Advanced Modular Manikin and Surgical Team Experience During a Trauma Simulation: Results of a Single-Blinded Randomized Trial.

BACKGROUND: Our aim was assess whether an integrated Advanced Modular Manikin (AMM) provides improved participant experience compared with use of peripheral simulators alone during a standardized trauma team scenario. Simulation-based team training has been shown to improve team performance. To address limitations of existing manikin simulators, the AMM platform was created that enables interconnectedness, interoperability, and integration of multiple simulators ("peripherals") into an adaptable, comprehensive training system. METHODS: A randomized single-blinded, crossover study with 2 conditions was used to assess learner experience differences when using the integrated AMM platform vs peripheral simulators. First responders, anesthesiologists, and surgeons rated their experience and workload with the conditions in a 3-scene standardized trauma scenario. Participant ratings were compared and focus groups conducted to obtain insight into participant experience. RESULTS: Fourteen teams (n = 42) participated. Team experience ratings were higher for the integrated AMM condition compared with peripherals (Cohen's d = .25, p = 0.016). Participant experience varied by background with surgeons and first responders rating their experience significantly higher compared with anesthesiologists (p < 0.001). Higher workload ratings were observed with the integrated AMM condition (Cohen's d = .35, p = 0.014) driven primarily by anesthesiologist ratings. Focus groups revealed that participants preferred the integrated AMM condition based on its increased realism, physiologic responsiveness, and feedback provided on their interventions. CONCLUSIONS: This first comprehensive evaluation suggests that integration with the AMM platform provides benefits over individual peripheral simulators and has the potential to expand simulation-based learning opportunities and enhance learner experience, especially for surgeons.

Development of a Field-Expedient Vascular Trauma Simulator.

The past few years have noted significant declines in combat casualty exposure over the course of a deployment. As a result, overall confidence and comfort in performing potentially life-saving therapies may wane during a deployment. Development of training simulators provides a method for bridging this gap. Herein, a field-expedient vascular trauma trainer for noncompressible torso hemorrhage is described. A low-fidelity simulator was created using a Penrose drain, intravenous tubing, suture, and a cardboard box. A higher-fidelity simulator was created using an aortobifemoral bypass graft, double-lumen endotracheal tube, suture, and an upper torso mannequin. The two trainers were successfully used to train for peripheral shunt placement and definitive vascular repair. The trainer makes use of supplies readily found at most Role 2 and 3 facilities and that are obtainable for Role 1 facilities providing damage control surgery. It provides a just-in-time way to develop and sustain confidence in the damage control principles applicable to vascular injuries.

Achieving Mastery of General Surgery Operative Skill in the Army Healthcare System.

INTRODUCTION: Operative case volumes for military surgeons are reported to be significantly lower than civilian counterparts. Among the concern that this raises is an inability of military surgeons to achieve mastery of their craft. MATERIAL AND METHODS: Annual surgical case reports were obtained from seven Army military treatment facilities (MTF) for 2012-2016. Operative case volume and cumulative operative time were calculated for active duty general surgeons and for individual MTFs. Subgroup analyses were also performed based upon rank. Results were extrapolated to calculate the amount of time it would take to reach a cumulative of 10,000 hours of operative time (the a priori definition for achieving mastery). RESULTS: One hundred and two active duty general surgeons operated at the seven MTFs during the study period and met the inclusion criteria. The average surgeon performed 108 ± 68 cases/year. The average surgeon operated 122 ± 82 hours/year. At this rate, it would take over 80 years to reach mastery of surgery. When stratified based upon rank, Majors averaged 113 ± 75 hours/year, Lieutenant Colonels averaged 170 ± 100 hours/year, and Colonels averaged 136 ± 101 hours/year (p < 0.05). When stratified based upon individual MTF, surgeons at the busiest facility averaged 187 ± 103 hours/year and those at the least busy facility averaged 85 ± 56 hours/year (p < 0.05). CONCLUSIONS: Obtaining mastery of general surgery is a nearly impossible proposition given the current care models at Army MTFs. Alternative staffing and patient care models should be developed if Army surgeons are to be masters at their craft.

Objective Evaluation of the Effects of Deployment on Laparoscopic Skills: The Simulation and Deployment Laparoscopic Skills Study.

OBJECTIVE: To assess the effects of deployment on basic laparoscopic skills of general surgeons and obstetrics/gynecology (OB/GYN) physicians. METHODS: This was a prospective 10-site study. Active duty Army OB/GYN and general surgery physicians scheduled to deploy were invited to participate. Before deployment, they performed fundamentals of laparoscopic surgery (FLS) tasks and specialty-specific procedures on a virtual reality laparoscopic simulator. Upon returning, physicians repeated the same evaluations. Questions about perceived comfort with laparoscopic procedures were asked before and after deployment. Statistical analysis included paired t tests for continuous variables and nonparametric for ordinal data with a p value of <0.05 considered significant. RESULTS: 121 deploying providers were invited to participate; 35 agreed and 29 completed the predeployment skills assessment. After deployment, 15 providers had postassessment evaluation data collected, and their results were used for analysis. Though physicians reported a decrease in their perception of preparedness for advanced laparoscopic procedures and complications, there was no decrement in their performance of FLS tasks or the basic laparoscopic procedures. CONCLUSION: Time away from regular clinical practice during deployments did not significantly affect surgeons' performance as measured by a virtual reality laparoscopic simulator. Additional study on effects on advanced procedures should be considered.

What Patients Really Want: Optimizing the Military Preoperative Evaluation Clinic.

The idea of the preoperative anesthesia clinic as a means of examining and treating the patient so that he will arrive in the operating theater as strong and healthy as possible is well established in practice and literature.However, problems in clinic design and execution often result in high patient waiting times, decreased patient and staff satisfaction, decreased patient capacity, and high clinic costs. Although the details of clinic design, outcomes, and satisfaction have been extensively evaluated at civilian hospitals, we have not found corresponding literature addressing these issues specifically within military preoperative evaluation clinics. We find that changing to an appointment-based (versus walk-in) system and eliminating data collection step redundancies will likely result in lower wait times, higher satisfaction, lower per patient costs, and a more streamlined and resource-efficient structure.

What is the future of training in surgery? Needs assessment of national stakeholders.

BACKGROUND: The Curriculum Committee of the American College of Surgeons-Accredited Educational Institutes conducted a need assessment to (1) identify gaps between ideal and actual practices in areas of surgical care, (2) explore educational solutions for addressing these gaps, and (3) shape a vision to advance the future of training in surgery. METHODS: National stakeholders were recruited from the committee members' professional network and interviewed via telephone. Interview questions targeted areas for improving surgical patient care, optimal educational solutions for training in surgery including simulation roles, and entities that should primarily bear training costs. We performed an iterative, qualitative analysis including member checking to identify key themes. RESULTS: Twenty-two interviewees included state/national board representatives, risk managers, multispecialty faculty/program directors, nurses, trainees, an industry representative, and a patient. Surgeons' communication with patients, families, and team members was raised consistently by stakeholders as a way to establish clear expectations regarding pre-, peri-, and postoperative care. Other comments highlighted the surgeon's development and demonstration and maintenance of cognitive and technical skills, including surgical judgment. Stakeholders also reiterated the critical need for surgeons to engage in on-going self-assessment and professional development to identify and remediate recognized limitations. Recommended learning modalities for meeting surgeons' needs included active learning (deliberate practice, diverse patient experiences), experiential learning (simulation), and peer and mentored learning (preceptorship). CONCLUSION: This first formal needs assessment of education for surgeons points to opportunities for educational programs in patient-centered communication, learning models that match preferences of new generations of trainees, and training in interprofessional/interdisciplinary team communication and teamwork.

Hemostasis in a noncompressible hemorrhage model: an end-user evaluation of hemostatic agents in a proximal arterial injury.

OBJECTIVE: 1. Evaluate hemostatic bandages by the end user using subjective and objective criteria. 2. Determine if user training and education level impact overall hemostatic outcomes. 3. Our hypothesis was that prior medical training would be directly linked to improved hemostatic outcomes in noncompressible hemorrhage indepen- dent of dressing used. DESIGN: Military personnel were given standardized instruction on hemostatic dressings as part of a tactical combat casualty care course (TC3). Soldiers were randomized to a hemostatic dressing. Proximal arterial (femoral and axillary) injuries were created in extremities of live tissue models (goat or pig). Participants attempted hemostasis through standardized dressing application. Evaluation of hemostasis was performed at 2- and 4-minute intervals by physicians blinded to participants' training level. SETTING: Military personnel that are due to deploy are given "refresher" instruction by their units as well as participating in the TC3 to further hone their medical skills prior to deployment. The TC3 is simulation training designed to simulate combat environments and real-life trauma scenarios. PARTICIPANTS: Military personnel due to deploy, physicians (residents and board certified surgeons), animal care technicians, and veterinarian support. RESULTS: Celox 42 (33%), ChitoGauze 11 (9%), Combat Gauze 45 (35%), and HemCon wafer 28 (22%) bandages were applied in 126 arterial injuries created in 45 animals in a standardized model of hemorrhage. Overall, no significant difference in hemostasis and volume of blood loss was seen between the 4 dressings at 2 or 4 minutes. Combat gauze was the most effective at controlling hemorrhage, achieving 83% hemostasis by 4 minutes. Combat gauze was also rated as the easiest dressing to use by the soldiers (p<0.05). When compared to nonmedical personnel, active duty soldiers with prior medical training improved hemostasis at 4 minutes by 20% (p = 0.05). CONCLUSIONS: There is no significant difference in hemostasis between hemostatic bandages for proximal arterial hemorrhage. Hemostasis significantly improves between 2 and 4 minutes using direct pressure and hemostatic agents. Prior medical training leads to 20% greater efficacy when using hemostatic dressings.

Management of complex extremity injuries: tourniquets, compartment syndrome detection, fasciotomy, and amputation care.

Historically, complex extremity injuries, otherwise known as mangled extremities, have been difficult management problems. This is especially true in multiply-injured patients where many priorities exist and where amputation is considered a failure of limb salvage. Over the past decade, advances in the total management of complex extremity injuries, from the placement of life-saving and limb-saving tourniquets in the prehospital setting to the advancement of prosthetics and rehabilitation months to years later, have resulted in superb functional results regardless of whether limb salvage or amputation is undertaken.

Factors influencing humanitarian care and the treatment of local patients within the deployed military medical system: casualty referral limitations.

BACKGROUND: Humanitarian medical care is an essential task of the deployed military health care system. The purpose of this study was to analyze referral acceptance in treating injured local national patients during Operation Enduring Freedom. METHODS: A prospective observation study of local nationals who were referred for humanitarian trauma care in Afghanistan from March through August 2009. RESULTS: Sixty-six patients were referred for evacuation for suspected non-coalition-caused injuries. The bed status at the receiving hospital was defined as green (able to accept patients), amber (nearing capacity), and red (at capacity). The only factor associated with acceptance was the accepting hospital bed status (odds ratio = 1.57%, 95% confidence interval, 1.11-2.22; P = .009). Factors not significant were age, the province of origin, the type of referring facility, a prior operation before the request, patient status/affiliation, or the mechanism of injury. CONCLUSIONS: Humanitarian medical care is directly related to the capacity for high-acuity care because bed availability is the predominate reason for acceptance or rejection.

Intensive skills week for military medical students increases technical proficiency, confidence, and skills to minimize negative stress.

The effects of stress induced cortisol on learning and memory is well documented in the literature.1-3 Memory and learning are enhanced at low levels while high levels are detrimental. Repetitive training in stressful situations enables management of the stress response4 as demonstrated by the high intensity training military members undergo to prepare for tactical situations. Appropriate management of one?s stress response is critical in the medical field, as the negative effects of stress can potentially hinder life-saving procedures and treatments. This also applies to physicians-in-training as they learn and practice triage, emergency medicine, and surgical skills prior to graduation. Rocky Vista University?s Military Medicine Honor?s Track (MMHT) held a week long high-intensity emergency medicine and surgical Intensive Skills Week (ISW), facilitated by military and university physicians, to advance students? skills and maximize training using the Human Worn Partial Surgical Task Simulator (Cut Suit). The short-term goal of the ISW was to overcome negative stress responses to increase confidence, technical and non-technical knowledge, and skill in surgery and emergency medicine in an effort to improve performance as third-year medical students. The long-term goal was to enhance performance and proficiency in residency and future medical practice. The metrics for the short-term goals were the focus of this pilot study. Results show an increase in confidence and decrease in perceived stress as well as statistically significant improvements in technical and non-technical skills and surgical instrumentation knowledge throughout the week. There is a correlative benefit to physician and non-physician military personnel, especially Special Operations Forces (SOF) medical personnel, from developing and implementing similar training programs when live tissue or cadaver models are unavailable or unfeasible.

Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department.

BACKGROUND: The military health care system is unique in that almost every physician deploys for ≥6 months to a combat or far-forward setting. The aim of this study was to determine the perceived changes in clinical skills in this deployed population. METHODS: A survey was sent out to all specialty consultants to the Army Surgeon General to query active duty staff physicians in their specialty areas who have deployment experience in August 2007. Questions concerning specialty, length of deployment, perceived changes in skills, skill use while deployed, and time to get back to baseline clinically after deployment were asked. RESULTS: Surveys were sent to approximately 1,500 physicians, of which 673 were usable, for a 45% response rate. More than 70% of respondents were deployed for >6 months. Fifty-nine percent reported that they were used in their specialties <40% of the time deployed. Surgeons rated surgical skills before and after deployment as 6.0 ± 1.0 and 4.0 ± 1.5, respectively (on a 7-point, Likert-type scale ranging from 1 = worst to 7 = best; P = .001). Most felt that the time needed to get back to predeployment skill levels was 1 to 6 months. CONCLUSIONS: There was significant perceived degradation in both the surgical and clinical skills of those deploying for >6 months, and the degradation was correlated with the length of time deployed. Most surgical specialists felt that it took them 3 to 6 months to return to their clinical and surgical performance baseline upon returning from a deployment and that 6 months was the most amount of time they could be deployed without a significant decrement in skills.

Transforming US Army trauma care: an evidence-based review of the trauma literature.

The US Army has been charged to transform to meet the demands of current and anticipated near-future combat needs, covering a full spectrum of military operations. The US Army combat trauma care system was created to deliver combat casualty care in a variety of situations and has been adapted to meet the needs of such care in both Operations Enduring Freedom and Iraqi Freedom. Questions related to our current system include the use and positioning of medical evacuation assets, the type of training for our trauma care providers, the positioning of these providers in proximity to the battlefield, and the type of units most suited to the wide variety of medical operations required of today's military medical team. The review was performed to evaluate available information in light of anticipated future needs to ensure preparedness. We reviewed trauma literature regarding the areas of civilian trauma systems, military trauma systems, presurgical trauma care, medical evacuation times, and the medical evacuation system. Among the conclusions drawn from the reviewed data include the following: regional trauma systems improve outcomes in significantly-injured patients; rural trauma care as part of a trauma system yields improved results compared to nontrauma hospitals and comparable results to those at a higher level center; and delivery of advanced trauma life support care has the potential to extend the period of time of safe medical evacuation to surgical capabilities. These lessons are used to discuss components of an improved system of trauma care, flexible for the varied needs of modern battlefield trauma and adaptable to provide support for anticipated future conflicts.

Incidence of low vitamin A levels and ocular symptoms after Roux-en-Y gastric bypass.

BACKGROUND: Previous reports have demonstrated a significant incidence of fat-soluble vitamin deficiency after bariatric surgery. The purpose of the present study was to determine the incidence of vitamin A deficiency after Roux-en-Y gastric bypass and to correlate the laboratory findings with ocular symptoms potentially related to vitamin A deficiency. METHODS: All patients who had undergone Roux-en-Y gastric bypass were invited to participate in a nutritional screening. The patients completed a detailed survey concerning ocular symptoms and had their vitamin A level evaluated. RESULTS: A low vitamin A level was identified in 7 (11%) of 64 RYBG patients. Ocular xerosis was present in 18 patients (27%), with night vision changes reported in 45 (68%). Visual disturbances were present in 7 patients (11%) found to have low vitamin A levels, with hypovitaminosis A present in 22% of patients with xerosis (P <.05). CONCLUSION: Low vitamin A levels and frequent ocular complaints that might be associated with decreased vitamin A are common findings in the post-RYBG patient population. Additional study is needed to assess the role of routine vitamin A screening and replacement in the postbariatric surgery patient.

Potential roles of military-specific response to natural disasters -- analysis of the rapid deployment of a mobile surgical team to the 2007 Peruvian earthquake.

The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.

Efficacy of three topical hemostatic agents applied by medics in a lethal groin injury model.

BACKGROUND: Advanced topical hemostatic agents are increasingly utilized to control traumatic hemorrhage. We sought to determine the efficacy of three chitosan based hemostatic agents in a lethal groin injury model when applied by combat medic first responders. METHODS: After creation of a standardized femoral artery injury in a goat model, medics attempted hemorrhage control with standard gauze dressing followed by randomization to one of three hemostatic agents in this two tiered study. In the first tier, medics were randomized to either a chitosan based one-sided wafer (OS) or a dual-sided, flexible, roll (DS). In the second tier, medics were randomized to the flexible DS dressing or a chitosan powder (CP). Efficacy of gauze, each chitosan agent, proper application, and participant surveys were obtained and included for analysis using univariate techniques. RESULTS: From January 2007 to June 2007, 55 (45%) DS, 36 (29%) OS, and 32 (26%) CP agents were used to treat 123 actively bleeding arterial injuries in 62 animals. Standard gauze failed to stop hemorrhage in 122 (99%) groins. Although all three chitosan agents were marginally effective at 2 min, the recommended time for application, hemostasis improved after 4 min. The DS dressing was the most effective, controlling hemorrhage 76% at 4 min. Of the failures, 3 (23%) DS and 9 (53%) OS were due to improper application. End-user survey results demonstrated that medics preferred the DS dressing 77% and 60% over the OS and CP, respectively. CONCLUSIONS: Chitosan based bandages are significantly more effective at hemorrhage control compared to standard gauze field dressings. The dual-sided chitosan dressing demonstrated better hemorrhage control than the one-sided dressing and the chitosan powder, and was less likely to fail despite application errors.

Laparoscopic gastric gastrointestinal stromal tumor resection: the mayo clinic experience.

HYPOTHESIS: Laparoscopic resection of gastric gastrointestinal stromal tumors (GISTs) is safe and effective. DESIGN: Retrospective medical record review. SETTING: Tertiary referral center. PATIENTS: Patients undergoing laparoscopic resection of gastric GISTs from April 1, 2000, to April 1, 2006. MAIN OUTCOME MEASURES: Demographic data, diagnostic workup, operative technique, tumor characteristics, morbidity, mortality, and follow-up. RESULTS: Thirty-three patients underwent attempted laparoscopic resection of gastric GISTs, with 31 operations completed laparoscopically. The mean patient age was 68 years (age range, 35-86 years). The female to male ratio was 18:15. Sixteen patients (49%) were asymptomatic, and their tumors were found incidentally. Of 24 patients (73%) who underwent preoperative endoscopic ultrasonography, the results of fine-needle aspiration verified the diagnosis in 13 patients (54%). The mean operative time was 124 minutes (range, 30-253 minutes). A combined endoscopic-laparoscopic approach was used in 11 patients (33%). The mean tumor size was 3.9 cm (range, 0.5-10.5 cm). Two patients (6%) underwent conversion to an open procedure. The median hospital stay duration was 3 days. The mean follow-up was 13 months (range, 3-64 months). There were no local recurrences. Three patients (9%) experienced complications, including 1 wound infection and 2 episodes of upper gastrointestinal tract bleeding. There were no mortalities. CONCLUSION: Although technically demanding, the laparoscopic approach to gastric GISTs is safe and effective, resulting in a short hospital stay duration and low morbidity.

Laparoscopic vs open colectomy for colon cancer: results from a large nationwide population-based analysis.

PURPOSE: Laparoscopic colectomy has only recently become an accepted technique for the treatment of colon cancer. We sought to analyze factors that affect the type of resection performed and associated outcomes from a large nationwide database. METHODS: All admissions with a primary diagnosis of colon cancer undergoing elective resection were selected from the 2003 and 2004 Nationwide Inpatient Samples. Multiple linear and logistic regression analyses were used to compare outcome measures and identify independent predictors of a laparoscopic approach. RESULTS: We identified 98,923 admissions (mean age 69.2 years). They were predominately Caucasian (81%), had localized disease (63%), had private insurance (56%), and had surgery performed in urban hospitals (87%). Laparoscopic resection was performed in 3,296 cases (3.3%) and was associated with a lower complication rate (18% vs 22%), shorter length of stay (6 vs 7.6 days), decreased need for skilled aftercare (5% vs 11%), and lower mortality (0.6% vs 1.4%, all P<0.01). There was no significant difference in the total hospital charges between the groups ($34,685 vs $34,178, P=0.19). Independent predictors of undergoing laparoscopic resection were age<70 (odds ratio [OR]=1.2, P<0.01), national region (Midwest OR=1.9, West OR=2.0, P<0.01), and lower disease stage (OR=2.5, P<0.01). Ethnic category and insurance status showed no significant association with operative method (P>0.05). CONCLUSIONS: Laparoscopy for colon cancer is associated with improved outcomes in unadjusted analysis and similar charges compared to open resection. We found no influence of race or payer status on the utilization of a laparoscopic approach.

Training physicians for combat casualty care on the modern battlefield.

INTRODUCTION: Trauma training among nonsurgical physicians in the military is highly variable in amount and quality. However, all deployed military physicians, regardless of specialty, are expected to provide combat casualty care. The goal was to assess the effectiveness of an intense modular trauma refresher course for nonsurgical physicians deploying to a combat zone. METHODS: All graduating nonsurgical residents participated in this 2.5-day course, consisting of 4 modules: (1) didactic session; (2) simulation with interactive human surgical simulators; (3) case presentations and triage scenarios from Iraq/Afghanistan with associated skill stations; and (4) live tissue surgical procedure laboratory. Competency tests, surveys, and after action comments were reviewed and compared before and after course completion. RESULTS: Between May 2005 and April 2007, 60 physicians participated in the course. By specialties, there were 32 internists, 16 pediatricians, 7 general practitioners, 4 obstetricians/gynecologists, and 1 "other" nonsurgical physician represented. Precourse and postcourse tests were administered to 31 of 60 participants. The mean test scores improved from 76% to 96% upon completion of the course (p < 0.01). Additionally, self-perceived confidence levels in handling battlefield casualties from questionnaires based on Likert scale responses (1 = not confident, 5 = confident) improved from an average of 2.3 before the course to 3.9 upon completion of the course (p < 0.01). CONCLUSION: All military physicians must be prepared to manage combat casualties. This hybrid training model may be an effective method to prepare nonsurgeons to deal with battle injuries. This course significantly improved the knowledge and confidence among primary care physicians.