European military surgical teams in combat theater: A survey study on deployment preparation and experience.

INTRODUCTION: Adequate (predeployment) training of the nowadays highly specialized Western military surgical teams is vital to ensure a broad range of surgical skills to treat combat casualties. This survey study aimed to assess the self-perceived preparedness, training needs, deployment experience, and post-deployment impact of surgical teams deployed with the Danish, Dutch, or Finnish Armed Forces. Study findings may facilitate a customized predeployment training. METHODS: A questionnaire was distributed among Danish, Dutch, and Finnish military surgical teams deployed between January 2013 and December 2020 (N = 142). The primary endpoint of self-perceived preparedness ratings, and data on the training needs, deployment experiences, and post-deployment impacts were compared between professions and nations. RESULTS: The respondents comprised 35 surgeons, 25 anesthesiologists, and 39 supporting staff members, with a response rate of 69.7 % (99/142). Self-perceived deployment preparedness was rated with a median of 4.0 (IQR 4.0-4.0; scale: 1 [very unprepared]-5 [more than sufficient]). No differences were found among professions and nations. Skills that surgeons rated below average (median <6.0; scale: 1 [low]-10 [high]) included tropical disease management and maxillofacial, neurological, gynecological, ophthalmic, and nerve repair surgery. The deployment caseload was most often reported as <1 case per week (41/99, 41.4 %). The need for professional psychological help was rated at a median of 1.0 (IQR 1.0-1.0; scale: 1 [not at all]-5 [very much]). CONCLUSIONS: Military surgical teams report overall adequate preparedness for deployment. Challenges remain for establishing broadly skilled teams because of a low deployment caseload and ongoing primary specializations. Additional training and exposure were indicated for several specialism-specific skill areas. The need for specific training should be addressed through customized predeployment programs.

Utility of multiple rule out CT screening of high-risk atraumatic patients in an emergency department-a feasibility study.

BACKGROUND: Several large trials have evaluated the effect of CT screening based on specific symptoms, with varying outcomes. Screening of patients with CT based on their prognosis alone has not been examined before. For moderate-to-high risk patients presenting in the emergency department (ED), the potential gain from a CT scan might outweigh the risk of radiation exposure. We hypothesized that an accelerated "multiple rule out" CT screening of moderate-to-high risk patients will detect many clinically unrecognized diagnoses that affect change in treatment. METHOD: Patients ≥ 40 years, triaged as high-risk or moderate-to-high risk according to vital signs, were eligible for inclusion. Patients were scanned with a combined ECG-gated and dual energy CT scan of cerebrum, thorax, and abdomen. The impact of the CT scan on patient diagnosis and treatment was examined prospectively by an expert panel. RESULTS: A total of 100 patients were included in the study, (53% female, mean age 73 years [age range, 43-93]). The scan lead to change in treatment or additional examinations in 37 (37%) patients, of which 24 (24%) were diagnostically significant, change in acute treatment in 11 (11%) cases and previously unrecognized malignant tumors in 10 (10%) cases. The mean size specific radiation dose was 15.9 mSv (± 3.1 mSv). CONCLUSION: Screening with a multi-rule out CT scan of high-risk patients in an ED is feasible and result in discovery of clinically unrecognized diagnoses and malignant tumors, but at the cost of radiation exposure and downstream examinations. The clinical impact of these findings should be evaluated in a larger randomized cohort.

[Isolated gallbladder agenesis without biliary atresia in a 16-year-old boy].

We present a case of a 16-year-old male patient with recurrent abdominal pain in the upper right quadrant, signed up for elective laparoscopic cholecystectomy due to a single gallstone seen on preoperative abdominal ultrasound. Because of dilatation of the common bile duct subsequent magnetic resonance cholangiopancreatography was performed, and surprisingly, the gallbladder was found missing. The operation was therefore cancelled. Even though gallbladder agenesis is a rare condition, it still represents a diagnostic challenge as most cases are found peroperatively, and the patients undergo unnecessary surgery.

No Circadian Variation in Surgeons' Ability to Diagnose Acute Appendicitis.

OBJECTIVE: To examine if there were circadian variations in surgeons' ability to diagnose acute appendicitis. DESIGN: Retrospective database study of all patients admitted to an acute surgical procedure under the potential diagnosis of acute appendicitis in a 4-year period. The day was divided into 2 time intervals, day to evening hours (08:00-23:59) and night hours (00:00-07:59). Relevant data regarding the admission and surgical procedures were categorized into these 2 time intervals. SETTING: Department of Surgery at a Danish university hospital in Copenhagen. PARTICIPANTS: A total of 2366 patients were included. There were no age limitations or selection in sex. RESULTS: There was no significant difference in the ability to diagnose appendicitis in day-evening hours vs night hours (p = 0.391), nor was any significant difference found on weekdays (Monday-Thursday) vs weekends (Friday-Sunday) (p = 0.278). There were no differences in duration of the procedures, rate of conversion, or severity of postoperative surgical complications between the 2 groups. More patients underwent diagnostic imaging during day to evening hours compared with night hours (308 vs 46; p = 0.014). The use of imaging had no effect on the ability to diagnose appendicitis. Male sex showed a higher probability of the diagnosis being appendicitis compared with other or no pathology (odds ratio: 3.094; p < 0.001). Age between 40 and 80 years was significantly associated with a higher probability of the diagnosis being appendicitis compared with other or no pathology. The negative appendectomy rate was 10.5%. CONCLUSION: We found no difference in the surgeons' ability to diagnose acute appendicitis during night hours compared with day to evening hours.

[The use of pre-hospital tourniquets in life-threatening extremity traumas]. / Anvendelse af præhospital tourniquet ved livstruende ekstremitetstraumer.

Tourniquets have been used for centuries. They have been called lifesavers and "an invention of the evil one". 90.9% of deaths on the battlefields result from haemorrhage. Lessons learned du­ring the wars in Iraq and Afghanistan have developed the treat­ment given to hypovolaemic patients on the battlefield. Treating bleeding and hypovolaemia is now considered as the primary intervention. The tourniquet has proven to be an indis­pensable tool treating wounded soldiers, with little risk of complications. The tourniquet might also show to be a valuable asset in a pre-hospital urban setting.

[The use of pre-hospital tourniquets in life-threatening in extremity traumas].

Tourniquets have been used for centuries. They have been called lifesavers and "an invention of the evil one". 90.9% of deaths on the battlefields result from haemorrhage. Lessons learned du-ring the wars in Iraq and Afghanistan have developed the treat-ment given to hypovolaemic patients on the battlefield. Treating bleeding and hypovolaemia is now considered as the primary intervention. The tourniquet has proven to be an indis-pensable tool treating wounded soldiers, with little risk of complications. The tourniquet might also show to be a valuable asset in a pre-hospital urban setting.

[Recruiting medical students for the surgical education]. / Rekruttering til hoveduddannelsen i kirurgi i Danmark.

For a longer period the interest for surgical education in Denmark has been low measured in the number of junior doctors choosing a surgical career. The Danish Surgical Society has reviewed the published data describing the factors involved when selecting a surgical career.

[Damage control surgery--a survey of a Cochrane review]. / Damage control kirurgi--en gennemgang af et Cochranereview.

Damage Control Surgery (DCS) has been the approach in dealing with multi-trauma patients for the last 15 years. In this Cochrane-review the authors seek to compare the outcome of DCS with the outcome after the conventional strategy which is often a time-consuming operation with definitive repair. However, no randomised controlled trials are found, and thus it is not possible to say whether DCS is superior to the conventional approach or not. It is not possible to perform any RCT with these patients. According to literature in general on this subject we believe, nevertheless, that the principles in DCS should be followed.

[Diaphragmatic hernia--admitted under the gallstone diagnosis]. / Diafragmahernie--indlagt under diagnosen galdestensanfald.

A 34-year old woman was admitted with pain in the upper right abdomen. The tentative diagnosis was gall stones, but none of the paraclinical results supported this diagnosis. A chest x-ray showed a completely white right lung. A later computertomography showed a colon-loop in the thorax and haemo-/pneumothorax. The patient's condition deteriorated, a life-threatening state of sepsis developed and she was transferred to a surgery facility where an incarcerated congenital diaphragmatic hernia was established. After surgery she was discharged with a temporary ostomy, but otherwise feeling well.

[What happens to gallstone patients discharged without cholecystectomy? Follow-up of 222 consecutive patients with initially untreated gallstones]. / Hvad sker der hos personer med galdeblaeresten, hvis de ikke får foretaget kolecystektomi? Opfølgning af 222 konsekutive patienter med initialt ubehandlet galdestenssygdom.

INTRODUCTION: The aim of this study was to investigate the cholecystectomy rate and rate of gallstone-related complications in patients formerly seen and discharged without operation from the Clinic for Day-Surgery, Glostrup University Hospital, Denmark. MATERIALS AND METHODS: From January 2000 to December 2002 a total of 222 patients with gallstones were discharged without operation (lap. cholecystectomy) from the day-surgery clinic. All admittances and surgical procedures in the follow-up period were identified by reading patient files and strategic searches in the National Patient Register in which all operations in Denmark are registered. RESULTS: The median follow-up period was 37 months (range 5-62 months). 25% of patients were operated in the follow-up period (cholecystectomy, n = 54, gallstone ileus, n=1). 13% had gallstone-related complications in the follow-up period. 9 patients had one or more endoscopic retrograde cholangiographies. There was no mortality or serious surgical complications. CONCLUSION: There is a lack of objective criteria for cholecystectomy in symptomatic cholecystolithiasis. The national guidelines in Denmark advocate cholecystectomy only in patients with socially disabling pain attacks. These guidelines are followed in our department and the strategy seems acceptable and patient-friendly, although the optimal treatment strategy for patients with symptomatic gallstone disease is still unknown.