A Systematic Review of Live Animal Use as a Simulation Modality ("Live Tissue Training") in the Emergency Management of Trauma.

INTRODUCTION: Live anaesthetized animals are used as simulation models to teach techniques in the emergency management of trauma. We aimed to explore how "live tissue training" (LTT) is designed, delivered and evaluated in order to better understand and characterize aspects of educational merit. METHODS: A systematic review was performed using PRISMA guidance. A combined approach, involving a 3-stage modified narrative synthesis process and reflexive thematic analysis was used to identify key concepts across the published literature. FINDINGS: Qualitative synthesis of 48 selected articles suggests that LTT is mainly used to teach military and civilian physicians and military medical technicians. The procedures trained vary with the learner population, from simple pre-hospital trauma tasks to advanced operative surgical skills. Many courses use a combination of didactic and practical training, with an animal model used to train practical application of knowledge and procedural skills. Descriptions of the learning interventions are limited, and explicit use of educational theory or pedagogic frameworks were absent within the literature. Four themes were identified regarding aspects of LTT that are valued by learners: "recreating the experience," relating to fidelity and realism; "tick tock" "dynamics of hemorrhage", encompassing the impact of bleeding and urgent pressure to act; "emotional impact" of conducting the training, and "self-efficacy: I believe I can do it." CONCLUSION: Thematic analysis of published literature suggests that there may be educational benefit in the use of live tissue models due to time criticality and bleeding, which creates a real-life event. LTT also invokes an emotional response, and learners experience an increase in self-efficacy from participation. We consider that these aspects and associated pedagogy should be addressed when researching and developing alternative simulation modalities, in order to intelligently replace, reduce and refine the use of animals in training practitioners in the emergency management of trauma.

Skill sets required for the management of military head, face and neck trauma: a multidisciplinary consensus statement.

INTRODUCTION: The evolution of medical practice is resulting in increasing subspecialisation, with head, face and neck (HFN) trauma in a civilian environment usually managed by a combination of surgical specialties working as a team. However, the full combination of HFN specialties commonly available in the NHS may not be available in future UK military-led operations, necessitating the identification of a group of skill sets that could be delivered by one or more deployed surgeons. METHOD: A systematic review was undertaken to identify those surgical procedures performed to treat acute military head, face, neck and eye trauma. A multidisciplinary consensus group was convened following this with military HFN trauma expertise to define those procedures commonly required to conduct deployed, in-theatre HFN surgical combat trauma management. RESULTS: Head, face, neck and eye damage control surgical procedures were identified as comprising surgical cricothyroidotomy, cervico-facial haemorrhage control and decompression of orbital haemorrhage through lateral canthotomy. Acute in-theatre surgical skills required within 24 hours consist of wound debridement, surgical tracheostomy, decompressive craniectomy, intracranial pressure monitor placement, temporary facial fracture stabilisation for airway management or haemorrhage control and primary globe repair. Delayed in-theatre procedures required within 5 days prior to predicted evacuation encompass facial fracture fixation, delayed lateral canthotomy, evisceration, enucleation and eyelid repair. CONCLUSIONS: The identification of those skill sets required for deployment is in keeping with the General Medical Council's current drive towards credentialing consultants, by which a consultant surgeon's capabilities in particular practice areas would be defined. Limited opportunities currently exist for trainees and consultants to gain experience in the management of traumatic head, face, neck and eye injuries seen in a kinetic combat environment. Predeployment training requires that the surgical techniques described in this paper are covered and should form the curriculum of future military-specific surgical fellowships. Relevant continued professional development will be necessary to maintain required clinical competency.

Optimising ballistic facial coverage from military fragmenting munitions: a consensus statement.

VIRTUS is the first United Kingdom (UK) military personal armour system to provide components that are capable of protecting the whole face from low velocity ballistic projectiles. Protection is modular, using a helmet worn with ballistic eyewear, a visor, and a mandibular guard. When all four components are worn together the face is completely covered, but the heat, discomfort, and weight may not be optimal in all types of combat. We organized a Delphi consensus group analysis with 29 military consultant surgeons from the UK, United States, Canada, Australia, and New Zealand to identify a potential hierarchy of functional facial units in order of importance that require protection. We identified the causes of those facial injuries that are hardest to reconstruct, and the most effective combinations of facial protection. Protection is required from both penetrating projectiles and burns. There was strong consensus that blunt injury to the facial skeleton was currently not a military priority. Functional units that should be prioritised are eyes and eyelids, followed consecutively by the nose, lips, and ears. Twenty-nine respondents felt that the visor was more important than the mandibular guard if only one piece was to be worn. Essential cover of the brain and eyes is achieved from all directions using a combination of helmet and visor. Nasal cover currently requires the mandibular guard unless the visor can be modified to cover it as well. Any such prototype would need extensive ergonomics and assessment of integration, as any changes would have to be acceptable to the people who wear them in the long term.

A pilot study to evaluate the utility of live training (LIVEX) in the operational preparedness of UK military trauma teams.

BACKGROUND: With the end of UK military operations in Iraq and Afghanistan, it is essential that peacetime training of Defence Medical Services (DMS) trauma teams ensures appropriate future preparedness. A new model of pre-deployment training involves placement of formed military trauma teams into civilian trauma centres. This study evaluates the benefit of 'live training during an exercise period' (LIVEX) for DMS trauma teams. METHODS: A cross-sectional questionnaire-based survey of participants was conducted. Quantitative data were collected prior to the start and on the final day. Written reports were collected from the coordinators. Thematic analysis was used to identify emergent themes in a supplementary, qualitative analysis. RESULTS: Each team comprised 13 personnel and results should be interpreted with knowledge of this small sample size. The response rate for both the pre-LIVEX and post-LIVEX questionnaire was 100%. By the end of the week, 89% of participants (n=23) stated LIVEX was an 'appropriate or very appropriate' way of preparing for an operational role compared with 40% (n=9) before the exercise (p<0.01). However, completing LIVEX made no difference to participants' personal perception of their own operational preparedness. Thematic analysis suggested greater training benefit for more junior members of the team; from Regulars and Reservists training together; and from two-way exchange of information between DMS and National Health Service medical staffs. CONCLUSIONS: Completing LIVEX made no statistically significant difference to participants' personal perception of their own operational preparedness, but the perception of LIVEX as an appropriate training platform improved significantly after conducting the training exercise.

Management of complex abdominal wall defects associated with penetrating abdominal trauma.

INTRODUCTION: The paradigm of Damage Control Surgery (DCS) has radically improved the management of abdominal trauma, but less well described are the options for managing the abdominal wall itself in an austere environment. This article describes a series of patients with complex abdominal wall problems managed at the UK-led Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan. METHOD: Contemporaneous review of a series of patients with complex abdominal wall injuries who presented to the Role 3 MTF between July and November 2012. RESULTS: Five patients with penetrating abdominal trauma associated with significant damage to the abdominal wall were included. All patients were managed using DCS principles, leaving the abdominal wall open at the end of the first procedure. Subsequent management of the abdominal wall was determined by a multidisciplinary team of general and plastic surgeons, intensivists and specialist nurses. The principles of management identified included minimising tissue loss on initial laparotomy by joining adjacent wounds and marginal debridement of dead tissue; contraction of the abdominal wall was minimised by using topical negative pressure dressing and dermal-holding sutures. Definitive closure was timed to allow oedema to settle and sepsis to be controlled. Closure techniques include delayed primary closure with traction sutures, components separation, and mesh closure with skin grafting. DISCUSSION: A daily multidisciplinary team discussion was invaluable for optimal decision making regarding the most appropriate means of abdominal closure. Dermal-holding sutures were particularly useful in preventing myostatic contraction of the abdominal wall. A simple flow chart was developed to aid decision making in these patients. This flow chart may prove especially useful in a resource-limited environment in which returning months or years later for closure of a large ventral hernia may not be possible.

Severe open tibial fractures in combat trauma: management and preliminary outcomes.

The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic-plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic-plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection.

Surgical training in Camp Bastion, Afghanistan.

INTRODUCTION: Surgical trauma care on operations is delivered by consultants. The DMS presently delivers training to surgeons to enable them to deliver this care as newly-qualified consultants. Deploying as a trainee is one of many training evolutions available to achieve this competency. This paper describes the process involved in trainees deploying, and the training received by the first author (CAF) during a recent deployment. METHODS: Pre-deployment training and the process for gaining recognition of training time by the GMC are described. All surgical procedures performed by the first author were recorded prospectively, together with the level of supervision. RESULTS: The first author performed 210 procedures in 124 operations on 87 patients in a seven week deployment. This was prospectively recognised for training by the GMC. All procedures were supervised by consultant trainers. Procedures included trauma surgical procedures and those under the specialties of Plastic Surgery, Orthopaedic Surgery and General Surgery. CONCLUSIONS: Deploying on operations as a trainee is invaluable in preparing DMS juniors for their future roles as consultants in the DMS. Training is received not only in a breadth of surgical and resuscitative procedures, beyond a trainee's "base specialty", but also in other critical aspects of deployments including Crew Resource Management.

Experimental investigation of two techniques of arterial microanastomosis used to manage a small-to-large diameter discrepancy.

INTRODUCTION: A limiting factor in the use of perforators as recipient vessels is the small-to-large diameter mismatch often encountered. Mismatches less than 1:1.5 may be managed by dilatation of the smaller vessel and by differentially-spaced suture bites. Beyond this ratio, little evidence exists to direct the choice of end-to-end anastomotic technique. Following in silico work and the characterisation of a rodent superficial caudal epigastric/femoral artery model, we conducted an experimental series examining two techniques - an oblique section of the smaller vessel and invaginating the smaller vessel inside the larger. MATERIALS AND METHODS: A paired design was used. To test for a difference in patency of >5% required a total of 156 animals (312 anastomoses). Side and technique were randomised. Two investigators performed the anastomoses. A single revision was permitted. Anastomoses were timed and patency was tested at one hour, one week and at six weeks. RESULTS: There was no significant difference in patency at each of the three time points (p = 0.8026, 0.2963 and 0.8137). The invagination technique was significantly faster to perform (p < 0.0001). There was a significant association between the investigator and both patency and the time taken to complete an anastomosis. Independent of the investigator, a revision was more likely to be necessary with the oblique end-to-end technique, and a revision having been performed showed a highly significant association with an anastomosis having failed at 1 h (p < 0.0001, OR 33.333). CONCLUSIONS: In the management of microarterial size discrepancy between 1:1.5 and 1:2.5, an invaginating anastomosis is faster to perform and produces comparable patency in a rat model.

Characterization of a rodent model for the study of arterial microanastomoses with size discrepancy (small-to-large).

Microsurgical autotransplantation of tissues is employed clinically to reconstruct defects following burns, trauma and surgical cancer ablation, and to correct congenital abnormalities. Transplant vessels of <3 mm are anastomosed by hand under the microscope. Experimentally, anastomotic patency rates decrease with increasing vessel diameter mismatch, and clinically, ratios of 3:1 or greater lead to unacceptably low arterial patency rates. A number of surgical techniques for dealing with size mismatch are described, but no one method has found favour, and few controlled studies of technique are reported. In this report, a rodent superficial caudal epigastric artery (SCEA)/femoral artery (FA) model for the study of these techniques is described in detail. The diameter ratio between these vessels lies in the clinically relevant range of 1:1.5-1:2.5. In the male Wistar rat, external vessel diameters were not found to increase markedly in size between animal weights of 300 and 500 g. The length of FA distal to the origin of the SCEA, which is important in allowing undisturbed distal run-off, was found to be negatively associated with animal body weight, implying that a smaller animal would be better for this model. Mean femoral arterial flow rate, measured by transit-time ultrasound, was noted to be statistically and physiologically significantly higher in the right artery when compared with the left. This model has advantages over interposition vein graft models in that it minimizes vessel compliance mismatch, and avoids the need for a second anastomosis.

A molten metal, high-pressure injection injury of the hand.

A case of high-temperature, high-pressure injection injury of the hand is reported. The injury is particularly severe in that it involves both a high-temperature thermal insult and a pressure effect, either of which, alone, can result in major disability. It is evident that the high temperature of the injected material considerably reduced the pressure required for penetration of the tissues.