Sustaining Clinical Readiness for Combat Casualty Care

Putting the ready in readiness: A post hoc analysis of surgeon performance during a military mass casualty situation in Afghanistan

BACKGROUND

All military surgeons must maintain trauma capabilities for expeditionary care contexts, yet most are not trauma specialists. Maintaining clinical readiness for trauma and mass casualty care is a significant challenge for military and civilian surgeons. We examined the effect of a prescribed clinical readiness program for expeditionary trauma care on the surgical performance of 12 surgeons during a 60-patient mass-casualty situation (MASCAL).

METHODS

The sample included orthopedic (four) and general surgeons (eight) who cared for MASCAL victims at Hamad Karzai International Airport, Kabul, Afghanistan, on August 26, 2021. One orthopedic and two general surgeons had prior deployment experience. The prescribed program included three primary measures of clinical readiness: 1, expeditionary knowledge (examination score); 2, procedural skills competencies (performance assessment score); and 3, clinical activity (operative practice profile metric). Data were attained from program records for each surgeon in the sample. Each of the 60 patient cases was reviewed and rated (performance score) by the Joint Trauma System's Performance Improvement Branch, a military-wide performance improvement organization. All scores were normalized to facilitate direct comparisons using effect size calculations between each predeployment measure and MASCAL surgical care.

RESULTS

Predeployment knowledge and clinical activity measures met program benchmarks. Baseline predeployment procedural skills competency scores did not meet program benchmarks; however, those gaps were closed through retraining, ensuring all surgeons met or exceeded the program benchmarks predeployment. There were very large effect sizes (Cohen's d ) between all program measures and surgical care score, confirming the relationship between the program measures and MASCAL trauma care provided by the 12 surgeons.

CONCLUSION

The prescribed program measures ensured that all surgeons achieved predeployment performance benchmarks and provided high-quality trauma care to our nation's service members.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Lateral Canthotomy/Cantholysis Performance Gap Analysis and Training Recommendations for Expeditionary Physicians

INTRODUCTION

Preservation of life, preservation of limb, and preservation of eyesight are the priorities for military medical personnel when attending to casualties. The incidences of eye injuries in modern warfare have increased significantly, despite personal eye equipment for service members. Serious eye injuries are often overlooked or discovered in a delayed fashion because they accompany other life- and limb-threatening injuries, which are assigned a higher priority. Prehospital military ocular trauma care is to shield the eye and evacuate the casualty to definitive ophthalmic care as soon as possible, with exceptions for treatment of ocular chemical injury and orbital compartment syndrome. Retrospective analysis of eye injuries in recent conflicts identified gaps in clinical capabilities with up to 96% of ocular injuries being suboptimally managed. Ocular compartment syndrome (OCS) is a complication associated with orbital hemorrhage, where significant morbidity occurs as a result of increasing intracompartment pressure. The ischemic tolerance of the retina and optic nerve is approximately 90 minutes, so OCS must be rapidly diagnosed and aggressively treated through lateral canthotomy/cantholysis (LC/C) to prevent permanent vision loss. LC/C procedures consist of using hemostats to crush the lateral canthal fold and cutting the lateral canthal tendon from the inferior crus to relieve increasing intracompartment pressure. The purpose of this study was to examine the baseline capabilities of military physicians and surgeons to accurately and independently perform the LC/C procedures and identify performance gaps that could be closed through focused professional development activities.

MATERIALS AND METHODS

This study received institutional review board approval at our institution. A total of 60 subjects voluntarily participated in the study from emergency medicine (15), general surgery (28), and ophthalmology (17). All procedural assessments were performed 1:1 by expert faculty ocular trauma specialists using a high-reliability eye trauma simulator (Sonalysts, Inc.). The competency standard was set at independent and accurate completion of all procedural components and all critical procedural components. Analyses were performed using descriptive statistics and analysis of variance to examine between-group differences (P < 0.05).

RESULTS

There was a significant difference between the total score performance and the critical score performance for the three groups (P < 0.001). Outcomes indicate a significant linear relationship between the expertise level of the clinical provider and the procedural performance of LC/C. Outcomes demonstrate the baseline surgical capabilities of the general surgeons transferred to LC/C performance; however, they were unfamiliar with the anatomy and the procedural techniques and requirements. The group of emergency medicine participants demonstrated performance gaps not only in the same areas as the general surgeons but also in their baseline surgical abilities. This suggests that different professional development activities are necessary for surgeons and physicians tasked with performing LC/V procedures.

CONCLUSIONS

We identified significant performance gaps among emergency medicine physicians, general surgeons, and ophthalmologists in their abilities to recognize and treat OCS through LC/C procedures. These sight-saving procedures are a critical competency for forward-situated clinicians in expeditionary contexts. We identified the need for targeted approaches to professional development for closing the performance gaps for both emergency medicine physicians and general surgeons.

Skill decay in surgeons deployed on military operations: a systematic review

INTRODUCTION

Decay of surgical skills due to paucity of opportunity to operate is a potential threat to patients being cared for by the Defence Medical Services while on operational deployment. Our aim was to review the literature regarding skill decay in the trained surgeon in order to understand how it may affect clinical performance and patient outcomes. We also wished to survey the likely causes of such decay and possible means of mitigation.

METHODS

A systematic review of the literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study bias assessment was also undertaken. Content summaries for the papers included study design and methodology, participant level of experience, measures and magnitude of effect, duration of no practice, and study limitations.

RESULTS

Five papers met the selection criteria. There were insufficient quantitative data on the impact of surgical skill decay on patient outcome, surgeon performance or mitigation strategies, and a meaningful quantitative synthesis could not be undertaken.

CONCLUSIONS

This systematic review of the literature found very little specific evidence confirming or refuting surgical skill decay in trained surgeons, with measurement of decay hampered by the lack of an accepted methodology. Studying this in the deployed setting may offer a firmer evidence base from which to generate policy. Potential mitigation strategies are discussed. PROSPERO registration number ID260846.

Case Volume and Readiness to Deploy: Clinical Opportunities for Active-Duty Surgeons Outside of Military Hospitals

BACKGROUND

The Military Health System (MHS) uses a readiness program that identifies the knowledge, skills, and abilities (KSAs) necessary for surgeons to provide combat casualty care. Operative productivity is assigned an objective score based on case type and complexity and totaled to assess overall readiness. As of 2019, only 10.1% of surgeons met goal readiness threshold. At one tertiary military treatment facility (MTF), leadership has taken an aggressive approach toward increasing readiness by forming military training agreements (MTAs) and allowing Off Duty Employment (ODE). We sought to quantify the efficacy of this approach.

STUDY DESIGN

Operative logs from 2021 were obtained from surgeons assigned to the MTF. Operations were assigned CPT codes and processed through the KSA calculator (Deloitte; London, UK). Each surgeon was then surveyed to identify time away from clinical duties for deployment or military training.

RESULTS

Nine surgeons were present in 2021 and spent an average of 10.1 weeks (19.5%) abroad. Surgeons performed 2,348 operations (Average [Avg] 261 ± 95) including 1,575 (Avg 175; 67.1%) at the MTF, 606 (Avg 67.3; 25.8%) at MTAs, and 167 (Avg 18.6, 7.1%) during ODE. Adding MTA and ODE caseloads increased KSA scores by 56% (17,765 ± 7,889 vs 11,391 ± 8,355). Using the MHS threshold of 14,000, 3 of 9 (33.3%) surgeons met the readiness threshold from MTF productivity alone. Including all operations, 7 of 9 (77.8%) surgeons met threshold.

CONCLUSIONS

Increased use of MTAs and ODE significantly augments average caseloads. These operations provide considerable benefit and result in surgeon readiness far exceeding the MHS average. Military leadership can maximize the chances of meeting readiness goals by encouraging clinical opportunities outside the MTF.

Five Influential Factors for Clinical Team Performance in Urgent, Emergency Care Contexts

INTRODUCTION

In deployed contexts, military medical care is provided through the coordinated efforts of multiple interdisciplinary teams that work across and between a continuum of widely distributed role theaters. The forms these teams take, and functional demands, vary by roles of care, location, and mission requirements. Understanding the requirements for optimal performance of these teams to provide emergency, urgent, and trauma care for multiple patients simultaneously is critical. A team's collective ability to function is dependent on the clinical expertise (knowledge and skills), authority, experience, and affective management capabilities of the team members. Identifying the relative impacts of multiple performance factors on the accuracy of care provided by interdisciplinary clinical teams will inform targeted development requirements.

MATERIALS AND METHODS

A regression study design determined the extent to which factors known to influence team performance impacted the effectiveness of small, six to eight people, interdisciplinary teams tasked with concurrently caring for multiple patients with urgent, emergency care needs. Linear regression analysis was used to distinguish which of the 11 identified predictors individually and collectively contributed to the clinical accuracy of team performance in simulated emergency care contexts.

RESULTS

All data met the assumptions for regression analyses. Stepwise linear regression analysis of the 11 predictors on team performance yielded a model of five predictors accounting for 82.30% of the variance. The five predictors of team performance include (1) clinical skills, (2) team size, (3) authority profile, (4) clinical knowledge, and (5) familiarity with team members. The analysis of variance confirmed a significant linear relationship between team performance and the five predictors, F(5, 240) = 218.34, P < .001.

CONCLUSIONS

The outcomes of this study demonstrate that the collective knowledge, skills, and abilities within an urgent, emergency care team must be developed to the extent that each team member is able to competently perform their role functions and that smaller teams benefit by being composed of clinical authorities who are familiar with each other. Ideally, smaller, forward-deployed military teams will be an expert team of individual experts, with the collective expertise and abilities required for their patients. This expertise and familiarity are advantageous for collective consideration of significant clinical details, potential alternatives for treatment, decision-making, and effective implementation of clinical skills during patient care. Identifying the most influential team performance factors narrows the focus of team development strategies to precisely what is needed for a team to optimally perform.

Dunning-Kruger Effect Between Self-Peer Ratings of Surgical Performance During a MASCAL Event and Pre-Event Assessed Trauma Procedural Capabilities

Objectives

The research question asked to what extent do self-rated performance scores of individual surgeons correspond to assessed procedural performance abilities and to peer ratings of procedural performance during a mass casualty (MASCAL) event?

Background

Self-assessment using performance rating scales is ubiquitous in surgical education as a proxy for direct measurement of competence. The validity and reliability of self-ratings as competency measures are susceptible to cognitive biases such as Dunning-Kruger effects, which describe how individuals over/underestimate their own performance compared to assessments from independent sources. The ability of surgeons to accurately self-assess their procedural performance remains undetermined.

Methods

A purposive sample of military surgeons (N = 13) who collectively cared for trauma patients during a MASCAL event participated in the study. Pre-event performance assessment scores for 32 trauma procedures were compared with post-event self and peer performance ratings using F tests (P < 0.05) and effect sizes (Cohen's d).

Results

There were no significant differences between peer ratings and performance assessment scores. There were significant differences between self-ratings and both peer ratings (P < 0.001) and performance assessment scores (P < 0.001). Effect sizes were very large for self to peer rating comparison (Cohen's d = 2.34) and self to performance assessment comparison (Cohen's d = 2.77).

Conclusions

The outcomes demonstrate that self-ratings were significantly lower than the independently determined assessment scores for each surgeon, revealing a Dunning-Kruger effect for highly skilled individuals underestimating their abilities. These outcomes underscore the limitations of self-assessment for measuring competence.

Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons

INTRODUCTION

As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention.

METHODS

This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d.

RESULTS

Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons).

CONCLUSION

There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.