105.16 Design and evaluation of a synthetic tissue for suturing and knot tying in laparoscopy training

Posted on January 31, 2019

C. M. Echeverri1, L. Cuevas1  1Pontificia Universidad Javeriana – Hospital Universitario San Ignacio,General Surgery,Bogota, DC, Colombia

Introduction:  The acquisition of psychomotor skills within the training process of a surgical resident requires repeated exposure and previous practice in the patient. The skills to suture and tie knots in laparoscopy are part of these and usually, the first exposure to the process is achieved in simulation centers, where the practice improves the final performance of the residents. Finding a product in the market that simulates this practice, easy and affordable, is difficult in our environment, mainly due to the high cost. We developed a semi-synthetic tissue manufactured at home, low- cost, reusable, replicable, with similar texture to the intestine and easy to use in the laparoscopic simulation environment.

Methods:  A descriptive observational study was carried out with 25 laparoscopic surgeons who evaluated the mentioned tissue, through laparoscopic suturing and knot tying, by means of a semi-structured survey of likert type perception.

Results: The overall score of the experience had a median of 9 on a visual analog scale from 0 to 10; As for the specific characteristics of the tissue, the perception was that the tissue allowed to perform very easily a simple suture for 68% (n = 17), continuous suture for 52% (n = 13) and intracorporeal knot tying for the 76 % (n = 19) of the surgeons. The characteristics most frequently described as better by the surgeons were consistency and firmness, as well as a progression in the ease to perform the proposed tasks. The characteristics that limited or hindered the development of the practice named by the surgeons were occasional resistance, different consistency in some tissue areas, particles, and 4 of them found no unfavorable characteristics.

Conclusion: The proposed tissue fulfills the desired characteristics when performed and provides a useful simulation model to improve the learning of knots and sutures by laparoscopy.

 

105.15 Systematic Review: Incorporation of Simulation in Orthopedic Surgery

Posted on January 31, 2019

R. Gulhar1, D. S. Brar1, G. Athwal1, R. Gulhar1  1California Northstate University College of Medicine,Elk Grove, CA, USA

Introduction:
Simulation training has played an important role in the training of surgical residents. Several factors including limited hours, financial pressure and increasing required knowledge have led to limited hands-on experience.  Simulation allows for a controlled environment to train residents. While it is thought simulation benefits trainees it is not clear how simulation translates to actual procedures. There are a number of simulation techniques including manikin-based, standardized patient, virtual reality, and tissue-based simulation. In this review, we compare how different techniques of virtual simulation translate into real-world applications.

Methods:
We looked at studies from the last 17 years in order to analyze the use of various form of simulation including virtual reality, anatomical models, 3D printing, and virtual reality in orthopedic surgery. We evaluated them on the basis of reduction in surgery time, improvement in surgery quality, and overall increased performance.

Results:
The systematic review in 2016 showed that of the 31 studies conducted on the use of virtual reality, 16% showed improvement in the surgery quality and 26% showed an overall increase in successful skill acquisition for the knee and shoulder arthroscopy. Another study in 2018 compared performance of dynamic hip screw fixation of femur fractures in virtual reality simulation and operation theatre. There was no significant difference in performance outcome which was measured by tip apex distance.

A study conducted in 2018 looked at virtual simulation and 3D printing techniques for the surgical treatment of acetabular fractures with plate fixation. The study found that the 3D printing group had a shorter total surgical duration and less blood loss than those in the control group. The postoperative results were similar for both groups. However, the complication rate was lower in the 3D printing group.

In 2018 a study was done on the use of anatomical models in simulation. It looked at efficacy and validation of simulation-based compartment syndrome course. Results found that PGY1 residents demonstrated significant improvement and were comparable to PGY5 resident performance after one month of training.

Conclusion:
There is continued need to assess the use of different simulation techniques in orthopaedic surgery. Many studies show the use and effective incorporation of virtual simulation in orthopedics surgery. Although virtual simulation has become more widespread in orthopaedics it still lags behind other surgeries. Thus, development of new virtual reality training methods will allow for more accurate and cost-effective ways to train residents. Further research needs to be conducted in order to standardize the different forms of virtual reality across the spectrum of orthopedic surgery.

105.14 Informed Consent In An EFIC Trial: How Long Does It Really Take?

Posted on January 31, 2019

J. M. Podbielski1, L. E. Vincent1, E. E. Fox1, C. E. Wade1, B. A. Cotton1, J. B. Holcomb1  1McGovern Medical School at UTHealth,Surgery/McGovern Medical School,Houston, TX, USA

Introduction: As clinical studies advance into an emergent setting, the use of exception from informed consent (EFIC) is increasing. EFIC requires researchers to inform the patient or their legally authorized representative (LAR) and obtain informed consent (IC) as soon as possible after the study intervention has begun.  Due to the critical nature of the study population, research staff may be unable to obtain IC in a timely fashion if at all. Notification and consent may be difficult due to LARs who may be too distraught to make decisions or unavailable to make decisions. This study describes the timing of notification and consent at one site in a large EFIC trial.

Methods: Our center enrolled 145 subjects in a recently completed randomized trial of transfusion ratios. During enrollment the research staff screened, enrolled and followed the patients through the first 24 hours. Attempts were made at least every 4 hours during the first 24 hours to inform the LAR/family/subject about the study and to obtain IC with attempts at least daily until hospital discharge. The Institutional Review Board approved a wavier for those patients who died prior to obtaining consent and for those subjects who were consent was unable to be obtained.

Results:Randomization occurred at a median of 26 minutes after hospital arrival. IC was obtained for 96 (66%) subjects, including 41 from the LAR, 31 from the patient, and 24 from both. Consent was waived for 37 (26%) subjects due to death or patient’s inability to consent. 12 (8%) refused to continue with the study. Median time to first notification of the LAR/subject was 22.4 hours from hospital arrival (Range: 4.8 hours–24 days). Median times to LAR and subject notification were 20.9 and 88.5 hours, respectively. 41% of the LARs/subjects provided IC at time of first notification. Median time to obtaining IC from LAR or subject was 20 minutes from time of notification, with a range of 0 to 14.8 days. The overall median injury severity score (ISS) score was 29 (IQR 21-41) and significant differences existed in ISS (p<0.001) among patients for whom IC was obtained (Median=35; IQR=25-52), patients who refused (Median=33; IQR=23-45) and patients in whom IC was waived (Median=43; IQR=24-63). There were no significant differences detected among patients who consented, refused or received a waiver by age, gender, race, Hispanic ethnicity or treatment group.

Conclusion:We have shown that notification and consent can be obtained in 92% of subjects (of these 72% actual, 28% waived) in an EFIC trial through diligent efforts of the research staff to contact patient and/or LAR. When planning an EFIC trial, research teams should be aware that substantial personnel effort are required throughout the study in conducting the IC process.

 

105.13 Modelling the Impact of a “Helicopter-First” Model of Aeromedical Retrieval

Posted on January 31, 2019

W. A. Smedley2, J. D. Kerby3, P. L. Bosarge3, D. B. Cox3, R. L. Griffin4, S. W. Stephens5, K. L. Stone2, J. O. Jansen3  1University Of Alabama at Birmingham,Division Of Acute Care Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, Alabama, USA 3University Of Alabama at Birmingham,Center For Injury Science, Division Of Acute Care Surgery, Department Of Surgery,Birmingham, Alabama, USA 4University Of Alabama at Birmingham,Department Of Epidemiology, School Of Public Health,Birmingham, Alabama, USA 5University Of Alabama at Birmingham,Alabama Resuscitation Center, Department Of Emergency Medicine,Birmingham, Alabama, USA

Introduction:  Helicopters are an essential part of emergency care systems in the United States and every year thousands of critically ill patients rely on air transport for survival. Trauma systems, in particular, have been developed around the concept of taking the patient directly to definitive care. However, in many locations, ground EMS are dispatched to the scene of an incident first, to assess the patient, and then call for a helicopter if needed. The time to definitive care therefore includes the helicopter’s flight “out” (to the scene), as well as flight “in” (to the trauma center). In addition to flight time, “mission ground time” (launch, landing, loading, and takeoff) has to be considered. As a result, the area and population from which casualties can be taken to level I and II trauma centers within a set time is often smaller than expected. We hypothesized that the primary dispatch of helicopters, to selected incidents, would increase the number of residents who might benefit from aeromedical retrieval. The aim of this study was, therefore, to compare the population coverage of these two models of service delivery in a single state.

Methods:  Geospatial analysis was utilized and based on georeferenced population data obtained from the U.S. Census Bureau. Ground-EMS-first coverage was calculated using elliptical coverage areas based on the location of helicopter bases, and level I and II trauma centers, using Microsoft Excel and arcGISTM. Heli-first coverage was evaluated by calculating circular isochrones around level I and II trauma centers, with a radius of 60 minute flight time, assuming a cruising speed of 246 km/hr.

Results: A heli-first policy would permit 4,633,063 residents, or 97% of the state’s population, to reach a level I trauma center within one flight hour. Furthermore, the state’s entire population would be able to reach a level I or II trauma center within one hour. This is in contrast to the traditional Ground-EMS-first approach which, under optimal conditions, permits 27% of the state’s population to reach a level I trauma center, and 60% of the state’s population to reach a level I or II within one hour.

Conclusion: Dispatching a helicopter as a first response is a contemporary approach to patient transport that provides relative quick access to specialist care for a large proportion of the population. However, such a policy would require additional, costly aeromedical resources. Our modelling only considers the “inbound” travel time, and not the time to reach a casualty, which may be short when local resources are used. Combined dispatch of local ground EMS units, and helicopters, may be optimal, but requires further study.

 

105.12 What Is Global Surgery? Identifying Misconceptions Among Medical Students and Health Care Professionals

Posted on January 31, 2019

M. N. Abraham2, P. J. Abraham1, H. Chen1, K. M. Hendershot1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, AL, USA 2University Of Alabama at Birmingham,School Of Medicine,Birmingham, AL, USA

Introduction:  Over the last five years, global surgery has emerged as a new field within academic surgery. Global surgery has been defined as “an area for study, research, practice, and advocacy that places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by surgical conditions or have a need for surgical care.” Despite such unifying attempts to provide a common definition, it is unclear whether health care professionals and medical students understand what is meant by the term “global surgery.” This study aims to characterize the understanding of global surgery and what it means to be an academic global surgeon.

Methods: One hundred medical students, residents, physicians, nurses, and allied health care professionals were interviewed on their perceptions of global surgery using a six-question qualitative survey. Respondents were categorized based on gender and apparent age <40 or >=40 years old. Survey responses were coded and analyzed for common themes by two reviewers independently. SPSS was utilized for statistical analysis.

Results: Of the 100 health care professionals surveyed, 61% did not know the meaning of global surgery. While there was no difference between men and women, participants under age 40 were significantly more likely to relay an accurate definition (51% vs 17%, p=0.001). Of participants with knowledge of global surgery, 44% had previous exposure to a global health field and 85% expressed interest in global health or global surgery. Respondents described components of academic global surgery as “research”, “teaching,” “practicing,” and using “evidence-based medicine.” An effective career in global surgery was most often categorized as “sustainable” and “impactful.”

Conclusion: Although often used in academic surgical settings, the term “global surgery” is not well-understood among health care professionals and medical students. Even among those who are familiar with the term, there is no clear consensus on what it means to be a global surgeon or what constitutes a successful career in global surgery.

 

105.11 Implementation of Hemorrhage-Control Training Into The Medical School Curriculum

Posted on January 31, 2019

J. T. Gowen1, J. D. Wolfe1, K. W. Sexton1, C. R. Thrush1, A. Privratsky1, W. C. Beck1, J. R. Taylor1, B. Davis1, M. K. Kimbrough1, R. D. Robertson1, A. Bhavaraju1  1University Of Arkansas for Medical Sciences,Department Of Surgery, Division Of Trauma And Acute Care Surgery,Little Rock, AR, USA

Introduction:  To comply with the ACS goal of zero preventable deaths from trauma, we incorporated hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of medical students with controlling major hemorrhage, and they will find this a valuable skillset for physicians and other health care professionals to possess.

Methods:  After IRB and institutional approval was obtained, hemorrhage-control training was taught to all third-year medical students during their surgery clerkship, beginning in May 2018. The training was completed in accordance with the American College of Surgeons’ Stop the Bleed (STB) program, details of which can be found at www.bleedingcontrol.org. Using a prospective study design, all trainees completed pre- and post-training surveys to gauge their prior experiences and comfort levels with controlling major hemorrhage, and their confidence levels with the techniques taught during the program. A knowledge quiz was completed immediately following the training. JMP Pro V13 (SAS; Cary, NC) was used for statistical analysis with significance set at p = 0.05.

Results: 47 students were trained and completed surveys. 43 out of 47 students (91%) reported only minimal first aid training or no experience at all with hemorrhage control; 1 student reported prior training. Comfort level with hemorrhage control and confidence level with all basic hemorrhage-control techniques showed statistically significant increases after training, with 100% of students reporting feeling confident or very confident in the application of these techniques. There was a trend towards, but not a statistically significant difference in students’ perceptions of the importance of this training for physicians (p=0.06) and the need to include STB training in medical school curricula (p=0.59) before and after STB training, which we attribute to the high positive response rates on the pre-survey. The mean percent correct on the quiz was 97.1%.

Conclusion: Hemorrhage-control training can be easily and effectively incorporated into the formal medical school curriculum with minimal effort via a single 2-hour Stop The Bleed course, increasing students’ comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education, and possibly that of other healthcare professionals. We believe this should be a standard part of undergraduate medical education. Further work needs to be done to determine retention of these skills over time and if this training can be similarly incorporated into the curricula of other allied health professional schools.

 

105.10 Training Global Surgery Advocates: Strengthening the Global Surgery Voice

Posted on January 31, 2019

D. Vervoort1, X. Ma2  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2Université de Montréal,Montréal, QUÉBEC, Canada

Introduction:  Five billion people worldwide lack access to safe surgery when needed, causing 17 million preventable deaths each year and responsible for one-third of the global burden of disease. Despite the increasing recognition as an indispensable part of healthcare, surgery remains perceived as a luxury, and difficulties of scaling up surgical care remain widespread. InciSioN – International Student Surgical Network – is the world’s leading trainee global surgery network comprising over 3,000 medical students, residents, and young doctors from over 70 countries. InciSioN provides a platform to foster the development of future generations of global surgeons, anaesthesiologists, and obstetricians around the world.

Methods:  To strengthen, unify, and escalate InciSioN’s voices around the world, Training Global Surgery Advocates (TGSA), a standardized three-day advocacy workshop, was created. The 27-hour workshop is built on traditional didactic lectures, role-play exercises, and small working group activities, as well as advocacy and diplomacy training to provide participants with the needed knowledge and skills to effectively advocate for global surgery. During the pilot program, participants performed a baseline elevator pitch advocating for global surgery on day 1 and a prepared elevator pitch at the end of day 3 to formally assess progress. A questionnaire on the perceived familiarity, knowledge and motivation regarding the workshop and its topics was filled by participants before the beginning of the workshop and immediately after the workshop. Assessment was done using a 5-point Likert scale (strongly disagree, disagree, neutral, agree, strongly agree) for 18 components.

Results: 25 participants were selected from a pool of 52 applicants, of which 14 medical students from 14 different countries (7 high-income countries, 7 low- and middle-income countries) were able to attend the workshop in Quebec City, Canada. 11 students were unable to participate due to restrictions by visa issues (9 people) or personal reasons (2 people). An average net increase of 1.73 points across all 18 components was observed among participants. Participants lauded the mix of theory and practical exercises to integrate knowledge into practice, the diversity of participants, and the focus on soft skills for advocacy and diplomacy. During the post-assessment, all participants agreed or strongly agreed (average of 4.64 points) on their motivation to train other medical students in their respective countries to become global surgery advocates.

Conclusion: TGSA significantly improved participants’ knowledge and advocacy skills in the field of global surgery. This type of mixed didactic and hands-on workshop appears to be feasible, enjoyable for participants, and effective in improving medical students involvement in the emerging field of global surgery.

 

105.09 In-person hemorrhage control training effectiveness and comprehension in low-resource rural Kenya

Posted on January 31, 2019

D. El-Gabri1, A. D. McDow1, S. A. Sullivan3, H. Jung2, K. L. Long1  3University Of Wisconsin,Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 1University Of Wisconsin,Division Of Endocrine Surgery/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA 2University Of Wisconsin,Division Of Trauma, Acute Care Surgery, Burn And Surgical Critical Care/ Division Of General Surgery/ Department Of Surgery/ University Of Wisconsin School Of Medicine And Public Health,Madison, WI, USA

Introduction:
The American College of Surgeons Committee on Trauma developed the Stop the Bleed (STB) program in 2015 as a mechanism to prepare the public for response to life-threatening bleeding or mass casualty incidents. Assessments of STB in the United States (US) have shown the training’s effectiveness in improving comfort and skill in aiding a trauma victim. While the program continues to spread throughout the US, to the best of our knowledge, it has not been conducted and evaluated in low or middle-income countries. Kenya has a high burden of injuries and violence accounting for 88.4 deaths per 100,000 people. Addressing this burden is a healthcare priority in the country. STB training represents a potential intervention that could reduce trauma morbidity and mortality in a country with limited healthcare resources. The purpose of this study was to assess the effectiveness and retention of STB training in Kenya as compared to implementation in the US, the population for which it was originally designed.  

Methods:
This quasi-experimental study assessed differences between a STB intervention post-test conducted in the US and in Kenya. The two samples consisted of volunteer participants with no medical background. The STB training was advertised, and any willing participants were recruited into the study. The population of interest was recruited in Migori Kenya (n=19), the comparison population in Wisconsin, United States (n=12). Each group received the same STB training course in July 2018 by physicians trained to give STB instruction from the same US institution. After completing the course, each group received the same 5-question post-test, designed to assess effectiveness and comprehension of the material. The quizzes were anonymous and taken voluntarily. The quiz scores between each group were compared using the Mann-Whitney U Test.

Results:
There is a statistically significant (p=0.04) difference in the quiz scores between the US (n=12) and Kenya samples (n=18). The Kenyan and US mean scores were 3.9 and 4.7 out of a possible 5, respectively. If one quiz question is excluded from analysis, there is no significant difference between the two group’s quiz scores (p=0.41). The individual question that significantly lowered the mean score in the Kenyan sample was: “What is the first step when approaching an injured, bleeding person?”, which may identify a difference in interpretation of the material.

Conclusion:
In general, both samples studied demonstrated good comprehension of the STB core concepts.  In detailed review of the post-test scores, only one question was significantly different in answers among the Kenya and US participants.  Additional studies to assess long-term retention of these concepts will be necessary in both populations.  Understanding the discrepancies between the assessments in differing populations may contribute to the validation and utility of this STB post-intervention evaluation.

105.08 EARLY ENGAGEMENT HAS A SUSTAINED POSITIVE IMPACT ON MEDICAL STUDENTS' PERCEPTIONS OF SURGICAL CAREERS

Posted on January 31, 2019

P. S. Virtanen1, L. Timsina1, T. Esposito2, G. Rozycki1, J. Hartwell1  2University of Illinois,Peoria, ILLINOIS, USA 1Indiana University School Of Medicine,General Surgery,Indianapolis, IN, USA

Introduction:
Prior studies have demonstrated that brief, early exposure of medical students to surgery  is effective, creates positive perceptions of surgical career options and helps overcome negative stereotypes medical students may have of surgery . Opportunities for preclinical medical student (MS1, MS2) exposure to surgical careers are not universally available nor are the long term effects of such engagement well understood. 

Methods:
Our institution’s Surgery Student Interest Group (SIG) created a trauma shadowing experience which included observation of rounds, trauma resuscitation, operative procedures and interactions with resident and attending staff. Students were recruited via a SIG website announcement and an on-line registration form. Follow-up electronic surveys were sent immediately after the experience to all participants (n=109). If one year had elapsed during the study period (December 2016-July 2018) since the shadowing experience, a 1-year follow up survey was sent (n=77). Data gathered included demographics, student perceptions about surgery, and the experience itself. Fisher’s exact tests and matched Wilcoxon signed-rank tests were performed.

Results:
Overall, 59 immediate surveys (54.1%) and 24 1-year follow up surveys (31.2%) were returned. Of the 59 immediate responses, 55.9% (n=33) were female, and 93.2% self-identified as MS1/MS2 (n=55). Of the immediate responses, 94.9% (n=56) would “definitely” or “somewhat” agree to recommend the experience to a peer. Significantly more immediate responders stated they were either “strongly considering” or “considering” a career in surgery after the experience compared to before the experience (69.5% vs 61.0%, p=0.012). This was particularly evident in female responders (72.7% vs 57.6%, p=0.0112). The experience was felt to be relevant to the career choice process by 94.9% of students immediately after and 92.2% at 1-year follow up (p=0.90). At immediate follow up, 96.6% (n=57) of students recalled a specific trauma team member who made a positive impression on them and this was sustained (87.5%, n=21) at 1-year follow up (p=0.142).  

Conclusions:
Student participants reported a positive impact on their perceptions of, and were significantly more likely to consider, a career in surgery after the shadowing experience. Student recall of the personal connection made to the trauma team is sustained over a 1-year period. Early, informal shadowing experiences may increase interest in surgical careers, particularly for female students, and this engagement appears to be sustained over time.

105.07 Assisting Youth Bystanders Become First-Responders To "Stop The Bleed"

Posted on January 31, 2019

B. J. Ringhouse1, R. Gonzalez1, H. Ton-That1, M. Anstadt1, D. Lavigne1, J. Justiniano1, P. Patel1  1Loyola Universtiy Medical Center,Surgery,Maywood, IL, USA

Introduction: Uncontrolled hemorrhage remains one of the leading causes of preventable traumatic death. The "Stop the Bleed" campaign teaches lay people how to control life-threatening bleeding allowing for earlier intervention and improving outcomes. This study aims to assess the impact of this course on participant preparedness and willingness to intervene when faced with life-threatening bleeding.

Methods: This survey-based study utilized a pre and post intervention questionnaire. The intervention consisted of an hour long "Stop the Bleed" didactic and interactive lesson focused on recognition of life-threatening bleeding and methods of bleeding control including direct pressure and tourniquet application. The survey focused on preparedness and willingness to assist in situations of life-threatening bleeding and barriers to providing assistance. Data was collected and analyzed to evaluate trends.

Results: 54 people participated in the course, of which 44 individuals submitted a pre and post questionnaire and were included in the study analysisi. Most were inner-city youth with median age of 17, mihnoritiues, and had no first-aid experience. After the "Stop the Bleed" course, willingness to assist increased to 100%. The reported comfort in using direct pressure techniques increased by 54% (pre 46%; post 100%) and in applying a tourniquet increased by 72% (pre 28%; post 100%). In addition, there was a reduction in barriers to intervening in life-threatening bleeding, specifically the fear of making a mistake or causing more harm.

Conclusion: This study demonstrates that after a 1-hour intervention, 100% of participants felt trained to use direct pressure and tourniquets to control bleeding and were willing to assist in the setting of life-threatening bleeding. Our results establish the "Stop the Bleed" campaign as a meaningful resource to train bystanders in an at-risk population and possibly reduce preventable deaths due to uncontrolled bleeding.

 

105.06 Stop The Bleed: Effective Training In Need Of Improvement

Posted on January 31, 2019

C. Villegas1, S. Liu1, J. Rosenberg1, R. Winchell1, M. Narayan1  1Weill Cornell Medical College,The Division Of Trauma, Burns, Critical And Acute Care Surgery,New York, NY, USA

Introduction:
The “Stop the Bleed” (StB) campaign was instituted to educate laypersons on how to perform bleeding control techniques in the event of mass casualty events that result in life-threatening hemorrhage.  Participants currently undergo a 90-min instructional and practice session, the latter incorporating a mannequin on which participants practice. We hypothesized participants would 1) increase content knowledge after StB participation: and 2) find that the training could be improved by a more life-like modification of the mannequin.

Methods:
From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training.  Participants provided demographic data regarding prior emergency training and experience and were asked pre- and post-test questions (5-point Likert scale) regarding likelihood of and confidence in responding to hemorrhage.  Individuals also evaluated the mannequin on whether it would improve their education if it were more life-like.  Scores were reported as medians with interquartile ranges (IQR).  Wilcoxon paired and unpaired tests were used as appropriate to evaluate differences with α=0.05 and subset analysis stratified by experience.

Results:
Of 402 participants, 310 had complete data on demographic and outcome data of interest.  On a composite, pre-test self-assessment of willingness and confidence to respond to hemorrhage in emergency situations, participants had a median score of 24 out of 30 points (IQR 19-27).  Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 26-30, p < 0.05).  Participants’ composite score on mannequin realism assessing compression, packing, and tourniquet application was 13 out of 15 (IQR 12-15), yet the participants reported that more realistic model would increase their confidence in technique (median 15, IQR 12-15).  Subset analysis of those individuals without prior training or experience in emergency response or hemorrhage control (n=117) demonstrated that they had the largest gains in pre- and post-test differentiation (median difference 8.5, IQR 4.3-12.0) compared to those with prior experience (n=193, median difference of 3.0, IQR 0.0-6.0, p <0.05).  Both subgroups reported that training would be enhanced if the mannequins were more realistic (median 15, IQR 12-15 for both groups).

Conclusion:
StB is an effective education program resulting in improved confidence in wound compression, packing, and tourniquet application. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement.  Regardless of background, participants overwhelmingly reported that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating cessation of hemorrhage is required to enable learners to actually “Stop the Bleed”. 
 

105.05 Effectiveness of Bleeding Control Training in Improving Confidence To Intervene

Posted on January 31, 2019

E. G. Andrade1, J. M. Hayes1, L. J. Punch1  1Washington University,Acute & Critical Care Surgery,St. Louis, MO, USA

Introduction: Injury is the leading cause of death for individuals aged 1-44 years old in the United States. More specifically, gun violence (GV) is the leading cause of death for black males aged 15-24, outweighing the nine following most common causes of death combined. Hemorrhage is the leading cause of preventable trauma death. Thus, bystander abillity to control life-threatening hemorrhage is an important area for intervention to decrease preventable trauma deaths. We sought to ascertain if the Bleeding Control (BC) 1.0 course from the American College of Surgeons (ACS) is effective in teaching hemorrhage control to community members (CM) and medical professionals (MP) and if the provision of BC kits influences participant willingness to intervene in the setting of life-threatening bleeding.

Methods: Faculty and volunteers from a level 1 trauma center held BC courses on location for CM and on site for medical students, surgical residents, and surgical staff. The course was taught in concordance with the standards set for BC 1.0 by the American College of Surgeons. Participants then assembled their own BC kits, which included personal protective equipment, a combat application tourniquet, hemostatic gauze, adhesive compression tape, a permanent marker, and trauma shears. Pre- and post-course surveys were administered to assess exposure to severe bleeding (SB), knowledge of BC technique, and willingness to intervene with and without the kit. Surveys were compared using Pearson's chi-squared.

Results: Eighty CM and sixty MP completed BC training. Personal exposure to SB varied greatly between groups; among CM, 54% had experienced SB in themselves, a relative or close friend, compared with 13.6% in MP. After BC training, confidence among MP to stop life-threatening bleeding improved from 25.9% to 83.6%(p< 0.01). For CM, confidence improved from 6.7% to 57%(p<0.01). With BC training and the BC kit, 88.3% of MP and 91% of CM reported there was no reason why they could not stop life-threatening bleeding. When asked to consider their ability to stop life-threatening bleeding after the course without a BC kit, 53.8% of MP were confident compared with 36.1% of CM.

Conclusion: Although participants with a medical background start at a higher level of confidence with bleeding control techniques, both groups had significant improvement in their level of confidence with stopping life threatening bleeding after taking the BC course. The importance of the bleeding control kit was more evident in the community group.

 

105.04 The Choices We Make: Ethical Dilemmas in Trauma

Posted on January 31, 2019

P. N. Chotai1, M. B. Patel1, B. M. Dennis1, O. D. Guillamondegui1, K. G. Meador2, K. A. Wallston3, A. B. Peetz1  1Vanderbilt University Medical Center,Division Of Trauma And Acute Care Surgery, Department Of General Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Center For Biomedical Ethics And Society At Vanderbilt,Nashville, TN, USA 3Vanderbilt University Medical Center,Institute Of Medicine And Public Health,Nashville, TN, USA

Introduction:
Trauma surgeons may often encounter complex patient situations that can be considered ethical challenges. These may require unique decision-making skills. Current literature is scarce in describing and characterizing ethical issues encountered by practicing trauma surgeons. We hypothesize variable incidence and estimates of self-efficacy of trauma surgeons’ ability to manage ethical problems in clinical practice.

Methods:
We surveyed members of the Eastern Association for the Surgery of Trauma (EAST) from January 5 to February 7, 2018 to ascertain their opinions and readiness on handling ethically challenging scenarios in their clinical trauma practice using a web-accessible survey via e-mail. The survey instrument was developed using published ethics literature and informal cognitive interviews of small focus groups that included trauma surgeons, physicians, ethicists, and other practitioners. Domains covered included perceived frequency and ability to manage ethical situations that present problems in trauma surgery practice. Common situations were defined as those situations that respondents encountered monthly or weekly. The ethical problems were categorized within seven larger categories: General ethics, Autonomy, Communication, Justice, End of Life, Conflict, and Other. Quantitative and qualitative analyses of the data were performed.

Results:
The response rate for the survey was 30.6% (548 respondents from 1794 invites); 28% of the respondents were female. Most respondents were white (74.6%) and under 55 years old (72.6%). A majority (85.4%) of respondents had completed fellowship training in either surgical critical care or trauma/acute care surgery.  Most respondents (86.6%) reported clinical practice in an American College of Surgeons (ACS) verified level I or II trauma center. The most commonly encountered ethical categories were Generic Ethical and Communication (79% of respondents reported that these were common issues in their clinical practice). Issues involving Conflict were least frequent (only 21% of respondents encountered these conflict issues on a monthly or weekly basis). Respondents’ ability to handle ethical situations did not differ among race or gender groups, size or geographic location of city of practice, completion of a fellowship training in trauma surgery, or trauma center verification level. Surgeons who reported high ability to handle ethical situations were more likely to be older (p=0.003), had been in practice 15 years or longer (linear relationship, rho = 0.21, p<0.001), had previously served on an ethics committee (p=0.038), and more frequently experienced ethically challenging situations in their clinical practice (p<0.05). Table 1 summarizes commonly encountered ethical situations in trauma surgery practice.

Conclusion:
An overwhelming majority of trauma surgeons encounter a range of ethical challenges on a regular basis in their clinical practice. Compared to younger and early career trauma surgeons, older and advanced career trauma surgeons reported higher ability and self-efficacy to manage ethical issues in clinical practice. To our knowledge, this is the first study to describe some of the unique ethical challenges that trauma surgeons face. We also identify a gap in knowledge regarding how trauma surgeons develop in addressing these problems effectively.
 

105.03 The Effect Of Body Mass Index On Penetrating Trauma Severity: A National Trauma Data Bank Analysis

Posted on January 31, 2019

L. A. De Leon Castro1, E. A. Alore1, J. W. Suliburk1, C. T. Wilson1, M. A. Davis1, S. R. Todd1  1Baylor College Of Medicine,Surgery,Houston, TX, USA

Introduction: The effect of body mass index (BMI) on penetrating injuries is not well described. The aim of this study was to describe the effect of BMI on the severity of penetrating injuries by abbreviated injury score (AIS). We hypothesized that increasing BMI would be protective against higher injury severity in patients with penetrating mechanisms.

Methods:  This was a retrospective analysis of penetrating trauma patients ≥ 16 years old from the 2007-2015 National Trauma Data Bank (NTDB). Patients transferred, dead on arrival, or with isolated brain injury were excluded. Patients were classified by BMI category as underweight (<18.99kg/m2), normal (19-24.99kg/m2), overweight (25-29.99kg/m2), obese (30-39.99kg/m2), and morbidly obese (≥40kg/m2). AIS severity was defined as minor (AIS 1-3) or major (AIS 4-6). Univariate and multivariate analyses were performed to assess association with BMI (significance, p<0.05).

Results: 83,826 patients were evaluated. The median age was 30 (IQR 23-41); 87% were men. Median BMI was 25.9 kg/m2 (IQR 23-30). The mechanism of injury was stab wound in 43% and firearm in 57%. The median AIS by region was 2 (IQR 1-3) for the abdomen, 3 (IQR 1-3) for the thorax, and 1 (IQR 1-2) for the extremities. The median injury severity score (ISS) was 5 (IQR 1-11). Overall mortality was 5.3%. On univariate analysis by BMI category, AIS severity was not significant for the abdomen (p=0.316), thorax (p=0.267), or extremities (p=0.184). This lack of significance continued when analyzed by mechanism of injury: stab wound – abdomen (p=0.350), thorax (p=0.471), or extremities (p=0.074); firearm – abdomen (p=0.172), thorax (p=0.340), or extremities (p=0.318). On multivariate analysis, AIS severity was not associated with BMI category for the abdomen (p=0.729), thorax (p=0.226), or extremities (p=0.232). Variables significantly associated with AIS severity were systolic blood pressure (abdomen: OR=0.986, CI=0.984-0.987, p<0.001; thorax OR=0.984, CI=0.982-0.985, p<0.001; extremities OR=0.977, CI=0.973-0.980, p<0.001), heart rate (abdomen: OR=1.008, CI=1.006-1.010, p<0.001; thorax OR=1.004, CI=1.002-1.006, p<0.001; extremities OR=1.021, CI=1.017-1.025, p<0.001) and firearm mechanism of injury (abdomen: OR=7.548, CI=6.562-8.681, p<0.001; thorax OR=2.223, CI=2.006-2.463, p<0.001; extremities OR=13.873, CI=8.752-21.992, p<0.001). Mortality did not vary significantly (p=0.552) across BMI categories.

Conclusion: Increased BMI is not associated with protection from penetrating injuries. Mortality did not vary significantly across BMI categories.

 

105.02 Medical Malpractice and Trauma Surgery, What Pays Out

Posted on January 31, 2019

M. S. Sussman1, M. Mulder1, S. Carranco1, E. L. Ryon1, B. Sussman1, S. Madiraju1, V. Hart1, K. Proctor1  1University Of Miami,Trauma Surgery/critical Care,Miami, FL, USA

Introduction:  Medical malpractice litigation is a source of anxiety for many surgeons. Previous studies indicate that a general surgeon’s chance of being involved in a malpractice claim by age 65 approaches 99%. Although single site analysis has indicated no increased risk of lawsuit for trauma surgeons, a review of a large, national, legal database is lacking. The purpose of this study is to explore the malpractice environment surrounding trauma surgery and acute care surgery services.

Methods:  Lexis Nexis is a mode of legal research that uses databases of court opinions, statutes, court documents, and secondary material. We searched 1987-2017, of all state and federal cases using the Boolean search Terms: “trauma” AND “medical malpractice” AND “case summary” AND NOT copyright.  Pediatrics, obstetrics, ophthalmologic and incomplete cases were excluded.

Results: During a 30-year period 231 malpractice cases were identified. Several trauma subspecialties were implicated in the lawsuits. These included trauma surgeons, acute care general surgeons (ACS), trauma orthopedics (TO), trauma neurosurgery (TN), and trauma anesthesia (TA). A majority of the cases involved emergent surgery (148/231, 64%). Preoperative assessment was responsible for 82 suits (35%). A total of 62 cases (27%) resulted in death.  A total of 20 cases (9%) resulted in monetary award to the plaintiff (patient) for an average payout of $1.1M (range, $35K – $6.4M). Examining trauma surgeons as a separate cohort, 12 malpractice suits resulted in payouts, eight of these (66%) were a result of delayed/missed diagnosis. Technical error was sited in 15% and neglect in 8% of cases where a payout was awarded. Looking at the other subspecialties (ACS, TO, TN, TA) involved, 8 cases resulted in payout, 100% of these cases were as a result of technical error.

Conclusion: Only a small fraction of medical malpractice cases that are filed result in a payout.  The majority of suits brought against trauma surgeons arise from delayed/missed diagnosis, whereas all of the suits brought against other subspecialties arise from technical error.  This is likely due to the fact that trauma surgeons serve as the frontline diagnosticians and must make rapid assessments. This study highlights the importance of the trauma assessment and time to diagnosis as targets for education on litigation prevention. Further investigation is warranted to understand the underlying causes for malpractice suits between trauma surgeons and other trauma subspecialties.

 

105.01 Residents as teachers at the Fundación Universitaria de Ciencias de la Salud: A Project for developing teaching residents.

Posted on January 31, 2019

A. Cordoba Chamorro1,2,3,4, E. Bayter4, J Messier3  1Universidad del Rosario, Bogotá, Colombia  2Universidad CES, Medellín, Colombia 3Hospital de San José, Bogotá, Colombia  4Fundación Universitaria de Ciencias de la Salud, Hospital de San José, Bogotá, Colombia

Introduction: Since it’s foundation Hospital de San José in Bogotá- Colombia has had a rich history of teaching and currently is an accredited University Hospital and a leading teaching institution. This fact, along with the results of studies developed in various countries, requires the Fundación Universitaria de Ciencias de la Salud (FUCS) and the Hospital de San José to create innovative programs focused on promoting teaching among residents.

Objective: To determine the perception residents have on their role as teachers of other residents, interns and medical students, as well as, the knowledge they have gained from fellow residents.

Materials and Methods: This study is based on the survey used by Sanchez- Mendiola et al. Study which was modified for our hospital enviroment. The amount of time a resident considers he spends teaching and how much of their knowledge comes from other residents, is assessed, as well as, the academic requirements and the preferred educational strategies needed to become proficient in teaching.

Results: Residents perceive that 47.72% of their knowledge comes from other residents; they identify lack of time and excessive work burden as the main obstacles for receiving training to enhance teaching skills, but they are aware of the importance their role as teachers represents and will invest an average of 5.3 hour a week to undertake training to teach.

Conclusion: Residents of the Fundación Universitaria de Ciencias de la Salud are aware of their role as teachers and are willing to dedicate some of their time to learning how to teach.

 

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