Does the subjective evaluation of medical student surgical knowledge correlate with written and oral exam performance?

BACKGROUND: Medical student performance evaluations have historically contained a significant subjective component. Multiple tools are used to assess fund of knowledge including subjective evaluation by faculty and residents as well as objective evaluations through standardized written and oral exams. We hypothesized that subjective evaluation of medical student knowledge would correlate with objective evaluation through written and oral exams. METHODS: Records of consecutive medical students assigned to the surgery clerkship from January 1999 and March 2001 were reviewed. The core surgical rotation consisted of two 4-week blocks on a private, county, or VA hospital service. Surgical knowledge was assessed subjectively by both faculty (FES) and senior residents (RES) using a 10-point scale with verbal anchors. Objective measures of student surgical knowledge included the National Board shelf exam (WE) and a semistructured oral exam (OE). Data are reported as mean +/- SEM. Spearman rank correlation coefficient (r) was used to assess relationships between groups (r > or = 0.5 --> positive correlation). RESULTS: A total of 354 students were evaluated. The mean FES was 7.8 +/- 0.05 (median = 7.75, range 4.75 to 9.75). The mean RES was 7.7 +/- 0.06 (median = 8.0, range 3.5 to 10.0). There was poor correlation between the subjective perception and objective measures of surgical knowledge (Table 1). Comparison of the FES and RES also showed poor correlation (r = 0.38). CONCLUSIONS: Subjective evaluation of surgical knowledge by faculty and residents correlates poorly with performance measured objectively. These results question whether subjective evaluation of surgical knowledge should be included as part of the evaluation process.

Predictive model for survival at the conclusion of a damage control laparotomy.

BACKGROUND: We employed modern statistical and data mining methods to model survival based on preoperative and intraoperative parameters for patients undergoing damage control surgery. METHODS: One hundred seventy-four parameters were collected from 68 damage control patients in prehospital, emergency center, operating room, and intensive care unit (ICU) settings. Data were analyzed with logistic regression and data mining. Outcomes were survival and death after the initial operation. RESULTS: Overall mortality was 66.2%. Logistic regression identified pH at initial ICU admission (odds ratio: 4.4) and worst partial thromboplastin time from hospital admission to ICU admission (odds ratio: 9.4) as significant. Data mining selected the same factors, and generated a simple algorithm for patient classification. Model accuracy was 83%. CONCLUSION: Inability to correct pH at the conclusion of initial damage-control laparotomy and the worst PTT can be predictive of death. These factors may be useful to identify patients with a high risk of mortality.

Is regionalization of trauma care using telemedicine feasible and desirable?

BACKGROUND: The judgement and skill of an experienced surgeon are crucial ingredients during trauma resuscitation, so that errors of omission, commission, and misprioritization can be avoided. Trauma represents a potential paradigm application for telemedicine owing to its ubiquitous and urgent nature and the limited availability of specialized care. METHODS: A two-phase project was performed, using an Advanced Trauma Life Support (ATLS)-based evaluation tool. In phase I, we reviewed 24 videotaped trauma resuscitations on a single pass. Clinical data thus observed were compared with the clinical chart for agreement. In phase II, we performed real time, remote, initial evaluations of 17 trauma victims. RESULTS: In phase I, 19 of 44 variables had agreement rates >90%, 10 had agreement rates between 70% and 90%. In phase II, agreement rates were similar to those in phase I, with improved accuracy in documenting initial and secondary vital signs and the secondary physical examination. CONCLUSION: Remote evaluation of trauma victims is feasible. Accurate clinical data can be recorded, tasks delegated, and therapeutic measures advised using telemedicine. This can make expert trauma care available to hospitals without advanced trauma systems and potentially reduce cost, prevent unnecessary transfers, and promote early transfer when indicated.

Pulmonary tractotomy as an abbreviated thoracotomy technique.

BACKGROUND: Operative abbreviated thoracotomy techniques in thoracic trauma include emergency center thoracotomy, ligation of major arterial branches, packing the thoracic cavity for diffuse bleeding, towel clip or Bogota bag closure of the chest, and pulmonary tractotomy. Pulmonary tractotomy with selective vascular ligation was originally described for deep through-and-through lung injuries that did not involve hilar vessels or airways. Pulmonary tractotomy has evolved into use as an abbreviated thoracotomy technique in patients with severe thoracic or multivisceral trauma. As with any operative technique in high-risk patients, specific procedure-related complications may occur and are analyzed herein. The objective of this manuscript is to review the indications, techniques, and results for pulmonary tractotomy in trauma patients requiring abbreviated thoracotomy. METHODS: Medical records were retrospectively reviewed for 30 of 32 consecutive tractotomy patients treated at Ben Taub General Hospital, during a 3-year period. By using a model for logistic regression analysis, the characteristics of each patient and their clinical course were tested for impact on mortality. RESULTS: Seventy percent of patients had at least one intraoperative parameter indicative of acidosis (pH < 7.2), coagulopathy (prothrombin time > 13.8 or partial thromboplastin time > 38.0 seconds), or hypothermia (core temperature < 34 degrees C), and 50% of patients manifested two of these three parameters. The mortality rate among the 30 patients was 17%. Three of the five patients who died were noted to be acidotic, coagulopathic, and hypothermic. Twelve of 25 patients who survived more than 1 day had at least one thoracic complication. There were no late deaths. There was one failed tractotomy and one missed injury. A second thoracotomy was not required for control of a lung injury in any patient. Logistic regression analysis showed that intraoperative blood loss was the only predictive factor for mortality. CONCLUSION: Pulmonary tractotomy is a simple and effective technique in injured patients who require an abbreviated thoracotomy and has an acceptable mortality and complication rate. This follow-up report notes that as definitive therapy, tractotomy continues to allow for direct control of bleeding and air leak and obviates the need for formal resection.

Remote clinical assessment for acute trauma: an initial experience.

Optimal care of the injured patient requires an organized approach, dedicated resources and clinical expertise. Victims of major trauma, however, frequently present to rural and suburban hospitals regardless of whether a dedicated trauma system in place. Immediate consultation by a trauma expert could potentially expedite effective evaluation and management of trauma victims, reducing the occurrence of unnecessary transport and leading to efficient stabilization and transport when needed. Remote assessment of trauma patients must be assesses for feasibility, safety and efficacy before widespread implementation. This project represents the initial steps towards the development of a functional telemedicine system for trauma care.

The logistics of damage control.

Damage control surgery is labor intensive and consumes extensive materials. The unusual logistic effort surrounding the critically injured patient is an integral part of the challenge of damage control surgery. This article is based on data gleaned from the major series in the literature and on the ongoing experience of the Ben Taub General Hospital with patients undergoing damage control surgery.

Subclavian artery obstruction by tube thoracostomy.

A case of subclavian artery obstruction by tube thoracostomy for penetrating trauma is presented. The obstruction was not physiologically significant; however, it did impede the assessment of the subclavian artery for potential injury using emergency center arteriography. The difficulty was easily corrected with repositioning of the chest tube. This previously undescribed complication of tube thoracostomy is presented with its clinical implications.

Penetrating thoracic vascular injuries.

1. Known injuries to the ascending aorta and arch are exposed by median sternotomy. Known injuries to the descending thoracic aorta can be exposed through a posterolateral thoracotomy. These injuries are more commonly diagnosed through emergent exploration by means of anterolateral thoracotomies. 2. Preoperative arteriography is extremely useful in managing penetrating injuries to the thoracic outlet, as it allows the choice of appropriate incisions for exposure and control. 3. Innominate artery, right common carotid or subclavian artery, as well as left intrathoracic common carotid artery injuries are best managed via median sternotomy with appropriate extension. 4. Left subclavian arteries are managed with high left anterolateral thoracotomy for proximal control combined with supraclavicular incision. 5. Distal subclavian arteries are managed with proximal control by a supraclavicular incision and distal control by an infraclavicular incision. 6. The bypass principle is useful for managing innominate or left carotid artery injuries. Ligation with brachiocephalic bypass can be a simple solution to a complex problem. 7. Soft grafts, fine sutures, and minimal mobilization are the techniques of choice. 8. Adjuncts such as Fogarty balloon catheters, Foley catheters, autotransfusion, shunts, and pulmonary tractotomy can be useful in managing these injuries. 9. Documentation of the preoperative neurovascular status of the patient should be performed, as well as discussion with the patient and the family, if available, of the potential outcome with appropriate documentation in the chart. 10. Rehabilitation services should be involved as appropriate to care for these patients. 11. Ligation is always an option to save the patient's life.