Animal model-based simulation training for three emergent and urgent operations of penetrating thoracic injuries

PURPOSE

To develop animal models of penetrating thoracic injuries and to observe the effects of the animal model-based training on improving the trainees' performance for emergent and urgent thoracic surgeries.

METHODS

With a homemade machine, animal models of lung injuries and penetrating heart injuries were produced in porcine and used for training of chest tube drainage, urgent sternotomy, and emergent thoracotomy. Coefficient of variation of abbreviated injury scale and blood loss was calculated to judge the reproducibility of animal models. Five operation teams from basic-level hospitals (group A) and five operation teams from level III hospitals (group B) were included to be trained and tested. Testing standards for the operations were established after thorough literature review, and expert questionnaires were employed to evaluate the scientificity and feasibility of the testing standards. Tests were carried out after the training. Pre- and post-training performances were compared. Post-training survey using 7-point Likert scale was taken to evaluate the feelings of the trainees to these training approaches.

RESULTS

Animal models of the three kinds of penetrating chest injuries were successfully established and the coefficient of variation of abbreviated injury scale and blood loss were all less than 25%. After literature review, testing standards were established, and expert questionnaire results showed that the scientific score was 7.30 ± 1.49, and the feasibility score was 7.50 ± 0.89. Post-training performance was significantly higher in both group A and group B than pre-training performance. Post-training survey showed that all the trainees felt confident in applying the operations and were generally agreed that the training procedure were very helpful in improving operation skills for thoracic penetrating injury.

CONCLUSIONS

Animal model-based simulation training established in the current study could improve the trainees' performance for emergent and urgent thoracic surgeries, especially of the surgical teams from basic-level hospitals.

Cardiothoracic Surgical Volume Within the Military Health System: Fiscal Years 2007 to 2017

BACKGROUND

Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown.

METHODS

We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis.

RESULTS

Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets.

CONCLUSIONS

Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume.

Thoracic Injury in Patients Injured by Explosions on the Battlefield and in Terrorist Incidents

Thoracic injury is common on the battlefield and in terrorist attacks, occurring in 10% to 70% of patients depending on the type of weapons used. Typical injuries seen include bullet, blast, and fragment injuries to the thorax, which are often associated with injuries to other parts of the body. Initial treatment prehospital and in the ED is carried out according to the principles of Tactical Combat Casualty Care or other standard trauma management systems. Immediately life-threatening problems including catastrophic hemorrhage are dealt with rapidly, and early consideration is given to CT scanning or rapid surgical intervention where appropriate. All patients should be given lung-protective ventilation. Treatment of these patients in the critical care unit is complicated by the severity of associated injuries and by features specific to combat trauma including blast lung injury, a high incidence of delirium, unusual infections such as colonization with multidrug-resistant Acinetobacter baumannii complex, and sometimes invasive fungal infections. A minority of patients with blast lung injury in published series have been successfully treated with prolonged respiratory support with high-frequency oscillatory ventilation and extracorporeal membrane oxygenation. The role of newer treatment options such as resuscitative endovascular balloon occlusion of the aorta is not yet known. In this article we review the relatively sparse literature on this group of patients and provide practical advice based on the literature and our institution's extensive experience of managing battlefield casualties.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Microbiology and risk factors associated with war-related wound infections in the Middle East

The Middle East region is plagued with repeated armed conflicts that affect both civilians and soldiers. Injuries sustained during war are common and frequently associated with multiple life-threatening complications. Wound infections are major consequences of these war injuries. The microbiology of war-related wound infections is variable with predominance of Gram-negative bacteria in later stages. The emergence of antimicrobial resistance among isolates affecting war-related wound injuries is a serious problem with major regional and global implications. Factors responsible for the increase in multidrug-resistant pathogens include timing and type of surgical management, wide use of antimicrobial drugs, and the presence of metallic or organic fragments in the wound. Nosocomial transmission is the most important factor in the spread of multidrug-resistant pathogens. Wound management of war-related injuries merits a multidisciplinary approach. This review aims to describe the microbiology of war-related wound infections and factors affecting their incidence from conflict areas in Iraq, Syria, Israel, and Lebanon.