Determining the educational impact of virtual patients on trauma team training during a multinational, large-scale civil military simulation exercise.

BACKGROUND: With asymmetrical conflicts ongoing, many countries have an increasing number of major trauma events but limited capacity to cope with these events. Training for such events comprises primarily of simulations requiring significant resources and that are time-consuming and expensive. Virtual patients are defined as computer-based programs presenting authentic cases support training in trauma management. HYPOTHESIS: Assisted learning technologies augment simulated trauma team training and can improve trauma team competencies. The aim was to investigate if virtual patients increased competencies in decision making required and to identify deficiencies in care for the management of trauma patients during a multinational civil military trauma exercise. METHODS: A prospective educational intervention study with mixed methods, measuring the effects of a novel virtual patient model on trauma teams, was performed. The population consisted of surgeons, anesthesiologists, emergency department physicians, nurses, and paramedics (n = 30) and constituted six trauma teams from eight countries; three trauma teams formed the participating group, and three were allocated as control group. The participating group was exposed to virtual patients before, during, and after the live simulation exercise. Data sources were derived from individual preassessments and postassessments, evaluations made by experts in trauma, and video recordings of performance during the live simulation exercise and analyzed by the thematic analysis method. RESULTS: Using virtual patients contributed to improved individual knowledge about the management of major trauma patients and improved teamwork. Virtual patients as support for reasoning in decision making were directly correlated to level of previous knowledge and experience. Two of the three participating trauma teams showed lower levels of existing knowledge and competence in managing major trauma patients and therefore made more efficient use of the virtual patients. CONCLUSION: Results demonstrated advantages using virtual patients during a major civil military trauma live simulation exercise and appear to be supportive especially for teams who are not as experienced. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Retrospective comparison of operative technique for chest wall injuries.

BACKGROUND: Surgical management of chest wall injuries is a common procedure. However, operative techniques are diverse, and no universal guidelines exist. There is a lack of studies comparing the outcome with different operative techniques for chest wall surgery. The aim of this study was to compare hospital outcomes between patients operated for chest wall injuries with a conventional method with large incisions and often a thoracotomy or a minimally invasive, muscle sparing method. PATIENTS AND METHODS: A retrospective study was carried out including patients ≥18 years operated for chest wall injuries 2010-2020. Patients were divided into two groups based on the surgery performed: conventional surgery (C-group) and minimally invasive surgery (M-group). Data on demographics, trauma, surgery, and outcomes were extracted from patient records. Primary outcome was length of stay on mechanical ventilator (MV-LOS). Secondary outcomes were length of stay in intensive care (ICU-LOS) and in hospital (H-LOS), and complications such as re-operation, incidence of empyema, tracheostomy, pneumonia, and mortality. RESULTS: Of 311 included patients, 220 were in the C-group and 91 in the M-group. The groups were similar in demographics and injury pattern. MV-LOS was 0 (0-65) in the C-group vs 0 (0-34) in the M-group (p < 0.001). ICU-LOS and H-LOS were significantly shorter in the M-group as compared to the C-group (p < 0.001), however with a large overlap. Tracheostomy was performed in 22.3% of patients in the C-group vs 5.4% in the M-group (p < 0.001). Pneumonia was diagnosed in 32.3% of patients in the C-group vs 16.1% in the M-group (p = 0.004). In-hospital mortality was lower in the M-group compared to the C-group but there was no difference in mortality within 30 days or a year. CONCLUSIONS: Our study indicates that a minimally invasive technique was favorable regarding clinical outcomes for patients operated for chest wall injuries.

A method for detailed determination of hospital surge capacity: a prerequisite for optimal preparedness for mass-casualty incidents.

BACKGROUND: Defined goals for hospitals' ability to handle mass-casualty incidents (MCI) are a prerequisite for optimal planning as well as training, and also as base for quality assurance and improvement. This requires methods to test individual hospitals in sufficient detail to numerically determine surge capacity for different components of the hospitals. Few such methods have so far been available. The aim of the present study was with the use of a simulation model well proven and validated for training to determine capacity-limiting factors in a number of hospitals, identify how these factors were related to each other and also possible measures for improvement of capacity. MATERIALS AND METHODS: As simulation tool was used the MACSIM® system, since many years used for training in the international MRMI courses and also successfully used in a pilot study of surge capacity in a major hospital. This study included 6 tests in three different hospitals, in some before and after re-organisation, and in some both during office- and non-office hours. RESULTS: The primary capacity-limiting factor in all hospitals was the capacity to handle severely injured patients (major trauma) in the emergency department. The load of such patients followed in all the tests a characteristic pattern with "peaks" corresponding to ambulances return after re-loading. Already the first peak exceeded the hospitals capacity for major trauma, and the following peaks caused waiting times for such patients leading to preventable mortality according to the patient-data provided by the system. This emphasises the need of an immediate and efficient coordination of the distribution of casualties between hospitals. The load on surgery came in all tests later, permitting either clearing of occupied theatres (office hours) or mobilising staff (non-office hours) sufficient for all casualties requiring immediate surgery. The final capacity-limiting factors in all tests was the access to intensive care, which also limited the capacity for surgery. On a scale 1-10, participating staff evaluated the accuracy of the methodology for test of surge capacity to MD 8 (IQR 2), for improvement of disaster plans to MD 9 (IQR 2) and for simultaneous training to MD 9 (IQR 3). CONCLUSIONS: With a simulation system including patient data with a sufficient degree of detail, it was possible to identify and also numerically determine the critical capacity-limiting factors in the different phases of the hospital response to MCI, to serve as a base for planning, training, quality control and also necessary improvement to rise surge capacity of the individual hospital.

Important learning points arising from the focused issue dedicated to the Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management.

The Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management was formulated in Germany by military medical personnel, who have been deployed to conflict areas, but also work in hospitals open for the lay public. In this manuscript we discuss different concepts and ideas taught in this course as these are described in a focused issue recently published in the European Journal of Trauma and Emergency Surgery. We provide reinforcement for some of the ideas conveyed. We provide alternative views for others. Injuries following explosions are different from blunt and penetrating trauma and at times demand a different approach. There are probably several ways to manage a mass casualty incident depending on the setup of the organization. An open discussion on the topics presented in the manuscripts included in the focused issue on military and disaster surgery should enrich everyone.

Military civilian partnerships: International proposals for bridging the Walker Dip.

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military, and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled "Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners" at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha, Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment among military surgeons. LEVEL OF EVIDENCE: Economic and Value Based Evaluations, level V.

The History of Swedish Military Healthcare System and Its Path Toward Civilian-Military Collaboration From a Total Defense Perspective.

INTRODUCTION: The interaction between military and civilian healthcare systems has contributed to the development of medical care. Swedish innovations such as the Seldinger technique for angiography, Leksell Gamma Knife for cranial surgery, and the introduction of pacemakers and ultrasound have contributed to the global development of medicine. Several authors have described the Swedish civilian healthcare system and its development. However, the development and history of its military healthcare system and its influence on the civilian healthcare system remain untold. This review aims to describe the historical development of the Swedish military healthcare system and its path toward civilian-military collaboration and a total defense healthcare system. MATERIAL AND METHODS: A search for all published scientific papers in Swedish and English, along with available legal documents and directives, was made. We used CINAHL, PubMed, Scopus, and Gothenburg University's databases and search engines. The following keywords, Swedish, military, civilian, healthcare, collaboration, and development, were searched for, alone or in combination, using a PRISMA flow chart. Duplicates, abstracts, and nonscientific publications were excluded. RESULTS: Each of the four distinct periods of historical development in the Swedish military healthcare system can be characterized by the changes necessary for transforming Sweden from an aggressive to a defensive and collaborative nation, with national and international engagement. Collaboration not only encompasses readiness and willingness to share resources and information, and to adjust routines and guidelines, but also needs a culture of consensus and respect for each other's limitations and capabilities. The definition of military medicine and the military physician's role in Sweden is imperative for further civilian-military collaboration. CONCLUSIONS: Recent global sociopolitical changes necessitate civilian-military healthcare collaboration. Although civilian-military healthcare partnerships in various medical fields have been reported earlier, the Swedish concept of total defense's healthcare system integration and collaboration may be a more fruitful approach. The collaboration within the total defense healthcare system will result in technical achievements, innovations, and medical advancements for the benefit of the whole nation.

Swedish emergency hospital surgical surge capacity to mass casualty incidents.

BACKGROUND: In Sweden the surgical surge capacity for mass casualty incidents (MCI) is managed by county councils within their dedicated budget. It is unclear whether healthcare budget constraints have affected the regional MCI preparedness. This study was designed to investigate the current surgical MCI preparedness at Swedish emergency hospitals. METHODS: Surveys were distributed in 2015 to department heads of intensive care units (ICU) and surgery at 54 Swedish emergency hospitals. The survey contained quantitative measures as the number of (1) surgical trauma teams in hospital and available after activating the disaster plan, (2) surgical theatres suitable for multi-trauma care, and (3) surgical ICU beds. The survey was also distributed to the Armed Forces Centre for Defence Medicine. RESULTS: 53 hospitals responded to the survey (98%). Included were 10 university hospitals (19%), 42 county hospitals (79%), and 1 private hospital (2%). Within 8 h the surgical capacity could be increased from 105 to 399 surgical teams, while 433 surgical theatres and 480 ICU beds were made available. The surgical surge capacity differed between university hospitals and county hospitals, and regional differences were identified regarding the availability of surgical theatres and ICU beds. CONCLUSIONS: The MCI preparedness of Swedish emergency care hospitals needs further attention. To improve Swedish surgical MCI preparedness a national strategy for trauma care in disaster management is necessary.

Disaster Radio for Communication of Vital Messages and Health-Related Information: Experiences From the Haiyan Typhoon, the Philippines.

OBJECTIVE: Crisis communication is seen as an integrated and essential part of disaster management measures. After Typhoon Haiyan (Yolanda) in the Philippines 2013, radio was used to broadcast information to the affected community. The aim of this study was to describe how disaster radio was used to communicate vital messages and health-related information to the public in one affected region after Typhoon Haiyan. METHODS: Mixed-methods analysis using qualitative content analysis and descriptive statistics was used to analyze 2587 logged radio log files. RESULTS: Radio was used to give general information and to demonstrate the capability of officials to manage the situation, to encourage, to promote recovery and foster a sense of hope, and to give practical advice and encourage self-activity. The content and focus of the messages changed over time. Encouraging messages were the most frequently broadcast messages. Health-related messages were a minor part of all information broadcast and gaps in the broadcast over time were found. CONCLUSION: Disaster radio can serve as a transmitter of vital messages including health-related information and psychological support in disaster areas. The present study indicated the potential for increased use. The perception, impact, and use of disaster radio need to be further evaluated. (Disaster Med Public Health Preparedness. 2016;10:591-597).

"To silence the deafening silence": Survivor's needs and experiences of the impact of disaster radio for their recovery after a natural disaster.

In the aftermath of the Haiyan typhoon, disaster radio was used to spread information and music to the affected population. The study described survivors' experiences of being in the immediate aftermath of a natural disaster and the impact disaster radio made on recovery from the perspective of the individuals affected. Twenty eight survivors were interviewed in focus groups and individual interviews analyzed with phenomenological-hermeneutic method. Being in disaster mode included physical and psychosocial dimensions of being in the immediate aftermath of the disaster. Several needs among the survivors were expressed. Disaster radio contributed to recovery by providing facts and information that helped the survivor to understand and adapt. The music played contributed to emotional endurance and reduced feelings of loneliness. To re-establish social contacts, other interventions are needed. Disaster radio is a positive contribution to the promotion of survivors' recovery after disasters involving a large number of affected people and severely damaged infrastructure. Further studies on the use and impact of disaster radio are needed.

Assessment of the accuracy of the Medical Response to Major Incidents (MRMI) course for interactive training of the response to major incidents and disasters.

BACKGROUND AND AIMS: The benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years and a variety of such models have been reported. However, reviews of this literature show that the majority of these reports have been characterized by significant limitations regarding validation of the accuracy of the training related to given objectives. In this study, precourse and postcourse self-assessment surveys related to the specific training objectives, as an established method for curriculum validation, were used to validate the accuracy of a course in Medical Response to Major Incidents (MRMI) developed and organized by an international group of experts under the auspices of the European Society for Trauma and Emergency Surgery. METHODS: The studied course was an interactive course, where all trainees acted in their normal roles during two full-day simulation exercises with real time and with simultaneous training of the whole chain of response: scene, transport, the different functions in the hospital, communication, coordination, and command. The key component of the system was a bank of magnetized casualty cards, giving all information normally available as a base for decisions on triage and primary management. All treatments were indicated with attachments on the cards and consumed time and resources as in reality. The trainees' performance was recorded according to prepared protocols and a measurable result of the response could be registered. This study was based on five MRMI courses in four different countries with altogether 235 participants from 23 different countries. In addition to conventional course evaluations and recording of the performance during the 2 exercise days, the trainees' perceived competencies related to the specific objectives of the training for different categories of staff were registered on a floating scale 1-10 in self-assessment protocols immediately before and after the course. The results were compared as an indicator of to which extent the training fulfilled the given objectives. These objectives were set by an experienced international faculty and based on experiences from recent major incident and disasters. RESULTS: Comparison of precourse and postcourse self-assessments of the trainees' perceived knowledge and skills related to the given objectives for the training showed a significant increase in all the registered parameters for all categories of participating staff. The average increase was for prehospital staff 74 percent (p<0.001), hospital staff 65 percent (p<0.001), and staff in coordinating/administrative functions 81 percent (p<0.001). CONCLUSIONS: The significant differences in the trainees' self-assessment of perceived competencies between the precourse and postcourse surveys indicated that the methodology in the studied course model accurately responded to the specific objectives for the different categories of staff.

Major trauma with multiple injuries in Swedish children.

OBJECTIVE: To describe the demographics, mechanisms, pattern, and severity of injury, the prehospital and hospital care during the first 24 hours, and the outcome in the most severely injured children in a paediatric intensive care unit (PICU). DESIGN: Retrospective review. SETTING: Paediatric intensive care unit (PICU), Sweden. SUBJECTS: 45 children (0-16 years of age) with multiple injuries admitted to the PICU in Gothenburg from January 1990 to October 2000, inclusive. MAIN OUTCOME MEASURE: Mortality within 30 days after injury. RESULTS: About 2/100000 children with multiple injuries were admitted to the PICU from the greater Gothenburg area each year from 1990-2000 inclusive. Injuries were more common in boys (n = 29, 64%). The mean age was 7 years (SD 5). Traffic related events (n = 29, 64%) and falls (n = 11, 24%) were the leading causes of injury. Thoracic and abdominal injuries were the most common (17% and 16% respectively). Three children died. CONCLUSION: Major trauma with multiple injuries is rare in Swedish children. When they are cared for at a centre with the necessary facilities and trained personnel they have a good chance of survival.