Can hyper-realistic physical models of peripheral vessel exposure and fasciotomy replace cadavers for performance assessment?

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings

BACKGROUND

A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner.

METHODS

We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000.

RESULTS

The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics.

CONCLUSIONS

While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

Evaluation of tools to assess operative competence in endovascular procedures: a systematic review

BACKGROUND

With an increase in the use of endovascular interventions as an alternative to open surgery and the unique technical skills required, current methods for assessing the competence of vascular surgery trainees may not be optimal, suggesting a need for a shift in assessment modalities. We conducted this systematic review to explore current assessment methods used in vascular surgery training to assess competence specific to endovascular procedures.

METHODS

A comprehensive literature search was performed with a structured search strategy using terms focusing on endovascular procedures and assessment. Inclusion and exclusion criteria were used in order to screen for suitable articles.

RESULTS

We identified 54 articles that satisfied the inclusion criteria. These included a single randomized controlled trial, a single systematic review, a single narrative review and a single literature review, with the vast majority having level 2 evidence. Global rating scales, proficiency assessments and written/oral examinations were described as standard current assessment tools. These modalities lack reproducibility and objectivity, neglecting the needs of assessment of endovascular procedures requiring specialized decision making and finger dexterity. Novel methods such as high fidelity simulation and virtual reality promote reproducible and objective assessment methods in the context of endovascular surgery, and have a promising future.

CONCLUSION

While current assessment methods in vascular surgery are widely supported the changing skills required of a vascular surgery trainee warrants a shift in assessment modalities to better align to these requirements. High fidelity simulations show promise, although they require more extensive research to understand their relative merits.

Augmented Reality Forward Damage Control Procedures for Nonsurgeons: A Feasibility Demonstration

Introduction

This article presents an emerging capability to project damage control procedures far forward for situations where evacuation to a formal surgical team is delayed. Specifically, we demonstrate the plausibility of using a wearable augmented reality (AR) telestration device to guide a nonsurgeon through a damage control procedure.

Methods

A stand-alone, low-profile, commercial-off-the-shelf wearable AR display was utilized by a remotely located surgeon to synchronously guide a nonsurgeon through proximal control of the distal external iliac artery on a surgical manikin. The manikin wound pattern was selected to simulate a rapidly exsanguinating junctional hemorrhage not controllable by nonsurgical means.

Results

This capability demonstration displayed successful use of AR technology, telecommunication, and procedural training and guidance in a single test pilot. The assisted physician assistant was able to rapidly control the simulated external iliac artery injury on this model. The telestration system used was commercially available for use with available civilian cell phone, wireless and satellite networks, without the need for dedicated high-speed networks.

Conclusions

A nonsurgeon, using a wearable commercial on-visual-axis telestration system, successfully performed a damage control procedure, demonstrating the plausibility of this approach.

Efficacy of Trauma Surgery Technical Skills Training Courses

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.