Lessons Learned: Large-Scale Perfused Cadaver Training in Three Different Curricular Environments.

BACKGROUND: Perfused cadavers are viable training models for operating room surgical skills, increasing fidelity of vascular anatomy, dissection, and tissue handling. In addition, perfused cadavers may have benefits in military medical training environments with a focus on hemorrhage control and vascular access. OBJECTIVES: We created a large-scale training exercise with perfused cadavers in three different environments and aim to share the curricular design and feedback from the exercise. METHODS: We conducted a 4-day simulation training exercise with 13 perfused cadavers in 3 different environments: hospital environment, the austere echelons of care environment, and a controlled-settings tent for hemorrhage control and needle decompression training. Through an anonymous online survey and an after-action review (AAR), we elicited feedback on advantages, disadvantages, costs, and comparison to models of porcine and fresh cadavers for procedures and existing courses. RESULTS: A total of 324 participants were trained with 13 perfused cadavers for over 4 days from a variety of specialties and on different procedures and surgical skills. Based on 130 respondents to the survey and the AAR, perfused cadavers were rated to have realistic arterial bleeding and bleeding control training. In addition, perfused cadavers provided increased realism and fidelity for surgical skills. There were disadvantages of logistical requirements, cleanup, costs, and mobility. CONCLUSION: Perfused cadavers can be implemented effectively for hemorrhage control training, surgical and procedure skills, and even exercises in austere environments, but require significant logistical and planning considerations. The training value is maximized with a progressive curriculum from hemorrhage control iterations to more invasive surgical procedures, such as thoracotomy and exploratory laparotomy.

Wound Complications Are Affected by Different Skin Closure Methods in Primary Hip and Knee Arthroplasty.

BACKGROUND: There is a lack of consensus on optimal skin closure and dressing strategies to reduce early wound complication rates after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: All 13,271 patients at low risk for wound complications undergoing primary, unilateral THA (7,816), and TKA (5,455) for idiopathic osteoarthritis at our institution between August 2016 and July 2021 were identified. Skin closure, dressing type, and postoperative events related to wound complications were recorded during the first 30 postoperative days. RESULTS: The need for unscheduled office visits to address wound complications was more frequent after TKA than THA (2.74 versus 1.78%, P < .001), and after direct anterior versus posterior approach THA (2.94 versus 1.39%, P < .001). Patients who developed a wound complication, had a mean of 2.9 additional office visits. Compared to the use of topical adhesives, skin closure with staples had the highest risk of wound complications (odds ratio 1.8 [1.07-3.11], P = .028). Topical adhesives with polyester mesh had higher rates of allergic contact dermatitis than topical adhesives without mesh (1.4 versus 0.5%, P < .0001). CONCLUSION: Wound complications after primary THA and TKA were often self-limited but increased burden on the patient, surgeon, and care team. These data, which suggest different rates of certain complications with different skin closure strategies, can inform a surgeon on optimal closure methods in their practice. Adoption of the skin closure technique with the lowest risk of complications in our hospital would conservatively result in a reduction of 95 unscheduled office visits and save a projected $585,678 annually.

Post-return of spontaneous circulation (ROSC) Accelerated Idioventricular Rhythm in the Setting of Severe Pancreatitis and Hyperkalemia.

A 73-year-old female with a history of coronary artery disease, hypertension, and diabetes presented to the emergency department in cardiac arrest. After cardiopulmonary resuscitation (CPR) and return of spontaneous circulation (ROSC), a post-ROSC electrocardiogram demonstrated Accelerated Idioventricular Rhythm (AIVR). The patient was found to have hyperkalemia due to anuric acute renal failure and antecedent severe pancreatitis. After medical management and dialysis, the patient recovered with good neurological recovery. AIVR traditionally has been seen or documented as occurring after ischemia and subsequent coronary artery reperfusion. However, etiologies that promote ventricular automaticity must be considered as well. Electrolyte disturbances, drug toxicities such as digoxin, volatile anesthetics, cardiomyopathies, and ischemia can lead to AIVR. Treatment involves considering and correcting any underlying etiology with avoidance of antiarrhythmics, which may precipitate hemodynamic instability and asystole.

COVID-19 Antibody Prevalence From July to September 2020: One Army Infantry Brigade's Experience.

OBJECTIVES: Lab companies developed serology tests for antibody detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with United States Food and Drug Administration (FDA) emergency use authorization. Antibody detection uses purified proteins of SARS-CoV-2 to determine antibody binding via enzyme-linked immunosorbent assay, chemiluminescent immunoassay (CLIA), or colloidal gold-based immunochromatographic assay. With the advent of coronavirus disease 2019 (COVID-19), nucleic acid amplification technology (NAAT) SARS-CoV-2 testing for active infection was not widely available to healthy, active-duty Soldiers. The purpose of this surveillance survey was to determine the prevalence of prior SARS-CoV-2 infection and symptoms of COVID-19 within a mechanized infantry brigade. MATERIALS AND METHODS: Active-duty military Servicemembers (= 18 years) from a mechanized infantry brigade provided serum samples for testing for the Elecsys® Anti-SARS-CoV-2 qualitative antibody test from June to September 2020 at Joint Base Lewis McChord (JBLM). In addition, participants filled out a questionnaire for symptoms and exposure to COVID-19 from January to September 2020. The surveillance team collected and analyzed antibody testing results and questionnaires from participants for antibody positivity rates and symptom prevalence. RESULTS: A total of 264 participants were tested, with one (0.4%) participant testing positive for the SARS-CoV-2 antibody. On the questionnaire, 144 of 264 (54.5%) endorsed symptoms of COVID-19 from January to September 2020. The most common symptoms were headache (35%), rhinorrhea (34%), cough (35%), and sore throat (31%). A total of 31 respondents (12%) had been quarantined as a trace contact to a COVID-19 positive patient. CONCLUSIONS: While there are limitations inherent to SARS-CoV-2 antibody testing and the survey, prevalence of prior SARS-CoV-2 infection is low. In this sample, symptoms for COVID-19 were prevalent with significant days of duty lost. Prevalence of prior SARS-CoV-2 infection in this sample may be generalizable to the larger brigade. Prevalence of symptoms of possible COVID-19 are not generalizable to the larger brigade. There is utility to further studies of SARS-CoV-2 antibody prevalence in military populations for purposes of vaccination triaging and deployment readiness.

Comparison of Intubation Using Personal Protective Equipment and Standard Uniform in Simulated Cadaveric Models.

Introduction: The use of personal protection equipment (PPE) for patient care can have an impact on the delivery of effective patient care. The purpose of this study is to examine the effects of basic PPE on intubation times and corresponding success rates in cadaver models. Methods: A prospective crossover design using a single cohort of emergency medicine residents was used for this study. The primary objective is to compare time with intubation in standard uniform (e.g., scrubs without PPE) and using PPE. The secondary objectives are measuring success rates of intubation and the perceived difficulty of intubation when using PPE. Results: The mean time to intubation in the standard uniform group was 18.85 s, whereas the mean time to intubation in the PPE group was 19.29. The overall success rate in the standard uniform group was 83% compared with the PPE group, which was 72%. The perceived difficulty was higher in the PPE group (3.38) when compared with the standard uniform. Conclusion: Although the mean intubation times between the groups were not significantly different, the overall success rate was significantly higher in the standard uniform group when compared with PPE group. The perceived difficulty rating was also noted to be significantly higher in the PPE group when compared with the standard uniform group.

Pacing-induced Cardiomyopathy.

We present a case of pacing-induced cardiomyopathy. The patient presented with clinical symptoms of dyspnea, leg swelling, and orthopnea several months after a dual-chambered pacemaker was placed for third-degree heart block. The echocardiogram demonstrated a depressed ejection fraction. Coronary angiography was performed, which showed widely patent vessels. Single- and dual-chambered pacemakers create ventricular dyssynchrony, which in turn can cause structural, molecular changes leading to cardiomyopathy. With early intervention of biventricular pacemaker replacement, these changes can be reversible; thus, a timely diagnosis and awareness is warranted.