injuries? analysis of a survey / Visão crítica de segurança previne lesões biliares? análise de um levantamento

ABSTRACT Background: The risk of bile duct injury (BDI) during cholecystectomy remains a concern, despite efforts proposed for increasing safety. The Critical View of Safety (CVS) has been adopted promoting to reduce its risk. Aim: To perform a survey to assess the awareness of the CVS, estimating the proportion of surgeons that correctly identified its elements and its relationship with BDI. Methods: An anonymous online survey was sent to 2096 surgeons inquiring on their common practices during cholecystectomy and their knowledge of the CVS. Results: A total of 446 surgeons responded the survey (21%). The percentage of surgeons that correctly identified the elements of CVS was 21.8% and 24.8% among surgeons claiming to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS (p=0.03). In the multivariate analysis, career length was the most significant factor related to BDI (p=0.002). Conclusions: The percentage of surgeons that correctly identified the Critical View of Safety was low, even among those who claimed to know the CVS. The percentage of surgeons that reported BDI was higher among those that incorrectly identified the elements of the CVS.

RESUMO Racional: O risco de lesão do ducto biliar (BDI) durante a colecistectomia continua a ser preocupante, apesar dos esforços propostos para aumentar a segurança. A Visão Crítica da Segurança (CVS) foi adotada e proposta para redução de seu risco. Objetivo: Realizar levantamento para avaliar a conscientização da CVS, e estimando a proporção de cirurgiões que identificaram corretamente seus elementos e sua relação com BDI. Métodos: Pesquisa online anônima foi enviada para 2096 cirurgiões perguntando sobre suas práticas comuns durante a colecistectomia e seu conhecimento da CVS. Resultados: Um total de 446 cirurgiões responderam a pesquisa (21%). A porcentagem que identificou corretamente os elementos da CVS foi de 21,8% e 24,8% entre os cirurgiões que afirmam conhecê-la. A porcentagem dos que relataram BDI foi maior entre os que incorretamente identificaram os elementos da CVS (p=0,03). Na análise multivariada, o tempo na carreira foi o fator mais significativo relacionado à BDI (p=0,002). Conclusões: A porcentagem de cirurgiões que identificaram corretamente a CVS foi baixa, mesmo entre aqueles que alegaram conhecê-la. A porcentagem de cirurgiões que relataram BDI foi maior entre aqueles que incorretamente identificaram os elementos da CVS.

Seguridad en cirugía mayor. Experiencia de cinco años / Safety in major surgery. Five-year experience

Introducción: los errores en cirugía existen desde que el hombre mismo se atrevió a violar la integridad del cuerpo humano buscando resolver un problema de salud. La Organización de la Salud, en el 2008 lanza el programa "Cirugías Seguras", pues ha calculado que se realizan 234 millones de cirugías mayores al año y se producen alrededor de un millón de muertes relacionadas con procedimientos quirúrgicos mayores. Objetivo: determinar la seguridad en las cirugías mayores. Material y Métodos: se realizó un estudio observacional descriptivo y retrospectivo analizando los resultados de las cirugías mayores en el servicio de cirugía general del Hospital Militar Docente "Dr. Mario Muñoz Monroy" de Matanzas, en el periodo comprendido de enero del 2011 a diciembre del 2015. Resultados: se realizó un total de 7366 cirugías mayores, electivas 5525(75%), urgentes 1841(25%). Fueron clasificadas como A1 7264 (98,6%), se efectuaron 127 reintervenciones (1,7%), se produjeron 107 eventos adversos (1,4%) y una mortalidad operatoria de 86 pacientes (1,16%). Conclusiones: son seguras las intervenciones de cirugías mayores. Los eventos adversos se presentaron por debajo de lo reportado en la literatura médica mundial. La mortalidad operatoria está dentro de parámetros aceptados en estándares internacionales (AU).

Introduction: mistakes in surgery are committed since the moment the man had the courage of violating the integrity of the human body looking for solving a health problem. The World Health Organization started the program Cirugías seguras (Safe Surgeries in English) in 2008, because they calculated that 234 millions of major surgeries are done and around a million of deaths are related with major surgical procedures every year. Aim: to determine the safety of the major surgeries. Materials and Methods: an observational, descriptive and retrospective study was carried out analyzing the results of the major surgeries in the Teaching Military Hospital "Dr. Mario Muñoz Monroy" of Matanzas in the period from January 2011 to December 2015. Results: a total of 7 366 major surgeries were done: 5 525 elective surgeries (75 %) and 1 841 emergency surgeries (25 %). 7 264 were classified as A1 (98,6); 127 surgical re-interventions were done (1,7 %); 107 adverse events took place (1,4 %) and the surgical mortality was 86 patients (1,16 %). Conclusions: major surgical interventions are safe. The adverse events were less than data reported in the international medical literature. Surgical mortality fulfills the parameters accepted in international standards (AU).

Evaluation of adherence to measures for the prevention of surgical site infections by the surgical team / Evaluación de la adhesión a las medidas para la prevención de infecciones del sitio quirúrgico por el equipo quirúrgico / Avaliação da adesão às medidas para a prevenção de infecções do sítio cirúrgico pela equipe cirúrgica

AbstractOBJECTIVEEvaluate pre- and intraoperative practices adopted by medical and nursing teams for the prevention of surgical infections.METHODA prospective study carried out in the period of April to May 2013, in a surgical center of a university hospital in Belo Horizonte, Minas Gerais.RESULTS18 surgeries were followed and 214 surgical gloves were analyzed, of which 23 (10.7%) had postoperative glove perforation detected, with 52.2% being perceived by users. Hair removal was performed on 27.7% of patients in the operating room, with the use of blades in 80% of the cases. Antibiotic prophylaxis was administered to 81.8% of patients up to 60 minutes prior to surgical incision. An average of nine professionals were present during surgery and the surgery room door remained open in 94.4% of the procedures.CONCLUSIONPartial adhesion to the recommended measures was identified, reaffirming a need for greater attention to these critical steps/actions in order to prevent surgical site infection.

ResumenOBJETIVOEvaluar las prácticas pre e intraoperatorias adoptadas por los equipos médicos y de enfermería con vistas a la prevención de infecciones quirúrgicas.MÉTODOEstudio prospectivo llevado a cabo en el período de abril a mayo de 2013, en un quirófano de un hospital universitario de Belo Horizonte, Minas Gerais.RESULTADOSFueron acompañadas 18 cirugías y analizados 214 guantes, de los que 23 (10,7%) tuvieron perforación detectada post cirugía, siendo el 52,2% percibidas por los usuarios. La tricotomía se hizo en el 27,7% de los pacientes en el quirófano, empleándose láminas en el 80% de los casos. La antibioticoprofilaxia fue administrada en el 91,8% de los pacientes hasta 60 minutos previos a la incisión quirúrgica. Se verificó un promedio de nueve profesionales presentes durante la cirugía y la puerta del quirófano se mantuvo abierta en el 94,4% de los procedimientos.CONCLUSIÓNSe identificó la adhesión parcial a las medidas recomendadas, reafirmando la necesidad de mayor atención a esas etapas críticas a fin de prevenir la infección del sitio quirúrgico.

RESUMOOBJETIVOAvaliar as práticas pré e intraoperatórias adotadas pelas equipes médicas e de enfermagem visando à prevenção de infecções cirúrgicas.MÉTODOEstudo prospectivo realizado no período de abril e maio de 2013, em um centro cirúrgico de um hospital universitário de Belo Horizonte, Minas Gerais.RESULTADOSForam acompanhadas 18 cirurgias e analisadas 214 luvas das quais 23 (10,7%) tiveram perfuração detectada pós-cirurgia, sendo 52,2% percebidas pelos usuários. A tricotomia foi feita em 27,7% dos pacientes na sala de cirurgia usando-se lâminas em 80% dos casos. A antibioticoprofilaxia foi administrada em 81,8% dos pacientes até 60 minutos antes da incisão cirúrgica. Verificou-se uma média de nove profissionais presentes durante a cirurgia e a porta da sala de cirurgia se manteve aberta em 94,4% dos procedimentos.CONCLUSÃOIdentificou-se a adesão parcial às medidas recomendadas, reafirmando uma necessidade de maior atenção a estas etapas críticas com o objetivo de prevenir a infecção do sítio cirúrgico.

El ambiente quirúrgico seguro: paradigma emergente en la práctica profesional de la cirugía / The safe surgical environment: emergent paradigm in the surgical professional practice

Desde que las Guerras Mundiales que se escenificaron en el siglo XX, en los teatros operacionales del conflicto en Europa, Norte de Africa, medio oriente, Asia, I y II Guerras Mundiales, Corea, Viet Nam, Afganistán Guerra Arabe- Israelí obligó a los países involucrados a atender a los millones de víctimas resultantes, planificando, organizando y rediseñando a pasos acelerados las estructuras de asistencia médica, capaces de suministrar recursos de atención masivo del trauma y estrategias para tratar a sus soldados y a la población civil. La consecuencia positiva para el avance de la medicina y especialmente de la cirugía de estos tragicos sucesos, fue la aparición y el desarrollo de la "cirugía compleja" y la conquista del abordaje quirúrgico de regiones del cuerpo humano, hasta ese momento vedados a la actividad del tratamiento quirúrgico: cavidad craneal, cirugía torácica, trauma cardiovascular, cirugía intestinal de urgencia, anestesia y manejo respiratorio, antibióticos, derivados sanguíneos, resucitación cardio-respiratoria y evacuación y trasporte de heridos. Varias décadas después el desarrollo de esta cirugía compleja, produjo un aumento desmesurado de la morbi-mortalidad ocasionado principalmente por los efectos de la anestesia inadecuada, hemorragias masivas, infección-sepsis y factores de error humano. Surgen entonces nuevas líneas de investigación clínica para identificar y disminuir estos factores. Esos esfuerzos logran al final del siglo XX y comienzos del XXI, resultados tangibles y eficaces mejorando los resultados finales de la cirugía. Por estos logros surge un nuevo paradigma en el mundo de la cirugía, conocido como "el ambiente quirúrgico seguro"; que comprende estrategias operativas y organizacionales, tales como: reingeniería de quirófanos, innovaciones tecnológicas, digitalización de aparatos de registro y la protección integral de los equipos humanos interactuantes en los servicios quirúrgicos. En este ensayo se describen...

Since the occurrence of the World Wars in the 20th. Century, at the military operational theatres in Europe, North Africa, Meddle East, Korea, Viet nam, Afghanistan and Israel the countries involved in these conflicts were forced to render medical care to the million of casualities in thousands of battlefields, specially organizing massive trauma care to military personnel also to civilian populations. The positive result of this tragic scenarios was that medicine as a whole and surgery, was the development of the so called "complex surgical care", and the conquest of the surgical approach of different regions of the human body, until then impossible to reach with therapeutic efficacy: intracranial structures, thoracic surgery, cardio-vascular injuries, acute intestinal trauma anesthesia and respiratory ventilation, antibiotics, blood replacement, cardio pulmonary resuscitation; and triage and the planning of transport of wounded soldiers. Some decades later, the development of the complex surgery reachers alarming levels of morbidity and mortality, mainly due to inadequate delivered anasthesia, massive hemorrhage, uncontrolled bacterial infections-sepsis and lethal consequences of human errors. New lines of clinical investigations and research conducted in the late XX century and early XXI century gave the answers to obtain strategies to diminish and fight this adverse factors; improving better outcomes for surgical therapies. This achievement gave birth to a new paradigm into the surgical world which is identified nowadays as the "safe surgical environment", compromising new strategies to redesing surgical operating rooms, application of technological discoveries, digitalization of patient's surveillance and bio protection of the surgical personnel avoiding events as accidents, thermal injuries, and infections with transmissible diseases in this scenario. In this paper will be described fundamental definitions of novel paradigm, reviewing concepts...

Implementación de la Lista de verificación de seguridad quirúrgica postoperatoria en la sala general / Post-operative surgical safety checklist implementation in the surgery ward

Introducción: La iniciativa de la OMS ha demostrado que el conocimiento adecuado de los riesgos que pueden llegar a poner en peligro el bienestar y la vida del paciente pueden ser disminuidos a través de la implementación de listas de verificación durante el acto quirúrgico. Objetivos: Identificar las acciones destinadas a brindar mayor seguridad al paciente desde la implementación de listas de verificación en el período postoperatorio. Lugar de Aplicación: Hospital Aeronáutico Central. Diseño: prospectivo, observacional. Población: 200 actos quirúrgicos. Método: Se analizaron las fallas identificadas utilizando Listas de Verificación en 200 actos quirúrgicos entre Abril y Octubre de 2011. Resultados: Se identificaron 20 (57%) partes quirúrgicos incompletos o mal confeccionados, 4 (11%) pacientes con analgesia inadecuada o insuficiente, 4 (11%) con indicación postquirúrgica de oxígeno sin colocar o colocado a flujo inadecuado y 3 (8,6%) pacientes con indicación de faja corporal sin colocar o colocada de forma incorrecta. Conclusiones: La utilización de Listas de Verificación permiten reducir los riesgos y a evitar eventos adversos prevenibles. En este aspecto, es fundamental la educación continua en todas las áreas de trabajo con el fin de lograr una real política de seguridad para el paciente quirúrgico.

Introduction: WHO initiative has shown that adequate knowledge of the risks that may endanger patients’ lives and well-being is essential and they can be diminished by implementing surgical safety checklists during surgery. Objectives: Identify actions aimed at providing better patient safety through the implementation of safety checklists in the postoperative period. Place of implementation: Hospital Aeronáutico Central. Design: prospective, observational. Population: 200 surgeries. Method: Analysis of errors identified using Surgical Safety Checklists in 200 surgeries, between April and October 2011. Results: The following was identified: 20 (57%) incomplete or defective surgery reports, 4 (11%) patients with inadequate or insufficient analgesia, 4 (11%) patients with postoperative indication of oxygen therapy not administered or placed with inadequate flow, and 3 (8.6%) patients with indication to wear abdominal binder were without them or they were wrongly placed. Conclusions: The use of Safety Checklists reduces risks and prevents avoidable adverse events. In this regard, continuing education in all work areas is vital in order to achieve a real safety policy for the surgical patient.

Cantidad y calidad de la información conocida por pacientes que consintieron cirugías de coordinación / Amount and quality of information received by patients who agreed to coordinated surgeries

El consentimiento informado supone un proceso de interacción y comunicaciónen que la cantidad y la calidad de la información es determinante de su validez. La información recibida por los pacientes no siempre es decodificada, comprendida o recordada.Objetivos: 1. Conocer la información que el paciente es capaz de transmitir luego de haber consentido un procedimiento quirúrgico de coordinación categorizado como cirugía mayor o alta cirugía. 2. Determinar si los pacientes conocían el diagnóstico preoperatorio, el tratamiento quirúrgico propuesto, sus posibles complicaciones y si deseaban conocer más respecto a su enfermedad o la cirugía propuesta.Material y método: se seleccionó una muestra de conveniencia de 60 pacientes ingresados para cirugía mayor o alta que habían recibido información y aceptado el tratamiento propuesto. Se aplicó un formulario de cinco preguntas.Resultados: los seleccionados fueron 39 mujeres y 21 hombres. Edad media: 59 años y 7 meses (rango: 19-84 años). La mayoría (n=55) dijo haber sido informada de su enfermedad. En 11,la enfermedad verbalizada no coincidió con el diagnóstico. Los casos de desconocimiento de la enfermedad y de discordancia con el diagnóstico correspondieron a pacientes oncológicos.El tratamiento consentido era desconocido por 13 pacientes. La mayoría (n=33) no conocíacompletamente los riesgos del tratamiento. La mayoría dijo no querer preguntar ni saber más, pero diez pacientes deseaban hacer más preguntas. Una parte considerable de los pacientes no recibió, no recordó o no pudo verbalizar información relevante para la toma de decisiones, lo que puede explicarse por mala cantidad y/o calidad de la información, o por factores dependientes del paciente, como la negación frente a la angustia generada por la enfermedad y su pronóstico... El desconocimiento del tratamiento no es justificable y entraña un problema ético.

Informed consent implies an interaction and communication process whereby the amount and quality of the information provided is essential for it to be valid.The information received by patients is not always appropriately decoded, understood or remembered. Objetives: 1. To learn about the information the patient is able to transmit once it has agreed to a coordinated surgery procedure that falls into the category of major or high surgery. 2. To determine whether patients knew the pre-surgical diagnosis, the suggested surgical treatment, the possible complications and diagnosis prior to surgery, and whether they were willing to learn more about their disease or the proposed surgery. Method: we selected a convenience sample of 60 patientswho were admitted for major or high surgery and had received information and accepted the proposed treatment.A five question form was used. Results: patients selected were 39 women and 21 men. Average age: 59 years and 7 months (19-84 years old). Most patients (n=55) stated they had been informed about their disease. In 11 cases, the disease described verbally did not coincide with the diagnosis. Cases where the disease was ignored and the diagnosis differed from the informationcorresponded to oncologic patients.In cases where consent to treatment had already been given, treatment was unknown to 13 patients. Most patients(n=33) were not fully aware of the treatmentÆs risks. Most patients stated they were not interested in askingmore questions or learning more, although ten wished to ask questions.A significant number of patients did notreceive or was unable to remember or verbally express information for the making of decisions, what could haveresulted from the scarce and/or low quality information or from factors that depend on the patient û such as refusalupon anguish generated by the disease and its prognosis...Ignorance of treatment cannot be justified and it implies an ethical problem.

O consentimento informado pressupõe um processo de interação e comunicação cuja validez é determinadapela qualidade e a quantidade de informação prestada ao paciente. Muitas vezes essa informação não édecodificada, compreendida ou lembrada adequadamente. Objetivos: 1. Conhecer a informação que o paciente écapaz de transmitir depois de ter dado consentimento a um procedimento cirúrgico considerado como cirurgia degrande porte ou de alta complexidade. 2. Determinar se os pacientes conheciam o diagnóstico pré-operatório e o tratamento cirúrgico proposto, e se queriam saber mais sobre sua patologia ou a cirurgia proposta. Material e método: um formulário com 5 perguntas foi respondido por uma amostra de 60 pacientes internados para cirurgia de grande porte ou de alta complexidade que haviam recebido informação e aceitado o tratamento proposto.Resultados: foram selecionadas 39 mulheres e 21 homens, com uma media de idade de 59 anos e 7 meses(intervalo: 19-84 anos). A maioria (n=55) declarou que havia recebido informação sobre sua doença. Em 11 casos a doença verbalizada pelo paciente não coincidia com o diagnóstico.Os casos em que o paciente não sabia qual era a doença ou esta não coincidia com o diagnóstico médico eram de pacientes oncológicos. Treze pacientes não conheciam o tratamento para os quais haviam dado consentimento, e a maioria (n=33) não conhecia todos osriscos do tratamento. A maior parte dos pacientes declarou não querer fazer perguntas nem receber mais informaçãoporém dez pacientes declararam desejar fazer mais perguntas. Uma parte considerável dos pacientes nãorecebeu, não lembrava ou não pode verbalizar informação relevante para a tomada de decisão, o que pode ser explicado pela má qualidade/quantidade da informação recebida ou por fatores dependentes do paciente como anegação devida a angustia gerada pela doença e seu prognóstico... Odesconhecimento do tratamento não é justificável já que isso implica um problema ético.

Treinar cirurgiões: hoje como sempre? / Surgions train: always like today?

Este artigo pretende discutir a metodologia de treinamento dos novos cirurgiões, considerando a realidade do momento atual e propondo uma reflexão orientada baseada em evidências a respeito das expectativas dos cirurgiões jovens e da realidade do mercado de trabalho em cirurgia. As descobertas cientificas e tecnológicas, o grande volume de informação imposto rotineiramente e as expectativas de administração logistica e de custos modificaram de forma radical a atividade do cirurgião com relação aos cirurgiões formados nas concepções clássicas. Há um reposicionamento da autoridade do médico frente ao paciente e à sociedade. A cultura contemporânea leva os jovens a ter expectativas próprias quanto à própria qualidade de vida e perspectivas profissionais. Tornou-se necessário modificar os padrões de treinamento dos cirurgiões para que se adeqüem à necessidade de aprendizado contínuo e adaptação a novos instrumentos tecnológicos e para que estejam aptos a uma interação social adequada à expectativa atual quanto à relação médico-paciente e entre profissionais de saúde. Estas adaptações estruturais são fundamentais para manter o interesse dos profissionais jovens em cirurgia.

This paper proposes to discuss the training methodologies for young surgeons, considering the modern needs, by discussing their expectations and the reality of the surgeons' job market nowadays. Scientific and technological novelties, the huge amount of information imposed daily, managerial interventions and cost issues modified radically the activities of the surgeons, especially if compared to classical conceptions. Recent re-readings of the classical ethical postulates demand a new behavior of the doctors concerning the patients and the society per se. Contemporaneous social culture bring about individual expectations concerning quality of life and professional perspective issues. It becomes necessary to modify the training methods for surgeons to make them adequate to the need of continuous learning and adaptation to new technological instruments. They also should adapt to social interactions with the patients and the other health professionals that fit nowadays expectations. Those structural adaptations are fundamental to maintain the interest of the new professionals in the area of surgery.

Auditoria médica al comité de evaluación de intervenciones quirúrgicas / Medical auditing to the evaluation committee of surgical interventions

Los procesos de evaluación son una actividad fundamental dentro del desarrollo del conocimiento. Éstas nos permiten, por una parte, pesquisar errores y corregirlos y, por otra, detectar conductas acertadas y reforzarlas. Nuestro objetivo fue determinar la calidad del trabajo del comité de intervenciones quirúrgicas en el servicio de cirugía general del Hospital Militar Docente Dr. Mario Muñoz Monroy,en el período de estudio: enero del 2004 a diciembre del 2007.

The processes of evaluation are a main activity in developing knowledge. They allow us, on the one hand, finding mistakes and correcting them, and on the other hand, detecting right behaviors and reinforcing them. Our objective was determining the works quality of the evaluation committee of surgical interventions in the general surgery service of the Teaching Military Hospital Dr. Mario Muñoz Monroy, during the studied period: January 2004 – December 2007.