Experiences of medical practitioners in the Australian Defence Force on live tissue trauma training.

INTRODUCTION: Care of battle casualties is a central role of military medical practitioners. Historically, certain trauma procedural skills have been learnt through live tissue training. However, faced with opposition from community members and academics, who argue equivalence of non-animal alternatives, this is now being phased out. This study explores Australian military medical practitioners' experiences of and attitudes towards live tissue training. METHOD: We performed a phenomenologically driven qualitative exploration of individuals' experiences of live tissue trauma training. 32 medical officers volunteered for the study. In-depth interviews were conducted with 15 practitioners (60% Army, 20% Air Force, 20% Navy; 33% surgical, 53% critical care, 13% general practice). Qualitative data were subjected to content analysis, with key themes identified using manual and computer-assisted coding. RESULTS: Live tissue training was valued by military medical practitioners, particularly because of the realistic feel of tissues and physiological responsiveness to treatment. Learner-perceived value of live tissue training was higher for complex skills and those requiring delicate tissue handling. 100% of surgeons and critical care doctors regarded live tissue as the only suitable model for learning repair of penetrating cardiac injury. Live tissue training was felt to enhance self-efficacy, particularly for rarely applied skills. Though conscious of the social and ethical context of live tissue training, >90% of participants reported positive emotional responses to live tissue training. CONCLUSION: In contrast to published research, live tissue training was thought by participants to possess characteristics that are not yet replicable using alternative learning aids. The experienced positive values of live tissue training should inform the decision to move towards non-animal alternatives.

Perioperative outcomes in intermediate and high-risk patients after major surgery following introduction of a dedicated perioperative medicine team: A single centre cohort study.

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital.Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77-279) h.Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today's surgical patients.

The rise and falls of electronic scooters: A Tasmanian perspective on electronic scooter injuries.

OBJECTIVE: Electronic scooter (eScooter) popularity has soared, despite public concerns around injury risk. We aimed to explore the burden of injury from eScooters presenting to Tasmania's major trauma centre during the first 6 months of the Hobart eScooter trial. METHODS: We screened all ED presentations and interhospital transfers from 11 December 2021 to 26 June 2022 to identify eScooter-associated injury. All injuries were coded using the Abbreviated Injury Scale and an Injury Severity Score (ISS) was computed for each presentation. Data were entered into the Tasmanian Trauma Registry and then exported into standard statistical software for descriptive analysis. RESULTS: There were 135 eScooter presentations to the ED and 31 were admitted. Patients were mostly young (median age 27 years) with an even sex distribution. Injuries were mostly minor (median ISS of 2) with injuries to soft tissues and the head and neck predominating. Approximately, one-third required operative interventions, but none required intensive care. Injured patients were less likely to have been wearing protective gear (36% helmet wearing) and alcohol intoxication was common (41% overall, 71% admitted patients). CONCLUSION: Overall, our 6-month prospective dataset shows that the Hobart eScooter trial has been associated with few major injuries.

Learning from the first 12 months of the Tasmanian Trauma Registry.

The Tasmanian Trauma Registry began collecting data in April 2020 and in April 2021 the first 12 months' data were submitted to the Australia New Zealand Trauma Registry. In this perspective, we share the lessons we have learned in establishing a trauma registry and acknowledge how important support from the broader trauma community has been in allowing Tasmania to participate in national benchmarking and quality assurance processes.

Working Relationally with Adolescents Who Have Experienced Complex Interpersonal Trauma: an Interpretative Phenomenological Analysis.

The study explores practitioners' experiences of working with adolescents with complex interpersonal trauma. Five mental health professionals were recruited via purposive and snowball sampling. Semi-structured interviews were conducted, audio-recorded and transcribed. Interpretative phenomenological analysis was employed to identify themes related to the research question. Three superordinate themes emerged: "The distance-relationship dynamic"; "The unknown self"; "Practitioners' presence". Participants reported the fragility of their relationships with clients, enhanced awareness of their professional and personal identity, and highlighted the importance of meeting their clients as persons. Results are discussed within the literature that considers the role of the person of the therapist to foster therapeutic change. Future research could explore the role of therapeutic distance, the interplay between transference-countertransference and attachment dynamics, and the relevance of practitioners' playfulness with traumatised youth. Finally, this study proposes a model of use of self as "compassion-in-action" to express practitioners' 'response-ability' to their clients' trauma as commitment to social justice.

Compassion and complex interpersonal trauma in adolescence: An early systematic review.

BACKGROUND: Whilst childhood trauma has been identified as a transdiagnostic risk factor for poly-psychopathology, compassion-focused interventions have emerged as transdiagnostic treatment modality. However, no previous systematic review has specifically explored the relationship between complex interpersonal trauma and compassion in adolescence. The aim of this early systematic review was to evaluate the existing evidence on the role of compassion in adolescents with complex interpersonal trauma. METHODS: A systematic search of electronic databases was undertaken to identify cross-sectional and intervention studies that examined the role of compassion in the amelioration of psychopathology in adolescence. RESULTS: Nine studies, including three intervention studies and six cross-sectional studies, met the inclusion criteria. The findings suggested a mediating role of compassion in trauma-specific and overall psychopathology. CONCLUSION: Despite the dearth of research, this review suggests that integrating compassion might mediate the relationship between complex trauma and psychopathology in adolescents.

Evaluating the need for an integrated geriatric service in older general surgery patients.

BACKGROUND: Despite the success of an orthogeriatric model in improving outcomes of older patients, there is a paucity of evidence in general surgical disciplines. The aim of this project was to assess the viability of acute kidney injury (AKI) as an indicator of the care of older patients admitted under general surgery. METHODS: A retrospective review of the medical records of patients aged 75 years and older admitted under general surgery between 1 July 2015 and 30 June 2018 at the Royal Hobart Hospital was conducted. Twenty randomly selected cases were reviewed by an expert panel to assess the preventability of AKI. RESULTS: Of 314 patients, the most common diagnosis was small bowel obstruction. Less than half of all patients underwent a procedural intervention. There were 32 (10%) cases of AKI; 13 (4%) had pre-hospital and 19 (6%) had inpatient. Diabetes and bowel ischaemia were over-represented in patients with an AKI, otherwise there was no significant difference between the groups. Patients with an AKI were significantly more likely to die, require an unplanned intensive care unit admission and less likely to return to their original residence. Overall, the expert panel agreed that the AKI was foreseeable and mitigable. CONCLUSION: Our patients presented with diagnoses that often did not require surgical intervention but not infrequently experienced medical complications. These patients may benefit from a shared model of care and AKI could be a useful indicator to measure the efficiency of this service.

Towards a national perioperative clinical quality registry: The diagnostic accuracy of administrative data in identifying major postoperative complications.

Accurately measuring the incidence of major postoperative complications is essential for funding and reimbursement of healthcare providers, for internal and external benchmarking of hospital performance and for valid and reliable public reporting of outcomes. Actual or surrogate outcomes data are typically obtained by one of three methods: clinical quality registries, clinical audit, or administrative data. In 2017 a perioperative registry was developed at the Alfred Hospital and mapped to administrative and clinical data. This study investigated the statistical agreement between administrative data (International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes) and clinical audit by anaesthetists in identifying major postoperative complications. The study population included 482 high-risk surgical patients referred to the Alfred Hospital anaesthesia postoperative service over two years. Clinical audit was conducted to determine the presence of major complications and these data were compared to administrative data. The main outcome was statistical agreement between the two methods, as defined by Cohen's kappa statistic. Substantial agreement was observed for five major complications, moderate agreement for three, fair agreement for six and poor agreement for two. Sensitivity and positive predictive value ranged from 0 to 100%. Specificity was above 90% for all complications. There was important variation in inter-rater agreement. For four of the five complications with substantial agreement between administrative data and clinical audit, sensitivity was only moderate (61.5%-75%). Using International Statistical Classification of Diseases and Related Health Problems (10th edition) Australian Modification codes to identify postoperative complications at our hospital has high specificity but is likely to underestimate the incidence compared to clinical audit. Further, retrospective clinical audit itself is not a highly reliable method of identifying complications. We believe a perioperative clinical quality registry is necessary to validly and reliably measure major postoperative complications in Australia for benchmarking of hospital performance and before public reporting of outcomes should be considered.

How important are Phase 1 interventions for complex interpersonal trauma? A pilot randomized control trial of a group psychoeducational intervention.

Although psychoeducational interventions are recommended as Phase 1 interventions for complex trauma, there is limited evidence on their efficacy. This pilot randomized control trial (RCT) investigated the efficacy of a pure psychoeducational intervention for complex trauma. A brief 10-session intervention was delivered to n = 44 female prisoners in a compressed format to accommodate short sentence lengths and was compared with usual care (n = 42). Results from an intent-to-treat (ITT) analysis indicated that there were no statistically significant differences between the two arms across the three assessment time points (including 1-month postintervention) for the main outcomes (Behavioural Assessment Checklist-Revised, ß = 4.60, 95% CI [-1.60, 10.88], p = .148; posttraumatic stress disorder [PTSD] Checklist, ß = -1.47, 95% CI [-4.30, 1.36], p = .303). Post hoc reliable change analyses suggested twice the number of adequate dose participants made progress in addressing PTSD symptoms compared with usual care (30.3% vs. 17.6%, OR 2.03, 95% CI [.64, 6.43]). Although further work in this area is required, initial results, overall, suggest that psychoeducational group-based treatment modalities achieve only small effect sizes in comparison with usual care.

Childhood adversity and psychosis in detained inpatients from medium to high secured units: Results from the Scottish census survey.

BACKGROUND: There is limited data available regarding the most common forms of psychiatric illness, the occurrence of childhood adversity, and the link between childhood adversity and criminal and psychiatric outcomes amongst forensic inpatients. AIMS: Using census data for all Scottish forensic inpatients, we investigated the most common primary psychiatric diagnoses in forensic settings, the occurrence of childhood adversity amongst forensic inpatients, and whether childhood adversity experiences significantly predict a range of criminal and psychiatric outcomes. METHOD: Data for the current study were drawn from 'The Scottish Forensic Network Inpatient Census' (N = 422). The Responsible Medical Officers and other members of the clinical team collected all data from official patient records. All forensic inpatients across high, medium, and low security sites were surveyed. RESULTS: The majority of patients had a psychotic disorder as their primary diagnosis (86.4%), with schizophrenia being the most common (70.0%). Childhood adversity was highly prevalent (79.2%), with physical abuse being the most common adverse experience (40.1%). Increased levels of childhood adversity were significantly associated with an increased risk of criminal convictions, self-reported abuse of animals, suicidal and self-injurious behaviour, and problematic use of drugs or alcohol. CONCLUSIONS: Considering the association between adversity and psychosis, trauma informed care is essential for the mental health and forensic needs of this population.

A systematic review and meta-analysis of group treatments for adults with symptoms associated with complex post-traumatic stress disorder.

BACKGROUND: No previous meta-analyses have specifically investigated the effectiveness of psychological group therapy for symptoms associated with complex interpersonal trauma, including whether trauma memory processing (TMP) therapies are superior to psychoeducational approaches alone. METHODS: A systematic review identified 36 randomised control trials (RCTs) which were included in the meta-analysis. RESULTS: Large significant effect sizes were evident for TMP interventions when compared to usual care for three outcome domains including: PTSD (k = 6, g = -0.98, 95% CI -1.53, -0.43), Depression (k = 7, g = -1.12, 95% CI -2.01, -0.23) and Psychological Distress (k = 6, g = -0.98, 95% CI 1.66, -0.40). When TMP and psychoeducation interventions were directly compared, results indicated a small non-significant effect in favour of the former for PTSD symptoms, (k = 4, g = -0.34, 95% CI -1.05, 0.36) and small non-significant effect sizes in favour of the latter for Depression (k = 3, g = 0.29, 95% CI -0.83, 1.4) and Psychological Distress (k = 6, g = 0.19, 95% CI -0.34, 0.71). LIMITATIONS: Heterogeneity and a limited number of high quality RCTs, particularly in the Substance Misuse and Dissociation domains, resulted in uncertainty regarding meta-analytical estimates and subsequent conclusions. CONCLUSIONS: Results suggest that TMP interventions are useful for traumatic stress whereas non-TMP interventions can be useful for symptoms of general distress (e.g. anxiety and depression). Thus, both TMP and psychoeducation can be useful for the treatment of complex interpersonal trauma symptoms and further research should unravel appropriate sequencing and dose of these interventions.

From Childhood Trauma to Self-Harm: An Investigation of Theoretical Pathways among Female Prisoners.

BACKGROUND: Despite empirical evidence suggesting complex associations between childhood trauma and self-harm, there is a dearth of research investigating this association in the female prison population. The current study explored pathways to self-harm following childhood trauma, by investigating the mediating roles of Post-traumatic Stress Disorder (PTSD) symptoms, emotion regulation and dissociation, in this relationship, within a sample of 89 female prisoners. METHODS: Cross-sectional, interview-format, questionnaire study within a female prison population. Measures of childhood trauma, self-harm, PTSD, emotion regulation and dissociation were administered. RESULTS: The majority of the sample (58.4%) reported history of self-harm. Bootstrapped mediation analyses indicated an indirect effect of emotion regulation on the relationship between childhood trauma and self-harm. An indirect effect was also found for PTSD arousal/reactivity cluster of symptoms. Multiple mediation analyses revealed that interactional effects were present for emotion regulation and arousal/reactivity, and emotion regulation and dissociation, respectively. CONCLUSION: Self-harm is highly prevalent among female prisoners. Interventions promoting emotion regulation and addressing arousal/reactivity symptoms following traumatization may provide an effective way of addressing this problem. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGES: Self-harm is highly prevalent amongst female prisoners, occurring in 58.4% of this sample. Emotion regulation and the arousal/reactivity symptom cluster of PTSD were found to mediate the relationship between childhood trauma and self-harm, both independently and simultaneously. Emotion regulation and dissociation were found to interactionally mediate this relationship. Strategies targeting emotion dysregulation and hyperarousal symptoms, amongst female prisoners who have experienced childhood trauma, may be helpful in reducing self-harming behaviours.

Posttraumatic stress disorder (PTSD) symptoms mediate the relationship between substance misuse and violent offending among female prisoners.

PURPOSE: Despite empirical evidence suggesting complex associations between psychological trauma, substance misuse, and violent offending, there is a dearth of research investigating these associations in the female prison population. METHODS: A cross-sectional, interview-format questionnaire study was undertaken with a sample of 89 female prisoners. History of traumatic events, DSM-5 PTSD, drug use, and offending behaviour were assessed. RESULTS: Traumatic experiences had occurred in 97.8 % of the sample, while 60.5 % met criteria for a PTSD diagnosis. The majority of the sample (70.8 %) reported using illicit drugs, and 59.6 % had committed at least one violent offence. History of drug use was significantly correlated with trauma, PTSD status, and violent offending. A mediation analysis identified an indirect effect of PTSD symptoms on the relationship between history of drug use and violent offending. CONCLUSIONS: The result of our mediation analysis further highlights the importance of addressing PTSD symptoms and substance misuse, among female offenders, to help prevent violent offending.

Exploring Australasian surgical trainees' satisfaction with operating theatre learning using the 'surgical theatre educational environment measure'.

BACKGROUND: Surgical trainees' operating theatre (OT) experiences significantly influence their ability to attain key professional competencies. A measure of trainees' satisfaction with this learning environment would allow recognition of characteristics of highly successful teaching venues and threats to trainee development. Our study aimed to validate the Surgical Theatre Educational Environment Measure (STEEM) and use it to explore Australasian surgical trainees' satisfaction with OT learning. METHODS: In a cross-sectional study, the STEEM was distributed electronically to all 1500 Royal Australasian College of Surgeons trainees in Australia and New Zealand. Trainee satisfaction was gauged using Likert-type items, an overall satisfaction measure and content analysis of free-text comments. The STEEM's psychometric properties were evaluated using exploratory factor analysis. RESULTS: Three hundred fifty-six responses were received. The STEEM's original subscales were not supported by the data; empirically grounded subscales were identified for further analysis. Most trainees were satisfied with their OT environment and satisfaction was higher in senior than junior trainees. Trainees' relationship with their supervisor correlated most strongly with overall satisfaction. Less positively, only half of trainees report discussing their operative role with their supervisor prior to surgery. CONCLUSIONS: The a priori STEEM subscales could not be replicated by factor analysis. We developed an empirically grounded instrument capable of identifying areas of trainee concern. The majority of trainees reported high levels of satisfaction. The revised instrument has potential to complement other sources of information to facilitate surgical supervisors' difficult task of optimizing trainees' compatibility with their OT learning environments.