Competence assessment of laparoscopic operative and cognitive skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA).

BACKGROUND: There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses. METHODS: Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA. RESULTS: The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001). CONCLUSIONS: OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Acute compartment syndrome of the thigh after joint replacement with anticoagulation.

We describe three patients with a compartment syndrome of the thigh, two after total hip replacement and one after total knee replacement. Two of the patients were fully anticoagulated. A compartment syndrome of the thigh is a rare, but important complication of joint replacement surgery if patients are receiving anticoagulants. Close observation is needed and when indicated monitoring of the intracompartmental pressure should be done. Early recognition of the signs and symptoms of an acute compartment syndrome and knowledge of the anatomy of the compartments of the thigh will help in the diagnosis and treatment of this potentially devastating complication.

Delayed diagnosis of injuries from the M1 aircraft accident. The Nottingham, Leicester, Derby, Belfast Study Group.

The incidence of a delay in the diagnosis of injuries from the 83 survivors of the M1 aircraft accident is described. A total of 32 injuries in 25 patients were not initially diagnosed, nine each in the upper and lower limbs and 14 in the spine. This was equivalent to 9.6 per cent of all the major injuries suffered by the survivors. Five patients required surgery for a late diagnosed injury. The incidence of a delayed diagnosis injury (DDI) was not related to the overall severity of injury. Delay in diagnosis of injuries after such a major accident was attributable to failure of clinical examination, failure to radiograph symptomatic areas and failure of radiographic interpretation.

Initial management of open fractures sustained in the M1 aircraft disaster. Nottingham, Leicester, Derby and Belfast (NLDB) Study Group.

There were 83 survivors of the M1 aircrash admitted to hospital; of these, 28 patients sustained a total of 40 open fractures. These open fractures were classified as 19 grade 3, 16 grade 2 and five grade 1. There were six upper limb fractures and 34 lower limb fractures. A high proportion of grade 3 open fractures were identified in this series (47 per cent) and one-half of these occurred at or below the ankle. This reflected the high energy and direction of the forces involved in the aircrash. The early results in terms of the incidence of wound infection (15 per cent), delayed wound healing (7.5 per cent) and skin flap necrosis (7.5 per cent) were similar to other series. The controversy over whether to leave grade 3 wounds open or closed was not clarified by this study, but the closure of grade 3 wounds after internal fixation is to be avoided. This study emphasizes the need for provision of adequate specialist manpower, equipment and resources to manage the unexpected major disaster successfully.