Design of a Novel Online, Modular, Flipped-classroom Surgical Curriculum for East, Central, and Southern Africa.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.

Choosing Surgery: Identifying Factors Leading to Increased General Surgery Matriculation Rate.

Tulane graduates have, over the past six years, chosen general surgical residency at a rate above the national average (mean 9.6% vs 6.6%). With much of the recent career choice research focusing on disincentives and declining general surgery applicants, we sought to identify factors that positively influenced our students' decision to pursue general surgery. A 50-question survey was developed and distributed to graduates who matched into a general surgery between the years 2006 and 2014. The survey evaluated demographics, exposure to surgery, and factors affecting interest in a surgical career. We achieved a 54 per cent (61/112) response rate. Only 43 per cent considered a surgical career before medical school matriculation. Fifty-nine per cent had strongly considered a career other than surgery. Sixty-two per cent chose to pursue surgery during or immediately after their surgery clerkship. The most important factors cited for choosing general surgery were perceived career enjoyment of residents and faculty, resident/faculty relationship, and mentorship. Surgery residents and faculty were viewed as role models by 72 and 77 per cent of responders, respectively. This study demonstrated almost half of those choosing a surgical career did so as a direct result of the core rotation experience. We believe that structuring the medical student education experience to optimize the interaction of students, residents, and faculty produces a positive environment encouraging students to choose a general surgery career.

Serum levels of calcium and albumin in survivors versus nonsurvivors after critical injury.

PURPOSE: Injured patients who require aggressive resuscitation with intravenous (IV) fluids and blood products will frequently acquire low levels of serum calcium (CA) and albumin (ALB) in the intensive care unit (ICU) as result of this therapy. The purpose of this longitudinal study was to determine the time course of CA and ALB during ICU admission in survivors (S) compared to nonsurvivors (N) after major trauma. The study design is to verify if CA, ALB, or albumin-corrected CA can be used as indicators of patient survivability after critical injury. MATERIALS AND METHODS: CA and ALB values were retrospectively recorded in 64 random subjects (S= 32 and N= 32) admitted to the Trauma ICU for 3 or more days. CA and ALB data points were partitioned into 6 time frames of ICU care. Mean values and standard error of the mean for each frame were obtained to depict parametric differences in the time profiles for S versus N. Subgroup analysis was used to determine the impact of blood transfusions on CA and ALB levels. Albumin-corrected CA was computed for every patient at each measurement point and then partitioned into the 6 time frames of ICU care. Parametric t-test and nonparametric rank sum analysis were used to evaluate the ability of CA, ALB, and ALB-corrected CA at discriminating S from N. Each predictive covariate was ranked, divided into quartiles (grades = normal, mild, moderate, severe), and correlated with patient survival likelihood (viz., ratio of S to N in each quartile). RESULTS: Parametric and non-parametric analysis of collected data indicates that the response patterns of CA were significantly different ( P<.00005 ) in S versus N. Time profiles of CA and ALB exhibited similar reductions in both S and N during the resuscitation phase (ie, "hypocalcemia of trauma"). But from these nadir points, CA response patterns in S tended to steadily elevate toward normal levels (ie, "responders"), while N exhibited no such increase in CA values (ie, "nonresponders"). Data revealed that survival likelihood in trauma patients after 3 ICU days is proportional to the upward response of CA from depressed values present after the initial resuscitation. Decreased CA levels after 3 ICU days were associated with decreased survival (Table 1). Rank sum testing showed that values of CA corrected for ALB creates less obvious difference in S and N than uncorrected CA. Subgroup analysis showed a linear decrease in CA and ALB levels with increasing units of blood transfused during treatment for trauma. CONCLUSIONS: CA changes during ICU care demonstrate distinct response patterns (P <.00005) for survivors versus nonsurvivors. The magnitude of upward response in CA after the fluid resuscitation phase is a marker that correlates with a patient's ability to withstand the physiologic stresses encountered during ICU treatment after major trauma. Our findings indicate that uncorrected CA values are a better guide for calcium replacement therapy in trauma patients than albumin-adjusted CA. This study suggests that response patterns of CA can be a useful reference to aid in monitoring the progress of critically injured patients.

Impact of infusion rates of fresh frozen plasma and platelets during the first 180 minutes of resuscitation.

BACKGROUND: Whether high-ratio resuscitation (HRR) provides patients with survival advantage remains controversial. We hypothesized a direct correlation between HRR infusion rates in the first 180 minutes of resuscitation and survival. STUDY DESIGN: This was a retrospective analysis of massively transfused trauma patients surviving more than 30 minutes and undergoing surgery at a level 1 trauma center. Mean infusion rates (MIR) of packed red blood cells (PRBC), fresh frozen plasma (FFP), and platelets (Plt) were calculated for length of intervention (emergency department [ED] time + operating room [OR] time). Patients were categorized as HRR (FFP:PRBC > 0.7, and/or Plts: PRBC > 0.7) vs low-ratio resuscitation (LRR). Student's t-tests and chi-square tests were used to compare survivors with nonsurvivors. Cox proportional hazards regression models and Kaplan-Meier curves were generated to evaluate the association between MIR for FFP:PRBC and Plt:PRBC and 180-minute survival. RESULTS: There were 151 patients who met criteria: 121 (80.1%) patients survived 180 minutes (MIR:PRBC 71.9 mL/min, FFP 92.0 mL/min, Plt 3.5 mL/min) vs 30 (19.9%) who did not survive (MIR:PRBC 47.3 mL/min, FFP 33.7 mL/min, Plt 1.1 mL/min), p = 0.43, p < 0.0001 and p < 0.011, respectively. A Cox regression model evaluated PRBC rate, FFP rate, and Plt rate (mL/min) as mortality predictors within 180 minutes to assess if they significantly affected survival (hazard ratios 1.01 [p = 0.054], 0.97 [p < 0.0001], and 0.75 [p = 0.01], respectively). Another model used stepwise Cox regression including PRBC rate, FFP rate, and Plt rate (hazard ratios 1.00 [p = 0.85], 0.97 [p < 0.0001], and 0.88 [p = 0.24], respectively), as well as possible confounding variables. CONCLUSIONS: This is the first study to examine effects of MIRs on survival. Further studies on the effects of narrow time-interval analysis for blood product resuscitation are warranted.

Mechanism of injury is not a predictor of trauma center admission.

Most trauma systems use mechanism of injury (MOI) as an indicator for trauma center transport, often overburdening the system as a result of significant overtriage. Before 2005 our trauma center accepted all MOI. After 2005 we accepted only those patients meeting anatomic and physiologic (A&P) triage criteria. Patients entered into the trauma center database were divided into two groups: 2001 to 2005 (Group 1) and 2007 to 2010 (Group 2) and also categorized based on trauma team activation for either A&P or MOI criteria. Overtriage was defined as patient discharge from the emergency department within 6 hours of trauma activation. A total of 9899 patients were reviewed. Group 1 had 6584 patients with 3613 (55%) activated for A&P criteria and 2971 (45%) for MOI. Group 2 had 3315 patients with 3149 (95%) activated for A&P criteria and 166 (5%) for MOI. Accepting only those patients meeting A&P criteria resulted in a decrease in the overtriage rate from 66 to 9 per cent. By accepting only those patients meeting A&P criteria, we significantly reduced our overtriage rate. Patients meeting MOI criteria were transported to community hospitals and transferred to the trauma center if major injuries were identified. Trauma center transport for MOI results in significant overtriage and may not be justified.

Not all mechanisms are created equal: a single-center experience with the national guidelines for field triage of injured patients.

BACKGROUND: Trauma systems use prehospital evaluation of anatomic and physiologic criteria and mechanism of injury (MOI) to determine trauma center need (TCN). MOI criteria are established nationally in a collaborative effort between the Centers for Disease Control and Prevention and the American College of Surgeons' Committee on Trauma and have been revised several times, most recently in 2011. Controversy exists as to which MOI criteria truly predict TCN. We review our single-center experience with past and present National Trauma Triage Criteria to determine which MOI predict TCN. METHODS: The trauma registry of an urban Level I trauma center was reviewed from 2001 to 2011 for all patients meeting only MOI criteria. Patients meeting any anatomic and physiologic criteria were excluded. TCN was defined as death, Injury Severity Score (ISS) of greater than 15, emergency department transfusion, intensive care unit admission, need for laparotomy/thoracotomy/vascular surgery within 24 hours of arrival, pelvic fracture, 2 or more proximal long bone fractures, or neurosurgical intervention during admission. Logistic regression analysis was used to identify which MOI predict TCN. RESULTS: A total of 3,569 patients were transported to our trauma center who met only MOI criteria and had the MOI recorded in the registry; 821 MOI patients (23%) were identified who met our definition of TCN. Significant predictors of TCN included death in the same passenger compartment, ejection from vehicle, extrication time of more than 20 minutes, fall from more than 20 feet, and pedestrian thrown/runover. Criteria not meeting TCN include vehicle intrusion, rollover motor vehicle collision, speed of more than 40 mph, injury from autopedestrian/autobicycle of more than 5 mph, and both of the motorcycle crash (MCC) criteria. CONCLUSION: With the exception of vehicle intrusion and MCC, the new National Trauma Triage Criteria accurately predicts TCN. In addition, extrication time of more than 20 minutes was a positive predictor of TCN in our system. Elimination of the vehicle intrusion and MCC criteria and reevaluation of extrication time merits further study.