A randomized controlled pilot trial of video-modelling versus telementoring for improved hemorrhage control wound packing.

INTRODUCTION: Exsanguination is the most preventable cause of death. Paradigms such as STOP THE BLEED recognize increased responsibility among the less experienced with Wound Packing (WP) being a critical skill. As even trained providers may perform poorly, we compared Video-modelling (VM), a form of behavioural modelling involving video demonstration prior to intervention against remote telementoring (RTM) involving remote real-time expert-guidance. METHODS: Search and Rescue (SAR-Techs), trained in WP were asked to pack a wound on a standardized simulator randomized to RMT, VM, or control. RESULTS: 24 SAR-Techs (median age 37, median 16.5 years experience) participated. Controls were consistently faster than RTM (p = 0.005) and VM (p = 0.000), with no difference between RTM and VM. However, 50% (n = 4) Controls failed to pack properly, compared to 100% success in both VM and RTM, despite all SAR-Techs feeling the task was "easy". DISCUSSION: Performance of a life-saving technique was improved through either VM or RTM, suggesting that both techniques are beneficial and complementary to each other. Further work should be extended to law enforcement/lay public to examine logistical challenges.

To Watch Before or Listen While Doing? A Randomized Pilot of Video-Modelling versus Telementored Tube Thoracostomy.

BACKGROUND: New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted. METHODS: Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure. RESULTS: There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000). CONCLUSIONS: Random evaluation revealed both paradigms have attributes. If VM can be utilized during "travel-time," it is quicker but without facilitating "trouble shooting." On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.

Factors associated with delays to medical assessment and diagnosis for patients with colorectal cancer.

OBJECTIVE: To identify factors associated with delays to medical assessment and diagnosis for patients with colorectal cancer (CRC). DESIGN: Data were collected through a standardized questionnaire. Clinical records were also reviewed. When necessary, patients were contacted by a member of the study team to collect missing data and confirm information. SETTING: Cross Cancer Institute in Edmonton, Alta. PARTICIPANTS: Patients newly diagnosed with a histologically proven colorectal adenocarcinoma were identified and eligible for the study. MAIN OUTCOME MEASURES: Associations between symptoms, tumour stage at operation, symptom duration, and tumour location were sought to identify factors associated with a delay in diagnosis of CRC. RESULTS: Surveys were completed by 93 patients. A total of 49% of patients had symptoms of CRC present for 1 month or less before seeing a physician, and 51% had symptoms for longer than 1 month. Seventy-five (86%) patients initially presented to family physicians for assessment, while 12 (14%) patients presented to the emergency department for their first physician encounters. Only 33 (38%) patients had digital rectal examinations during their first visits. Women were more likely to present to physicians with longer than 1 month of symptoms, while men were more likely to present with less than 1 month of symptoms (P = .03). Abdominal pain, blood in the stool, and change in stool size were the most frequent symptoms encountered. Twenty-two (26%) patients delayed seeking treatment because they thought their symptoms were not serious and 12 (14%) believed that their family physicians had taken inappropriate action. Fifteen (18%) patients attributed their delays to waiting too long for specialist referral and diagnostic tests. CONCLUSION: This study highlights the important role patients and physicians both play in delays in the diagnosis of CRC. Efforts to diminish future delays must focus on educating the public and practising physicians about important symptoms and signs of CRC. Additionally, the value of a digital rectal examination must be emphasized, along with continued promotion of CRC screening.

The Canadian general surgery resident: defining current challenges for surgical leadership.

BACKGROUND: Surgery training programs in Canada and the United States have recognized the need to modify current models of training and education. The shifting demographic of surgery trainees, lifestyle issues and an increased trend toward subspecialization are the major influences. To guide these important educational initiatives, a contemporary profile of Canadian general surgery residents and their impressions of training in Canada is required. METHODS: We developed and distributed a questionnaire to residents in each Canadian general surgery training program, and residents responded during dedicated teaching time. RESULTS: In all, 186 surveys were returned for analysis (62% response rate). The average age of Canadian general surgery residents is 30 years, 38% are women, 41% are married, 18% have dependants younger than 18 years and 41% plan to add to or start a family during residency. Most (87%) residents plan to pursue postgraduate education. On completion of training, 74% of residents plan to stay in Canada and 49% want to practice in an academic setting. Almost half (42%) of residents identify a poor balance between work and personal life during residency. Forty-seven percent of respondents have appropriate access to mentorship, whereas 37% describe suitable access to career guidance and 40% identify the availability of appropriate social supports. Just over half (54%) believe the stress level during residency is manageable. CONCLUSION: This survey provides a profile of contemporary Canadian general surgery residents. Important challenges within the residency system are identified. Program directors and chairs of surgery are encouraged to recognize these challenges and intervene where appropriate.

Evidence based curriculum design--use of a surgical database to identify non-perceived needs in educating otolaryngologists on pediatric conditions.

OBJECTIVE: To identify the common non-otolaryngological diagnoses (N-OD) encountered by a pediatric otolaryngologist in surgical patients. This information may help in educating otolaryngologists on relevant pediatric conditions among their patients. DESIGN/SETTING: Cross-sectional, retrospective database review of entries from 2006 to 2008 at a tertiary pediatric centre involving the patient case load of a busy pediatric otolaryngologist. MAIN OUTCOME MEASURES: The main outcome of this study was to identify the common (N-OD) encountered by a pediatric otolaryngologist. Conditions excluded from the analysis were surgical complications and diagnoses managed primarily by otolaryngologists (sleep disordered breathing and allergic rhinitis). RESULTS: 1357 pediatric surgical entries were identified. Of these, 524 (38.6%) entries contained N-OD and underwent surgery. A total of 580 N-OD were identified for these 524 patients. The N-OD were identified and categorized into the following subheadings: syndromes/associations, respiratory and cardiac, gastrointestinal, developmental, metabolic, and miscellaneous conditions. The most common N-OD are gastro-esophageal reflux disease, obesity, history of prematurity, congenital heart disease, asthma developmental delay and Down syndrome. The commonest categories encountered were developmental (138), cardio-respiratory (114) and gastro-intestinal (114). CONCLUSIONS: This paper identifies the common N-OD encountered by a pediatric otolaryngologist in children managed at a tertiary level. The highlighted N-OD may help as a guide on curriculum content for training residents and fellows and continued medical education.

Post-operative bleeding is less after partial intracapsular tonsillectomy than bipolar total procedure.

OBJECTIVE: To compare bleeding after partial intracapsular tonsillectomy (PIT) and bipolar diathermy tonsillectomy (BDT). DESIGN: Retrospective chart review. SETTING: Stollery Children's Hospital, tertiary pediatric referral centre. PATIENTS: All children (