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Sellier A, Beucler N, Joubert C, Julien C, Tannyeres P, Anger F, Bernard C, Desse N, Dagain A. Emergency Cranial Surgeries Without the Support of a Neurosurgeon: Experience of the French Military Surgeons. Mil Med 2024; 189:598-605. [PMID: 35906867 DOI: 10.1093/milmed/usac227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 07/03/2022] [Accepted: 07/23/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Unlike orthopedic or visceral surgeons, French military neurosurgeons are not permanently deployed on the conflict zone. Thus, craniocerebral war casualties are often managed by general surgeons in the mobile field surgical team. The objective of the study was to provide the feedback of French military surgeons who operated on craniocerebral injuries during their deployment in a role 2 surgical hospital without a neurosurgeon. MATERIALS AND METHODS A cross-sectional survey was conducted by phone in March 2020, involving every military surgeon currently working in the French Military Training Hospitals, with an experience of cranial surgery without the support of a neurosurgeon during deployment. We strived to obtain contextual, clinical, radiological, and surgical data. RESULTS A total of 33 cranial procedures involving 64 surgeons were reported from 1993 to 2018. A preoperative CT scan was not available in 18 patients (55%). Half of the procedures consisted in debridement of craniocerebral wounds (52%, n = 17), followed by decompressive craniectomies (30%, n = 10), craniotomy with hematoma evacuation (15%, n = 5), and finally one (3%) surgery with exploratory burr holes were performed. The 30-day survival rate was 52% (n = 17) and 50% (n = 10/20) among the patients who sustained severe traumatic brain injury. CONCLUSIONS This survey demonstrates the feasibility and the plus-value of a neurosurgical damage control procedure performed on the field by a surgeon nonspecialized in cranial surgery. The stereotyped neurosurgical techniques used by the in-theater surgeon were learned during a specific predeployment training course. However, the use of a live telemedicine neurosurgical support seems indispensable and could benefit the general surgeon in strained resources setting.
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Affiliation(s)
- Aurore Sellier
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Nathan Beucler
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Christophe Joubert
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Clément Julien
- Department of Visceral Surgery, Laveran Military Hospital, Marseille 13384, France
| | - Paul Tannyeres
- Department of Orthopedic surgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Florent Anger
- Department of Orthopedic surgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Cédric Bernard
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Nicolas Desse
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
| | - Arnaud Dagain
- Department of Neurosurgery, Sainte-Anne Military Hospital, Toulon Cedex 9 8800, France
- French Military Health Service Academy, École du Val-de-Grâce, Paris Cedex 5 75230, France
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Stern CA, Glaser JJ, Stockinger ZT, Gurney JM. An Analysis of Head and Neck Surgical Workload During Recent Combat Operations From 2002 to 2016. Mil Med 2023; 188:e1401-e1407. [PMID: 36574225 DOI: 10.1093/milmed/usac402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/28/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION In battle-injured U.S. service members, head and neck (H&N) injuries have been documented in 29% who were treated for wounds in deployed locations and 21% who were evacuated to a Role 4 MTF. The purpose of this study is to examine the H&N surgical workload at deployed U.S. military facilities in Iraq and Afghanistan in order to inform training, needed proficiency, and MTF manning. MATERIALS AND METHODS A retrospective analysis of the DoD Trauma Registry was performed for all Role 2 and Role 3 MTFs, from January 2002 to May 2016; 385 ICD-9 CM procedure codes were identified as H&N surgical procedures and were stratified into eight categories. For the purposes of this analysis, H&N procedures included dental, ophthalmologic, airway, ear, face, mandible maxilla, neck, and oral injuries. Traumatic brain injuries and vascular injuries to the neck were excluded. RESULTS A total of 15,620 H&N surgical procedures were identified at Role 2 and Role 3 MTFs. The majority of H&N surgical procedures (14,703, 94.14%) were reported at Role 3 facilities. Facial bone procedures were the most common subgroup across both roles of care (1,181, 75.03%). Tracheostomy accounted for 16.67% of all H&N surgical procedures followed by linear repair of laceration of eyelid or eyebrow (8.23%) and neck exploration (7.41%). H&N caseload was variable. CONCLUSIONS H&N procedures accounted for 8.25% of all surgical procedures performed at Role 2 and Role 3 MTFs; the majority of procedures were eye (40.54%) and airway (18.50%). These data can be used as planning tools to help determine the medical footprint and also to help inform training and sustainment requirements for deployed military general surgeons especially if future contingency operations are more constrained in terms of resources and personnel.
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Affiliation(s)
- Caryn A Stern
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Jacob J Glaser
- Naval Medical Research Unit, 3650 Chambers Pass, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
| | - Zsolt T Stockinger
- Naval Hospital Jacksonville & Navy Medicine Reediness and Training Command, 2080 Child St, Jacksonville, Florida 32214, USA
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, Texas 78234, USA
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Woodle S, Ravindra VM, Dewar C, Yokoi H, Meister M, Curry B, Miller C, Ikeda DS. Craniotomies at an overseas military treatment facility: Maintaining readiness for the unit and the surgeon. Clin Neurol Neurosurg 2023; 230:107742. [PMID: 37178524 DOI: 10.1016/j.clineuro.2023.107742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Craniotomy and craniectomy are common neurosurgical procedures with wide applications in both civilian and military practice. Skill maintenance for these procedures is required for military providers in the event they are called to support forward deployed service members suffering from combat and non-combat injuries. The presents investigation details the performance of such procedures at a small, overseas military treatment facility (MTF). MATERIALS AND METHODS A retrospective review of craniotomy procedures performed at an overseas military treatment facility (MTF) over a 2-year period (2019-2021) was performed. Patient and procedural data were collected for all elective and emergent craniotomies including surgical indications, outcomes, complications, military rank, and impact on duty status and tour curtailment. RESULTS A total of 11 patients underwent a craniotomy or craniectomy procedure with an average follow-up of 496.8 days (range 103-797). Seven of the 11 patients were able to undergo surgery, recovery, and convalesce without transfer to a larger hospital network or MTF. Of the 6 patients that were active duty (AD), one returned to full duty while three separated and two remain in partial duty status at latest follow-up. There were four complications in four patients with one death. CONCLUSIONS In this series, we demonstrate that cranial neurosurgical procedures can be performed safely and effectively while at an overseas MTF. There are potential benefits to the AD service members, their unit, and family as well as to the hospital treatment team and surgeon as this represents a clinical capability requisite to maintain trauma readiness for future conflicts.
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Affiliation(s)
- Samuel Woodle
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Callum Dewar
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Hana Yokoi
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Melissa Meister
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Brian Curry
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Charles Miller
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
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Borg TM, Cavale N, Abu-Sittah G, Ghanem A. Plastic and Maxillofacial Training for War-Zones - A Systematic Review. Craniomaxillofac Trauma Reconstr 2023; 16:154-162. [PMID: 37222978 PMCID: PMC10201192 DOI: 10.1177/19433875221083416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Study Design Injuries sustained in war-zones are variable and constantly developing according to the nature of the ongoing conflict. Soft tissue involvement of the extremities, head and neck often necessitates reconstructive expertise. However, current training to manage injuries in such settings is heterogenous. This study involves a systematic review. Objective To evaluate interventions in place to train Plastic and Maxillofacial surgeons for war-zone environments so that limitations to current training can be addressed. Methods A literature search of Medline and EMBase was performed using terms relevant to Plastic and Maxillofacial surgery training and war-zone environments. Articles that met the inclusion criteria were scored then educational interventions described in included literature were categorised according to their length, delivery style and training environment. Between-group ANOVA was performed to compare training strategies. Results 2055 citations were identified through this literature search. Thirty-three studies were included in this analysis. The highest scoring interventions were over an extended time-frame with an action-oriented training approach, using simulation or actual patients. Core competencies addressed by these strategies included technical and non-technical skills necessary when working in war-zone type settings. Conclusions Surgical rotations in trauma centers and areas of civil strife, together with didactic courses are valuable strategies to train surgeons for war-zones. These opportunities must be readily available globally and be targeted to the surgical needs of the local population, anticipating the types of combat injuries that often occur in these environments.
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Affiliation(s)
- Tiffanie-Marie Borg
- Academic Plastic Surgery Group, Barts and the London School of
Medicine and Dentistry, Queen Mary University of London, London,
UK
- Department of Surgery, Queen’s Hospital, London, UK
| | | | | | - Ali Ghanem
- Academic Plastic Surgery Group, Barts and the London School of
Medicine and Dentistry, Queen Mary University of London, London,
UK
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Ravindra VM, Tadlock MD, Gurney JM, Kraus KL, Dengler BA, Gordon J, Cooke J, Porensky P, Belverud S, Milton JO, Cardoso M, Carroll CP, Tomlin J, Champagne R, Bell RS, Viers AG, Ikeda DS. Attitudes Toward Neurosurgery Education for the Nonneurosurgeon: A Survey Study and Critical Analysis of U.S. Military Training Techniques and Future Prospects. World Neurosurg 2022; 167:e1335-e1344. [PMID: 36103986 DOI: 10.1016/j.wneu.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The U.S. military requires medical readiness to support forward-deployed combat operations. Because time and distance to neurosurgical capabilities vary within the deployed trauma system, nonneurosurgeons are required to perform emergent cranial procedures in select cases. It is unclear whether these surgeons have sufficient training in these procedures. METHODS This quality-improvement study involved a voluntary, anonymized specialty-specific survey of active-duty surgeons about their experience and attitudes toward U.S. military emergency neurosurgical training. RESULTS Survey responses were received from 104 general surgeons and 26 neurosurgeons. Among general surgeons, 81% have deployed and 53% received training in emergency neurosurgical procedures before deployment. Only 16% of general surgeons reported participating in craniotomy/craniectomy procedures in the last year. Nine general surgeons reported performing an emergency neurosurgical procedure while on deployment/humanitarian mission, and 87% of respondents expressed interest in further predeployment emergency neurosurgery training. Among neurosurgeons, 81% had participated in training nonneurosurgeons and 73% believe that more comprehensive training for nonneurosurgeons before deployment is needed. General surgeons proposed lower procedure minimums for competency for external ventricular drain placement and craniotomy/craniectomy than did neurosurgeons. Only 37% of general surgeons had used mixed/augmented reality in any capacity previously; for combat procedures, most (90%) would prefer using synchronous supervision via high-fidelity video teleconferencing over mixed reality. CONCLUSIONS These survey results show a gap in readiness for neurosurgical procedures for forward-deployed general surgeons. Capitalizing on capabilities such as mixed/augmented reality would be a force multiplier and a potential means of improving neurosurgical capabilities in the forward-deployed environments.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Department of Neurosurgery, University of California San Diego, San Diego, California, USA; Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Matthew D Tadlock
- Department of Surgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA; 1st Medical Battalion, 1st Marine Logistics Group, Camp Pendleton, California, USA
| | - Jennifer M Gurney
- U.S. Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, Texas, USA
| | - Kristin L Kraus
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Jennifer Gordon
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Jonathon Cooke
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Paul Porensky
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Shawn Belverud
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Jason O Milton
- Department of Neurosurgery, Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Mario Cardoso
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Christopher P Carroll
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Jeffrey Tomlin
- Department of Brain and Spine Surgery, Naval Medical Center, Portsmouth, Virginia, USA
| | - Roland Champagne
- Bioskills Training Center, Naval Medical Readiness Training Command, San Diego, California, USA
| | - Randy S Bell
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Angela G Viers
- Department of Surgery, U.S. Naval Hospital Okinawa, Okinawa, Japan
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
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Rask DMG, Tansey KA, Osborn PM. Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System. Mil Med 2022; 188:usab534. [PMID: 34986247 DOI: 10.1093/milmed/usab534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/07/2021] [Accepted: 12/14/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.
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Affiliation(s)
- Dawn M G Rask
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
| | - Kimberly A Tansey
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Patrick M Osborn
- Business Operations Division, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
- Department of Orthopaedic Surgery, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
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Hurst ND, Durning SJ, Cervero RM, Morrison Ponce D. Train for the Game: What Is the Learning Environment of Deployed Navy Emergency Medicine Physicians? AEM EDUCATION AND TRAINING 2021; 5:e10521. [PMID: 34041430 PMCID: PMC8138097 DOI: 10.1002/aet2.10521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 07/29/2020] [Accepted: 08/08/2020] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Medicine is a practice characterized by ongoing learning, and unique qualities of the operational learning environment (LE) may affect learner needs. When physicians move between differing practice environments learners may encounter situations for which they are unprepared. Using a conceptual framework specific to the LE, we therefore asked the following research question: what is the difference in LE for Navy emergency medicine (EM) physicians who practice in U.S. hospitals but serve an operational environment, and how do these differences shape their learning needs? METHODS We interviewed Navy EM physicians who recently deployed to explore their perceptions of the deployed LE, how it differed from the LE they practice in stateside, and the perceived effect this difference had on their learning needs. We used the constant comparative method to gather and analyze data until thematic saturation was achieved. RESULTS We interviewed 12 physicians and identified six interconnected themes consistent with the LE framework in the literature: 1) patient care is central to the learning experience; 2) professional isolation versus connectedness; 3) a sense of meaningful practice engages the learner in the LE; 4) physicians as educators shape the LE; 5) team trust impacts the LE; and 6) the larger military organization impacts the LE. CONCLUSIONS Our themes span the conceptual framework put forth by previous work and did not find themes outside this framework. These interconnected themes describe the difference in LE between the stateside and deployed setting and impact the learning needs of Navy EM physicians. These results inform strategies to position the deployed medical unit for success.
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Affiliation(s)
- Nicole D. Hurst
- Uniformed Services University of the Health SciencesBethesdaMDUSA
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Sellier A, Beucler N, Desse N, Julien C, Tannyeres P, Bernard C, Joubert C, Dagain A. Evaluation of neurosurgical training of French military surgeons prior to their deployment. Neurochirurgie 2021; 67:454-460. [PMID: 33766563 DOI: 10.1016/j.neuchi.2021.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/27/2020] [Accepted: 03/06/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND A specific training course was formalized in 2007 in order to facilitate the management of cranio-encephalic injuries by French military general surgeons during deployment, within the Advanced Course for Deployment Surgery (ACDS). The objective is to evaluate the neurosurgical pre-deployment training course attended by the military surgeons. METHODS From June 2019 to September 2019, we conducted a cross-sectional survey in the form of a digital self-completed questionnaire, addressed to all graduated military surgeons working in the French Military Training Hospitals. The survey included: (1) a knowledge assessment; and (2) a self-assessment of the training course. The participating surgeons were classified into two groups according to their participation (group 1) or not (group 2) in the neurosurgical module. The main outcome was the score received on the knowledge assessment. RESULTS Among the 145 military surgeons currently in service, 76 participated in our study (53%), of which 49 were classified in group 1 (64%) and 27 in group 2 (36%). Group 1 surgeons had a significantly higher score than Group 2 at the knowledge assessment (mean 21.0±7.1 vs. 17.8±6.0, P=0.041). The most successful questions were related to TBI diagnosis and surgical technique, while the least successful questions dealt with "beyond emergency care" and surgical indications. CONCLUSION The French pre-deployment neurosurgical training course provides a strong neurosurgical background, sufficient to perform life-saving procedures in a modern conflict situation. However, neurosurgical specialized advice should be solicited whenever possible to assist the in-theatre surgeon in surgical decisions.
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Affiliation(s)
- A Sellier
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France.
| | - N Beucler
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France
| | - N Desse
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France
| | - C Julien
- Department of Visceral Surgery, Sainte-Anne Military Hospital, Toulon, France
| | - P Tannyeres
- 9th Army Medical Center, 144th medical unit, French Military Health Service, Canjuers, France
| | - C Bernard
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France
| | - C Joubert
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France
| | - A Dagain
- Department of Neurosurgery, Sainte-Anne Military Hospital, 1, Boulevard Sainte Anne, BP 600, 8800 Toulon cedex 9, France; French Military Health Service Academy - École du Val-de-Grâce, Paris, France
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Nealeigh MD, Kucera WB, Artino AR, Bradley MJ, Meyer HS. The Isolated Surgeon: A Scoping Review. J Surg Res 2021; 264:562-571. [PMID: 33461780 DOI: 10.1016/j.jss.2020.12.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Surgeons in resource-limited environments often provide care outside the expected scope of current general surgery training. Geographically isolated patients may be unwilling or unable to travel for specialty care. These same patients also present with life-threatening emergencies beyond the typical breadth of a general surgeon's practice, in hospitals with limited professional and material support. This review characterizes the unique role of isolated surgeons, so individual surgeons and health care organizations may focus professional development resources more efficiently, with the ultimate goal of improved patient care. METHODS We performed a scoping review of the isolated surgeon, reviewing 25 years of literature regarding isolated US civilian and military surgeons. We examined emerging themes regarding the definition of an isolated surgeon, the scope of surgical practice beyond current training norms, and training gaps identified by surgeons in an isolated role. RESULTS From 904 articles identified, we included 91 for final review. No prior definition exists for the isolated surgeon, although multiple definitions describe rural surgeons, patients, or hospitals; we propose an initial definition from consistent themes in the literature. Isolated surgeons across varied practice settings consistently performed relatively large volumes of cases of, and identified training gaps in, orthopedic, obstetric and gynecologic, urologic, and vascular surgery subspecialties. Life-threatening, "rare-but-real" cases in the above and neurosurgical disciplines are uncommon, but consistent across practice settings. CONCLUSIONS This review represents the largest examination of the isolated surgeon in the current literature. Clarifying the identity, practice components, and training gaps of the isolated surgeon represent the first step in formalizing support for this small but critical group of surgeons and their patients.
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Affiliation(s)
- Matthew D Nealeigh
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland.
| | - Walter B Kucera
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Anthony R Artino
- Department of Health, Human Function, & Rehabilitation Sciences, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Matthew J Bradley
- Department of Surgery, Walter Reed National Military Medical Center and the Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Holly S Meyer
- Center for Health Professions Education, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Outcomes following penetrating neck injury during the Iraq and Afghanistan conflicts: A comparison of treatment at US and United Kingdom medical treatment facilities. J Trauma Acute Care Surg 2020; 88:696-703. [PMID: 32068717 PMCID: PMC7182242 DOI: 10.1097/ta.0000000000002625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental digital content is available in the text. The United States and United Kingdom (UK) had differing approaches to the surgical skill mix within deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.
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11
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Abstract
BACKGROUND Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps. METHODS Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX). RESULTS Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period. CONCLUSION Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone. LEVEL OF EVIDENCE Therapeutic/Care Management IV.
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Azari D, Greenberg C, Pugh C, Wiegmann D, Radwin R. In Search of Characterizing Surgical Skill. JOURNAL OF SURGICAL EDUCATION 2019; 76:1348-1363. [PMID: 30890315 DOI: 10.1016/j.jsurg.2019.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/17/2019] [Accepted: 02/20/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE This paper provides a literature review and detailed discussion of surgical skill terminology. Culminating in a novel model that proposes a set of unique definitions, this review is designed to facilitate shared understanding to study and develop metrics quantifying surgical skill. DESIGN Objective surgical skill analysis depends on consistent definitions and shared understanding of terms like performance, expertise, experience, aptitude, ability, competency, and proficiency. STRUCTURE Each term is discussed in turn, drawing from existing literature and colloquial uses. IMPLICATIONS A new model of definitions is proposed to cement a common and consistent lexicon for future skills analysis, and to quantitatively describe a surgeon's performance throughout their career.
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Affiliation(s)
- David Azari
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Caprice Greenberg
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin; Department of Surgery, Wisconsin Surgical Outcomes Research (WiSOR) Program, University of Wisconsin-Madison, Madison, Wisconsin
| | - Carla Pugh
- Department of Surgery, Stanford University, Stanford, California
| | - Douglas Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Robert Radwin
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin; Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin.
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Nealeigh MD, Kucera WB, Bradley MJ, Jessie EM, Sweeney WB, Ritter EM, Rodriguez CJ. Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons. JOURNAL OF SURGICAL EDUCATION 2019; 76:1139-1145. [PMID: 30952458 DOI: 10.1016/j.jsurg.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/13/2018] [Accepted: 12/10/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Newly-graduated military general surgeons often find themselves isolated at sea, solely responsible for all surgical care of several thousand sailors, regardless of the surgical specialty training required for any individual procedure. This educational need assessment explored trends in afloat surgical care over the last 25 years, and assessed trainees' preparedness for their expected role as an isolated surgeon. DESIGN A sample of deidentified US Navy Ship's Surgeon case logs were reviewed to determine afloat case load trends in 5 common afloat case categories (urologic/gynecologic, anorectal, hernia, appendectomy, and hand/orthopedic/trauma) from 1990s to 2017. Individual procedures were mapped to American College of Surgeons/Military Health System Knowledge, Skills, and Attitudes line items to ensure afloat-relevant skills were identified. Recent military resident case logs were then compared with afloat cases to evaluate relevant trainee experience. SETTING US Navy ships at sea from 1995 to 2017. PARTICIPANTS US Navy afloat-deployed surgeons, totaling 1340 cases within the study period. RESULTS Case log analysis of 1340 surgeries, comprising >200 months at sea, reflected 46 named procedures; 34 of 46 (74%) correlated to an intraoperative knowledge, skills, and attitudes item. The most common surgeries were vasectomy, (304 of 1340, 23%). No difference in case mix was apparent comparing pre- and post-2000 deployments (representing afloat laparoscopic integration) in 4 of 5 categories, while hernias proportionally declined. Case volume per deployment markedly declined overall (p < 0.001) and in each category. Resident case log analysis from 2012 to 2016 showed experience was limited in urologic/gynecologic, orthopedic, and open appendectomy categories. CONCLUSIONS No formal case repository exists for afloat surgery, making detailed analysis problematic. Current training provides excellent surgical education but minimal exposure to rare-but-real cases expected on deployments, which may not translate to competency for the isolated, afloat surgeon. Military surgical leadership should embrace training for these cases and assertively invest in the development of the military's newest surgeons.
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Affiliation(s)
- Matthew D Nealeigh
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Walter B Kucera
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Matthew J Bradley
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Elliot M Jessie
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - W Brian Sweeney
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - E Matthew Ritter
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Carlos J Rodriguez
- Department of Surgery at the Uniformed Services University, the Walter Reed National Military Medical Center, Bethesda, Maryland
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Mackenzie CF, Tisherman SA, Shackelford S, Sevdalis N, Elster E, Bowyer MW. Efficacy of Trauma Surgery Technical Skills Training Courses. JOURNAL OF SURGICAL EDUCATION 2019; 76:832-843. [PMID: 30827743 DOI: 10.1016/j.jsurg.2018.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/07/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Because open surgical skills training for trauma is limited in clinical practice, trauma skills training courses were developed to fill this gap, The aim of this report is to find supporting evidence for efficacy of these courses. The questions addressed are: What courses are available and is there robust evidence of benefit? DESIGN We performed a systematic review of the training course literature on open trauma surgery procedural skills courses for surgeons using Kirkpatrick's framework for evaluating complex educational interventions. Courses were identified using Pubmed, Google Scholar and other databases. SETTING AND PARTICIPANTS The review was carried out at the University of Maryland, Baltimore with input from civilian and military trauma surgeons, all of whom have taught and/or developed trauma skills courses. RESULTS We found 32 course reports that met search criteria, including 21 trauma-skills training courses. Courses were of variable duration, content, cost and scope. There were no prospective randomized clinical trials of course impact. Efficacy for most courses was with Kirkpatrick level 1 and 2 evidence of benefit by self-evaluations, and reporting small numbers of respondents. Few courses assessed skill retention with longitudinal data before and after training. Three courses, namely: Advanced Trauma Life Support (ATLS), Advanced Surgical Skills for Exposure in Trauma (ASSET) and Advanced Trauma Operative Management (ATOM) have Kirkpatrick's level 2-3 evidence for efficacy. Components of these 3 courses are included in several other courses, but many skills courses have little published evidence of training efficacy or skills retention durability. CONCLUSIONS Large variations in course content, duration, didactics, operative models, resource requirements and cost suggest that standardization of content, duration, and development of metrics for open surgery skills would be beneficial, as would translation into improved trauma patient outcomes. Surgeons at all levels of training and experience should participate in these trauma skills courses, because these procedures are rarely performed in routine clinical practice. Faculty running courses without evidence of training benefit should be encouraged to study outcomes to show their course improves technical skills and subsequently patient outcomes. Obtaining Kirkpatrick's level 3 and 4 evidence for benefits of ASSET, ATOM, ATLS and for other existing courses should be a high priority.
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Affiliation(s)
- Colin F Mackenzie
- Shock Trauma Anesthesiology Research Center, Baltimore, Maryland; University of Maryland School of Medicine, Baltimore, Maryland.
| | | | | | - Nick Sevdalis
- Center for Implementation Science, Kings College, London, UK.
| | - Eric Elster
- Department of Surgery, The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland.
| | - Mark W Bowyer
- Department of Surgery, The Uniformed Services University of Health Sciences and the Walter Reed National Military Medical Center, Bethesda, Maryland.
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Stern CA, Stockinger ZT, Todd WE, Gurney JM. An Analysis of Orthopedic Surgical Procedures Performed During U.S. Combat Operations from 2002 to 2016. Mil Med 2019; 184:813-819. [DOI: 10.1093/milmed/usz093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/15/2019] [Accepted: 04/02/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Orthopedic surgery constitutes 27% of procedures performed for combat injuries. General surgeons may deploy far forward without orthopedic surgeon support. This study examines the type and volume of orthopedic procedures during 15 years of combat operations in Iraq and Afghanistan.
Materials and Methods
Retrospective analysis of the US Department of Defense Trauma Registry (DoDTR) was performed for all Role 2 and Role 3 facilities, from January 2002 to May 2016. The 342 ICD-9-CM orthopedic surgical procedure codes identified were stratified into fifteen categories, with upper and lower extremity subgroups. Data analysis used Stata Version 14 (College Station, TX).
Results
A total of 51,159 orthopedic procedures were identified. Most (43,611, 85.2%) were reported at Role 3 s. More procedures were reported on lower extremities (21,688, 57.9%). Orthopedic caseload was extremely variable throughout the 15-year study period.
Conclusions
Orthopedic surgical procedures are common on the battlefield. Current dispersed military operations can occur without orthopedic surgeon support; general surgeons therefore become responsible for initial management of all injuries. Debridement of open fracture, fasciotomy, amputation and external fixation account for 2/3 of combat orthopedic volume; these procedures are no longer a significant part of general surgery training, and uncommonly performed by general/trauma surgeons at US hospitals. Given their frequency in war, expertise in orthopedic procedures by military general surgeons is imperative.
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Affiliation(s)
- Caryn A Stern
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, TX 78234
| | - Zsolt T Stockinger
- Naval Hospital Jacksonville & Navy Medicine Readiness and Training Command, 2080 Child St, Jacksonville, FL 32214
| | - William E Todd
- Naval Hospital Jacksonville & Navy Medicine Readiness and Training Command, 2080 Child St, Jacksonville, FL 32214
| | - Jennifer M Gurney
- Joint Trauma System, DoD Center of Excellence for Trauma, 3611 Chambers Dr, Joint Base San Antonio, Fort Sam Houston, TX 78234
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Mancini DJ, Smith BP, Polk TM, Schwab CW. Forward Surgical Team Experience (FSTE) Is Associated With Increased Confidence With Combat Surgeon Trauma Skills. Mil Med 2019; 183:e257-e260. [PMID: 29741715 DOI: 10.1093/milmed/usy080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 04/06/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Little is known regarding the confidence of military surgeons prior to combat zone deployment. Military surgeons are frequently deployed without peers experienced in combat surgery. We hypothesized that forward surgical team experience (FSTE) increases surgeon confidence with critical skill sets. Methods We conducted a national survey of military affiliated personnel. We used a novel survey instrument that was piloted and validated by experienced military surgeons to collect demographics, education, practice patterns, and confidence parameters for trauma and surgical critical care skills. Skills were defined as crucial operative techniques for hemorrhage control and resuscitation. Surveyors were blinded to participants, and surveys were returned electronically via REDCap database. Data were analyzed with SPSS using appropriate models. Significance was considered p < 0.05. Results Of 174 distributed surveys, 86 were completed. Nine individuals failed to characterize their FSTE, thus leaving a sample size of 77. At the time of first deployment, 78.4% were alone or with less experienced surgeons and 53.2% had less than 2 yr of post-residency practice. The respondents' confidence in damage control techniques and seven other trauma skills increased relative to FSTE. After adjusting for years of practice, number of trauma resuscitations performed per month and pre-deployment training, there remained a significant positive association between FSTE and confidence in damage control, thoracic surgery, extremity/junctional hemorrhage control, trauma systems administration, adult critical care and airway management. Conclusions Training programs and years of general surgery practice do not replace FSTE among military surgeons. Pre-deployment training that mimics FST skill sets should be developed to improve military surgeon confidence and outcomes. Level of Evidence Prognostic and Epidemiologic, Level IV.
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Affiliation(s)
- D Joshua Mancini
- Department of Surgery, Dartmouth-Hitchcock, 1 Medical Center Dr, Lebanon, NH
| | - Brian P Smith
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 51N 39th Street, Medical Office Building 1st Floor, Suite 120, Philadelphia, PA
| | - Travis M Polk
- Naval Medical Center Portsmouth, 620 John Paul Jones Cir, Portsmouth, VA
| | - C William Schwab
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 51N 39th Street, Medical Office Building 1st Floor, Suite 120, Philadelphia, PA
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Reed AM, Janak JC, Orman JA, Hudak SJ. Genitourinary Injuries Among Female U.S. Service Members During Operation Iraqi Freedom and Operation Enduring Freedom: Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project. Mil Med 2018; 183:e304-e309. [DOI: 10.1093/milmed/usx079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Amy M Reed
- Brooke Army Medical Center, 3551 Roger Brook Dr., JBSA Fort Sam Houston, San Antonio, TX
| | - Judson C Janak
- Joint Trauma System, 3698 Chambers Pass STE B, JBSA Fort Sam Houston, San Antonio, TX
| | - Jean A Orman
- Joint Trauma System, 3698 Chambers Pass STE B, JBSA Fort Sam Houston, San Antonio, TX
| | - Steven J Hudak
- Brooke Army Medical Center, 3551 Roger Brook Dr., JBSA Fort Sam Houston, San Antonio, TX
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Can hyper-realistic physical models of peripheral vessel exposure and fasciotomy replace cadavers for performance assessment? J Trauma Acute Care Surg 2017; 83:S130-S135. [PMID: 28301396 DOI: 10.1097/ta.0000000000001419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Work-hour restrictions have reduced operative experience for residents. The Advanced Surgical Skills for Exposure in Trauma (ASSET) course fills this training gap. Cadaver use has limitations including cost and availability. Hyper-realistic synthetic models may provide an alternative to cadavers. We compared same surgeon performance between synthetic and cadaveric models to determine interchangeability for formative evaluation. METHODS Forty residents (<4 weeks after ASSET) and 35 faculty (mean, 2.5 ± 1.3 years after ASSET) exposed axillary, brachial, and femoral arteries, and performed lower extremity fasciotomy. Separate evaluators and random starting order between models were used for participants. Individual procedure scores and aggregate procedure scores, a trauma readiness index, evaluated participants. Student's t and χ tests were used where appropriate. p Values less than 0.05 were considered significant. RESULTS For same surgeons, faculty, but not residents, had higher trauma readiness index on the synthetic model (0.63 vs. 0.70, p < 0.01; 0.63 vs. 0.67, p = 0.06, respectively). Scores were not significantly different between models for residents except for the brachial artery exposure (0.68 vs. 0.75, p < 0.01), which was the least realistic of all procedures. Faculty did significantly better on the synthetic model in all procedures. All participants completed procedures nearly twice as quickly (5.61 ± 3.21 vs. 10.08 ± 4.66 minutes) and performed fewer errors on the synthetic model (113 vs. 53, p < 0.01; 118 vs. 76, p = 0.03, respectively). CONCLUSION Same surgeons performed procedures quicker and with fewer errors on the synthetic model. Residents performed similarly on both model types, this likely represents the unfamiliarity neophytes bring to new procedures. This suggests that the synthetic model, with easily discernible and standardized anatomy, may be useful in the early stages of training to understand critical procedural steps. The difficulty of the cadaver is more apt to assess and evaluate the experienced surgeon and identify opportunities for improvement. LEVEL OF EVIDENCE Prognostic, level III.
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Edwards MJ, Edwards KD, White C, Shepps C, Shackelford S. Saving the Military Surgeon: Maintaining Critical Clinical Skills in a Changing Military and Medical Environment. J Am Coll Surg 2016; 222:1258-64. [DOI: 10.1016/j.jamcollsurg.2016.03.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 10/21/2022]
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Malgras B, Barbier O, Petit L, Rigal S, Pons F, Pasquier P. Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali. Injury 2016; 47:99-103. [PMID: 26264878 DOI: 10.1016/j.injury.2015.07.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/10/2015] [Accepted: 07/27/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. METHODS All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. RESULTS 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. CONCLUSION this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.
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Affiliation(s)
- Brice Malgras
- 14th Parachutist Forward Surgical Team, France; Department of Digestive Surgery, Val de Grace Military Teaching Hospital, 74 boulevard de Port Royal, 75005 Paris, France.
| | - Olivier Barbier
- 14th Parachutist Forward Surgical Team, France; Department of Orthopedic Surgery, Begin Military Teaching Hospital, 69 avenue de Paris, 94160 Saint Mandé, France
| | - Ludovic Petit
- Medical Unit of the 8th French Military Parachutist Unit, avenue Jacques Desplats, 81100 Castres, France
| | - Sylvain Rigal
- Clinic of Traumatology and Orthopaedics, Percy Military Teaching Hospital, 101 avenue de Henri Barbusse, 92140 Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val de Grace, 1 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Pasquier
- 14th Parachutist Forward Surgical Team, France; Intensive Care Unit, Begin Military Teaching Hospital, 69 avenue de Paris, 94160 Saint Mandé, France
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O'Reilly D, Lordan J, Streets C, Midwinter M, Mirza D. Maintaining surgical skills for military general surgery: the potential role for multivisceral organ retrieval in military general surgery training and practice: Table 1. J ROY ARMY MED CORPS 2015; 162:236-8. [DOI: 10.1136/jramc-2015-000444] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 07/02/2015] [Indexed: 11/04/2022]
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Pasquier P, Dubost C, Boutonnet M, Chrisment A, Villevieille T, Batjom E, Bordier E, Ausset S, Puidupin M, Martinez JY, Bay C, Escarment J, Pons F, Lenoir B, Mérat S. Predeployment training for forward medicalisation in a combat zone: the specific policy of the French Military Health Service. Injury 2014; 45:1307-11. [PMID: 24952973 DOI: 10.1016/j.injury.2014.05.037] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/22/2014] [Accepted: 05/28/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To improve the mortality rate on the battlefield, and especially the potentially survivable pre-Medical Treatment Facility deaths, Tactical Combat Casualty Care (TCCC) is now considered as a reference for management of combat casualty from the point of injury to the first medical treatment facility. TCCC comprises of a set of trauma management guidelines designed for use on the battlefield. The French Military Health Service also standardised a dedicated training programme, entitled "Sauvetage au Combat" (SC) ("forward combat casualty care"), with the characteristic of forward medicalisation on the battlefield, the medical team being projected as close as possible to the casualty at the point of injury. The aim of our article is to describe the process and the result of the SC training. MATERIALS AND METHODS Records from the French Military Health Service Academy - École du Val-de-Grâce administration, head of the SC teaching programme, defining its guidelines, and supporting its structure and its execution, were examined and analyzed, since the standardisation of the SC training programme in 2008. The total number of trainees was listed following the different courses (SC1, SC2, SC3). RESULTS At the end of 2013, every deployed combatant underwent SC1 courses (confidential data), 785 health-qualified combatants were graduated for SC2 courses and 672 Role 1 physician-nurse pairs for SC3 courses. CONCLUSION The SC concept and programmes were defined in France in 2007 and are now completely integrated into the predeployment training of all combatants but also of French Military Health Service providers. Finally, SC teaching programmes enhance the importance of teamwork in forward combat medicalisation settings.
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Affiliation(s)
- Pierre Pasquier
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Clément Dubost
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Mathieu Boutonnet
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Anne Chrisment
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Thierry Villevieille
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Emmanuel Batjom
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Emmanuel Bordier
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
| | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Marc Puidupin
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - Jean-Yves Martinez
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - Christian Bay
- Tactical Care Training Department, French Military Health Service Academy - École du Val-de-Grâce, Paris, France.
| | - Jacques Escarment
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Desgenettes (Military Teaching Hospital), Lyon, France.
| | - François Pons
- French Military Health Service Academy - École du Val-de-Grâce, Paris, France.
| | - Bernard Lenoir
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Percy (Military Teaching Hospital), Clamart, France.
| | - Stéphane Mérat
- Department of Anesthesiology and Intensive Care Unit, Hôpital d'Instruction des Armées Bégin (Military Teaching Hospital), Saint-Mandé, France.
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Hoencamp R, Tan ECTH, Idenburg F, Ramasamy A, van Egmond T, Leenen LPH, Hamming JF. Challenges in the training of military surgeons: experiences from Dutch combat operations in southern Afghanistan. Eur J Trauma Emerg Surg 2014; 40:421-8. [DOI: 10.1007/s00068-014-0401-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/23/2014] [Indexed: 10/25/2022]
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A concluding after-action report of the Senior Visiting Surgeon program with the United States Military at Landstuhl Regional Medical Center, Germany. J Trauma Acute Care Surg 2014; 76:878-83; discussion 883. [DOI: 10.1097/ta.0000000000000159] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brennan J. Head and neck trauma in Iraq and Afghanistan: different war, different surgery, lessons learned. Laryngoscope 2013; 123:2411-7. [PMID: 23553408 DOI: 10.1002/lary.24096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/19/2013] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS The objectives are to compare and contrast the head and neck trauma experience in Iraq and Afghanistan and to identify trauma lessons learned that are applicable to civilian practice. STUDY DESIGN A retrospective review of one head and neck surgeon's operative experience in Iraq and Afghanistan was performed using operative logs and medical records. METHODS The surgeon's daily operative log book with patient demographic data and operative reports was reviewed. Also, patient medical records were examined to identify the preoperative and postoperative course of care. RESULTS The head and neck trauma experiences in Iraq and Afghanistan were very different, with a higher percentage of emergent cases performed in Iraq. In Iraq, only 10% of patients were pretreated at a facility with surgical capabilities. In Afghanistan, 93% of patients were pretreated at such facilities. Emergent neck exploration for penetrating neck trauma and emergent airway surgery were more common in Iraq, which most likely accounted for the increased perioperative mortality also seen in Iraq (5.3% in Iraq vs. 1.3% in Afghanistan). Valuable lessons regarding soft tissue trauma repair, midface fracture repair, and mandible fracture repair were learned. CONCLUSION The head and neck trauma experiences in Iraq and Afghanistan were very different, and the future training for mass casualty trauma events should reflect these differences. Furthermore, valuable head and neck trauma lessons learned in both war zones are applicable to the civilian practice of trauma. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Joseph Brennan
- Department of Surgery, San Antonio Military Medical Center, San Antonio, Texas, U.S.A
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Combat readiness for the modern military surgeon: data from a decade of combat operations. J Trauma Acute Care Surg 2012; 73:S64-70. [PMID: 22847097 DOI: 10.1097/ta.0b013e3182625ebb] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.
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Schoenfeld AJ. The combat experience of military surgical assets in Iraq and Afghanistan: a historical review. Am J Surg 2012; 204:377-83. [PMID: 22440274 DOI: 10.1016/j.amjsurg.2011.09.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 09/26/2011] [Accepted: 09/26/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND The Forward Surgical Team and Combat Support Hospital have been used extensively only during the past decade in Iraq and Afghanistan. The scope of their operational experience and historical development remain to be described. METHODS The literature was searched to obtain publications regarding the historical development of Forward Surgical Teams and Combat Support Hospitals, as well as their surgical experiences in Iraq and Afghanistan. Relevant publications were reviewed in full and their results summarized. RESULTS The doctrine behind the use of modern military surgical assets was not well developed at the start of the Iraq and Afghanistan conflicts. The Forward Surgical Team and Combat Support Hospital were used in practice only over the past decade. Because of the nature of these conflicts, both types of modern military surgical assets have not been used as intended and such units have operated in various roles, including combat support elements and civilian medical treatment facilities. CONCLUSIONS As more research comes to light, a better appreciation for the future of American military medicine and surgery will develop.
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Affiliation(s)
- Andrew J Schoenfeld
- Department of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 N. Piedras St., El Paso, TX 79920, USA.
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Cruz JASD, Passerotti CC, Frati RMC, Reis STD, Okano MTR, Gouveia ÉM, Biolo KD, Duarte RJ, Nguyen H, Srougi M. Surgical Performance During Laparoscopic Radical Nephrectomy Is Improved With Training in a Porcine Model. J Endourol 2012; 26:278-82. [DOI: 10.1089/end.2011.0367] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Carlo Camargo Passerotti
- Department of Urology, College of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
- Urology Department, College of Medicine, Nove de Julho University (UNINOVE), São Paulo, Brazil
| | | | | | | | - Éder Maxwell Gouveia
- Department of Urology, College of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Karlo Dornelles Biolo
- Department of Urology, College of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Ricardo Jordão Duarte
- Department of Urology, College of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
| | - Hiep Nguyen
- Department of Urology, Children's Hospital, Boston, Harvard Medical School, Boston, Massachusetts
| | - Miguel Srougi
- Department of Urology, College of Medicine, University of São Paulo (FMUSP), São Paulo, Brazil
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Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department. Am J Surg 2011; 201:666-72. [DOI: 10.1016/j.amjsurg.2011.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 01/24/2011] [Accepted: 01/24/2011] [Indexed: 11/21/2022]
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