A Novel Paradigm for Surgical Skills Training and Assessment of Competency.

Importance: Sustainment of comprehensive procedural skills in trauma surgery is a particular problem for surgeons in rural, global, and combat settings. Trauma care often requires open surgical procedures for low-frequency/high-risk injuries at a time when open surgical experience is declining in general and trauma surgery training. Objective: To determine whether general surgeons participating in a 2-day standardized trauma skills course demonstrate measurable improvement in accuracy and independent performance of specific trauma skills. Design, Setting, and Participants: General surgeons in active surgical practice were enrolled from a simulation center with anatomic laboratory from October 2019 to October 2020. Differences in pretraining/training and posttraining performance outcomes were examined using (1) pretraining/posttraining surveys, (2) pretraining/posttraining knowledge assessment, and (3) training/posttraining faculty assessment. Analysis took place in November 2020. Interventions: A 2-day standardized, immersive, cadaver-based skills course, developed with best practices in instructional design, that teaches and assesses 24 trauma surgical procedures was used. Main Outcomes and Measures: Trauma surgery capability, as measured by confidence, knowledge, abilities, and independent performance of specific trauma surgical procedures; 3-month posttraining skill transfer. Results: The study cohort included 65 active-duty general surgeons, of which 16 (25%) were women and 49 (75%) were men. The mean (SD) age was 38.5 (4.2) years. Before and during training, 1 of 65 participants (1%) were able to accurately perform all 24 procedures without guidance. After course training, 64 participants (99%) met the benchmark performance requirements for the 24 trauma procedures, and 51 (78%) were able to perform them without guidance. Procedural confidence and knowledge increased significantly from before to after the course. At 3 months after training, 37 participants (56%) reported skill transfer to trauma or other procedures. Conclusions and Relevance: In this study, direct measurement of procedural performance following standardized training demonstrated significant improvement in skill performance in a broad array of trauma procedures. This model may be useful for assessment of procedural competence in other specialties.

The Joint Counterterrorism Awareness Workshop Series (JCTAWS): Integrating disciplines for enhanced capabilities during a complex coordinated attack.

Evolving threats, such as Complex Coordinated Terrorist Attacks (CCTAs) and other High-Threat Active Violence Incidents, require a comprehensive "Whole of Community" approach to enhance readiness within the emergency management mission. Engaging all community stakeholders, inclusive of the private sector, public safety organizations, and the health and healthcare communities, is essential for risk reduction by preventing and limiting consequences from such critical incidents. The Joint Counterterrorism Awareness Workshop Series (JCTAWS) is a unique interdisciplinary table-top exercise sponsored by the Department of Homeland Security/Federal Emergency Management Agency, Federal Bureau of Investigation, and National Counterterrorism Center, and is designed to test plans and capabilities surrounding a CCTA. JCTAWS focuses on response integration between and across disciplines and jurisdictions. The workshop stimulates participant identification of best practices and gaps so that plans can be refined and resources realigned to improve response coordination for CCTAs.

Perceptions of Simulator- and Live Tissue-Based Combat Casualty Care Training of Senior Special Operations Medics.

The relative effectiveness of live tissue (LT)- and inanimate simulation (SIM)-based training of combat medics is the subject of intense debate. A structured interview was utilized to determine the training modality preferences and the perceived value of LT- and SIM-based combat casualty care training of 25 senior special operations medics. Participant demographics and training experience, Likert scale-based assessment of training modality value, selection of preferred training modality for 11 combat casualty care procedures, and 12 open-ended questions probing opinions of the limitations and benefits of LT- and SIM-based training were collected from this convenience sample. All participants indicated significant combat medic experience and training. Of the 11 procedures questioned, LT was identified as superior for seven with mixed responses for the remaining four. LT was consistently identified as an essential training modality with tactile sensation and the physiologic responses of animal models to injury and therapy as primary benefits. Across procedures, 100% of participants felt that LT should be used in combat casualty care training and 96% felt that SIM should also be utilized. Repeatability and accuracy of size/weight were identified as key benefits of SIM training. Respondents reported that capability, self-confidence, success, and resilience of the combat medic all benefitted from LT training. The overriding theme was the general superiority of LT with recognition of the unique and complementary benefits of SIM.

Live tissue versus simulation training for emergency procedures: Is simulation ready to replace live tissue?

BACKGROUND: Training of emergency procedures is challenging and application is not routine in all health care settings. The debate over simulation as an alternative to live tissue training continues with legislation before Congress to banish live tissue training in the Department of Defense. Little evidence exists to objectify best practice. We sought to evaluate live tissue and simulation-based training practices in 12 life-saving emergency procedures. METHODS: In the study, 742 subjects were randomized to live tissue or simulation-training. Assessments of self-efficacy, cognitive knowledge, and psychomotor performance were completed pre- and post-training. Affective response to training was assessed through electrodermal activity. Subject matter experts gap analysis of live tissue versus simulation completed the data set. RESULTS: Subjects demonstrated pre- to post-training gains in self-efficacy, cognitive knowledge, psychomotor performance, and affective response regardless of training modality (P < .01 each). With the exception of fluid resuscitation in the psychomotor performance domain, no statistically significant differences were observed based on training modality in the overall group. Risk estimates on the least pretest performance subgroup favored simulation in 7 procedures. Affective response was greatest in live tissue training (P < .01) and varied by species and model. Subject matter experts noted significant value in live tissue in 7 procedures. Gap analysis noted shortcomings in all models and synergy between models. CONCLUSION: Although simulation has made significant gains, no single modality can be identified definitively as superior. Wholesale abandonment of live tissue training is not warranted. We maintain that combined live tissue and simulation-based training add value and should be continued. Congressional mandates may accelerate simulation development and improve performance.

Expected and Unexpected Consequences of the Affordable Care Act: The Impact on Patients and Surgeons-Pro and Con Arguments.

The Patient Protection and Affordable Care Act (PPACA), called the Affordable Care Act (ACA) or "ObamaCare" for short, was enacted in 2010. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract (SSAT) hosted a debate with an expert panel to discuss the ACA and its impact on surgical care after the first year of patient enrollment. The purpose of this debate was to focus on the impact of ACA on the public and surgeons. At the core of the ACA are insurance industry reforms and expanded coverage, with a goal of improved clinical outcomes and reduced costs of care. We have observed supportive and opposing views on ACA. Nonetheless, we will witness major shifts in health care delivery as well as restructuring of our relationship with payers, institutions, and patients. With the rapidly changing health care landscape, surgeons will become key members of health systems and will likely need to lead transition from solo-practice to integrated care systems. The full effects of the ACA remain unrealized, but its implementation has begun to change the map of the American health care system and will surely impact the practice of surgery. Herein, we provide a synopsis of the "pro" and "con" arguments for the expected and unexpected consequences of the ACA on society and surgeons.

Urotrauma: AUA guideline.

PURPOSE: The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries. MATERIALS AND METHODS: A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. RESULTS: Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries. CONCLUSIONS: Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

Feasibility of supraglottic airway use by combat lifesavers on the modern battlefield.

BACKGROUND: Airway compromise is a contributor to preventable mortality on the battlefield. Supraglottic airway devices are an accepted intervention for these casualties. Combat Medics, civilian prehospital care providers, and lay civilians have demonstrated proficiency with supraglottic airways. However, the Combat Lifesaver (CLS) course includes no instruction on their use. OBJECTIVE: The purpose of this study was to assess feasibility of instructing CLS students to use a supraglottic airway (the King LT-D); compare their timed performance with that of Special Operations Combat Medics (SOCM); and assess their confidence utilizing the device. METHODS: After standardized instruction, students were timed and evaluated in the placement of a King LT-D in a manikin. Student confidence was assessed by Likert-scaled surveys, and free response remarks collected before and after training. RESULTS: 27 of 28 CLS students successfully used a King LT-D airway device in under 60 seconds following brief instruction. Placement times were not significantly different from those of SOCM. Self-rated confidence scores improved from an initial 1.4/5 to 4.9/5 following manikin trials. Both CLS and SOCM recommended the airway for future battlefield CLS use. CONCLUSIONS: CLS students are capable and confident in the use of a supraglottic airway device after only brief instruction.

Self-rated readiness for performance of needle decompression in combat lifesaver training.

BACKGROUND: The Combat Lifesaver course taught to nonmedical personnel includes instruction on performing needle thoracostomy to decompress tension pneumothorax, the second leading cause of preventable combat death. Although the Tactical Combat Casualty Care curriculum is pushed to the lowest level of battlefield first responders, the instruction of this advanced procedure is routinely limited to a verbal block of instruction with a standardized presentation. OBJECTIVE: The purpose of this study was to assess the confidence of nonmedical personnel in their preparation to perform a needle thoracostomy before Combat Lifesaver training, after verbal instruction on the procedure, manikin training, and practice on a human cadaver. METHODS: Confidence was assessed by Likert scale surveys, as well as free response remarks collected before and after training. RESULTS: Self-rated preparedness scores improved significantly with each level of training. Maximal improvements followed cadaver training, from a mean score of 2.31/5 before instruction to 4.75/5 following cadaver training (matched pairs t test: p < 0.005). CONCLUSIONS: Cadaver training provided the largest single educational confidence boost for needle decompression skills, and is an effective method of enhancing confidence in needle decompression.

All-terrain vehicle safety in Florida: is legislation really the answer?

Florida is among the nation's leaders in all-terrain vehicle (ATV)-related injuries and fatalities. We hypothesized that patients sustaining injuries while in compliance with ATV laws would demonstrate less severe injury patterns and improved outcomes when compared with noncompliant patients. We reviewed patients treated for ATV-related injuries over a 36-month period. We grouped patients according to conformity with Florida statutes and compared demographics, admission status, injuries sustained, and outcome measures. Three hundred seventy-seven patients were treated for ATV-related injuries. In 294 cases, sufficient data existed to assess compliance with Florida's statutes regarding ATV rider safety: safety helmet use for persons younger than age 16 years and prohibition of ATV operation on roadways. Forty-three per cent (n = 126) had violated one or both statutes; 57 per cent (n = 168) had violated neither. The group in violation was younger (15 vs 24 years, P < 0.001) and wore helmets less often (6 vs 34%, P < 0.001). Groups required admission at similar rates (62% violators vs 60% nonviolators, P = 0.770), showed similar injury patterns, and had comparable mortality rates (2% violators vs 5% nonviolators, P = 0.451). Current Florida laws are inadequate to prevent ATV-related injuries and their sequelae. This issue should be addressed through an increased focus on safety education for ATV operators.

Disaster triage systems for large-scale catastrophic events.

Large-scale catastrophic events typically result in a scarcity of essential medical resources and accordingly necessitate the implementation of triage management policies to minimize preventable morbidity and mortality. Accomplishing this goal requires a reconceptualization of triage as a population-based systemic process that integrates care at all points of interaction between patients and the health care system. This system identifies at minimum 4 orders of contact: first order, the community; second order, prehospital; third order, facility; and fourth order, regional level. Adopting this approach will ensure that disaster response activities will occur in a comprehensive fashion that minimizes the patient care burden at each subsequent order of intervention and reduces the overall need to ration care. The seamless integration of all orders of intervention within this systems-based model of disaster-specific triage, coordinated through health emergency operations centers, can ensure that disaster response measures are undertaken in a manner that is effective, just, and equitable.