Simulation Training in Trauma.

Trauma care is the classic high-acuity event for which simulation training has the potential to greatly improve outcomes. While not a new concept, the variability and availability of training modalities in trauma continues to rapidly multiply. Spanning the continuum of fidelity, simulation extends from simple trauma scenario discussion, to advanced virtual reality experiences. The choice of simulation is largely dependent upon the desired outcome, which is broadly divided into either task-oriented or non-technical skill acquisition.

New Advances in the Care of the Hemorrhaging Patient.

Thirty-three percent of early traumatic deaths are secondary to hemorrhage. In addition to timing to source control, the literature has seen a surge of research on adjuncts in hemorrhage control. This review focuses on three of the latest interventions in the management of the bleeding patient; an endovascular aortic occlusive balloon, tranexamic acid (TXA), and updates to the massive transfusion protocol.

Surgical resident technical skill self-evaluation: increased precision with training progression.

BACKGROUND: Surgical resident ability to accurately evaluate one's own skill level is an important part of educational growth. We aimed to determine if differences exist between self and observer technical skill evaluation of surgical residents performing a single procedure. MATERIALS AND METHODS: We prospectively enrolled 14 categorical general surgery residents (six post-graduate year [PGY] 1-2, three PGY 3, and five PGY 4-5). Over a 6-month period, following each laparoscopic cholecystectomy, residents and seven faculty each completed the Objective Structured Assessment of Technical Skills (OSATS). Spearman's coefficient was calculated for three groups: senior (PGY 4-5), PGY3, and junior (PGY 1-2). Rho (ρ) values greater than 0.8 were considered well correlated. RESULTS: Of the 125 paired assessments (resident-faculty each evaluating the same case), 58 were completed for senior residents, 54 for PGY3 residents, and 13 for junior residents. Using the mean from all OSATS categories, trainee self-evaluations correlated well to faculty (senior ρ 0.97, PGY3 ρ 0.9, junior ρ 0.9). When specific OSATS categories were analyzed, junior residents exhibited poor correlation in categories of respect for tissue (ρ -0.5), instrument handling (ρ 0.71), operative flow (ρ 0.41), use of assistants (ρ 0.05), procedural knowledge (ρ 0.32), and overall comfort with the procedure (ρ 0.73). PGY3 residents lacked correlation in two OSATS categories, operative flow (ρ 0.7) and procedural knowledge (ρ 0.2). Senior resident self-evaluations exhibited strong correlations to observers in all areas. CONCLUSIONS: Surgical residents improve technical skill self-awareness with progressive training. Less-experienced trainees have a tendency to over-or-underestimate technical skill.

In-flight ultrasound identification of pneumothorax.

Ultrasound is a standard adjunct to the initial evaluation of injured patients in the emergency department. We sought to evaluate the ability of prehospital, in-flight thoracic ultrasound to identify pneumothorax. Non-physician aeromedical providers were trained to perform and interpret thoracic ultrasound. All adult trauma patients and adult medical patients requiring endotracheal intubation underwent both in-flight and emergency department ultrasound evaluations. Findings were documented independently and reviewed to ensure quality and accuracy. Results were compared to chest X-ray and computed tomography (CT). One hundred forty-nine patients (136 trauma/13 medical) met inclusion criteria. Mean age was 44.4 (18-94) years; 69 % were male. Mean injury severity score was 17.68 (1-75), and mean chest injury score was 2.93 (0-6) in the injured group. Twenty pneumothoraces and one mainstem intubation were identified. Sixteen pneumothoraces were correctly identified in the field. A mainstem intubation was misinterpreted. When compared to chest CT (n = 116), prehospital ultrasound had a sensitivity of 68 % (95 % confidence interval (CI) 46-85 %), a specificity of 96 % (95 % CI 90-98 %), and an overall accuracy of 91 % (95 % CI 85-95 %). In comparison, emergency department (ED) ultrasound had a sensitivity of 84 % (95 % CI 62-94 %), specificity of 98 % (95 % CI 93-99 %), and an accuracy of 96 % (95 % CI 90-98 %). The unique characteristics of the aeromedical environment render the auditory element of a reliable physical exam impractical. Thoracic ultrasonography should be utilized to augment the diagnostic capabilities of prehospital aeromedical providers.

Emergent surgical airway: comparison of the three-step method and conventional cricothyroidotomy utilizing high-fidelity simulation.

BACKGROUND: Surgical airway creation has a high potential for disaster. Conventional methods can be cumbersome and require special instruments. A simple method utilizing three steps and readily available equipment exists, but has yet to be adequately tested. OBJECTIVE: Our objective was to compare conventional cricothyroidotomy with the three-step method utilizing high-fidelity simulation. METHODS: Utilizing a high-fidelity simulator, 12 experienced flight nurses and paramedics performed both methods after a didactic lecture, simulator briefing, and demonstration of each technique. Six participants performed the three-step method first, and the remaining 6 performed the conventional method first. Each participant was filmed and timed. We analyzed videos with respect to the number of hand repositions, number of airway instrumentations, and technical complications. Times to successful completion were measured from incision to balloon inflation. RESULTS: The three-step method was completed faster (52.1 s vs. 87.3 s; p = 0.007) as compared with conventional surgical cricothyroidotomy. The two methods did not differ statistically regarding number of hand movements (3.75 vs. 5.25; p = 0.12) or instrumentations of the airway (1.08 vs. 1.33; p = 0.07). The three-step method resulted in 100% successful airway placement on the first attempt, compared with 75% of the conventional method (p = 0.11). Technical complications occurred more with the conventional method (33% vs. 0%; p = 0.05). CONCLUSION: The three-step method, using an elastic bougie with an endotracheal tube, was shown to require fewer total hand movements, took less time to complete, resulted in more successful airway placement, and had fewer complications compared with traditional cricothyroidotomy.

Provider X-ray exposure in the trauma bay: results of a radiation field analysis.

Radiation exposure during trauma care has increased in recent years. Radiation risk to providers during the care of injured patients is not well defined. We aimed to gather environmental exposure data from dosimeters placed at fixed points in the trauma bay to act as surrogates for personnel radiation exposure during trauma team activations. Forty-four (44) radiation dosimeters were placed throughout a single trauma bay in a university level 1 trauma center. We analyzed shallow (SDE) and deep dose equivalents (DDE) over 6 months. We measured distance from the radiation source for each dosimeter. Four controls were included. We recorded patient injury and X-ray data for each patient. During the study period, 417 patients were evaluated in the trauma bay under study. Mean ISS was 14.3 (range 0-75). A total of 2,107 plain X-rays were taken, with a mean of 5.1 X-rays per patient (range 0-32). Extremity films were most often performed, followed by chest and shoulder films. No measurable dose was identified with the dosimeter controls. The majority (27, 68 %) of dosimeters registered the lowest doses (<1 mSv DDE). Five dosimeters revealed doses between 1 and 2 mSv DDE. Four dosimeters registered over 2 mSv DDE, with a mean DDE of 3 mSv. Distances of less than 5 ft from the radiation source had the highest DDE dose. Maximum annual occupational DDE dose is conventionally 50 mSv. None of the dosimeters registered DDE doses over 4.31 mSv during the study period, supporting low radiation risk to providers in the trauma bay.

Hemostatic dressings reduce tourniquet time while maintaining hemorrhage control.

Tourniquet application has become first-line treatment for extremity hemorrhage on the battlefield and has seen increased use in the civilian arena. We hypothesized that an effective windlass tourniquet could be removed after application of a hemostatic dressing in a swine model of peripheral vascular injury. A tourniquet was placed proximally in 50 forelimb-injured swine after 30 seconds of hemorrhage with cessation of hemorrhage in all cases. Hemcon, ActCel, Quikclot, Celox, or standard gauze was then placed over the wound with direct pressure for three minutes. The tourniquet was then removed. Success was determined if no bleeding was identified. Standard gauze resulted in a 100 per cent failure rate with active bleeding present after each application. Celox was successful in maintaining hemostasis in 6 of 10 (60%) subjects. Quikclot succeeded in 80 per cent of subjects. ActCel maintained hemostasis in nine (90%) subjects, whereas HemCon was successful in all instances (100%). All four hemostatic dressings were superior to gauze in maintaining hemostasis after removal of an effective tourniquet. Use of hemostatic dressings in conjunction with a tourniquet may reduce tourniquet times and improve outcomes in peripheral vascular injury and warrants further study.

Evidence-Based Selection of Surgical Residents.

Residency programs should use a systematic method of recruitment that begins with defining unique desired candidate attributes. Commonly sought-after characteristics may be delineated via the residency application. Scores from standardized examinations taken in medical school predict academic success, and may correlate to overall performance. Strong letters of recommendation and a personal history of prior success outside the medical field both forecast success in residency. Interviews are crucial to determining fit within a program, and remain a valid measure of an applicant's ability to prosper in a particular program, even with many interviews being completed in the virtual realm.

Assessing Immunity by Quantitative Measurement of SARS-CoV-2 IgG Antibodies in Fingerstick Samples.

COVID-19 has affected billions of people around the world directly or indirectly. The response to the pandemic has focused on preventing the spread of the disease and improving treatment options. Diagnostic technologies have played a key role in this response since the beginning of the pandemic. As vaccines and other treatments have been developed and deployed, interest in understanding and measuring the individual level of immune protection has increased. Historically, use of antibody titers to measure systemic immunity has been constrained by an incomplete understanding of the relationship between antibodies and immunity, the lack of international standards for antibody concentration to enable cross-study comparisons, and insufficient clinical data to allow for the development of robust antibody-immunity models. However, these constraints have recently shifted. With a deeper understanding of antibodies, the promulgation of WHO antibody standards, and the development of immunity models using datasets from multiple COVID-19 vaccine trials, certain types of quantitative antibody tests may now provide a way to monitor individual or community immunity against COVID-19. Specifically, tests that quantitate the concentration of anti-RBD IgG -antibodies that target the receptor binding domain of the S1 spike protein component of the SARS-CoV-2 virus - show promise as a useful and scalable measure of the COVID-19 immunity of both individuals and communities. However, to fulfill this promise, a rapid and easy-to-administer test is needed. To address this important clinical need, Brevitest deployed its point-of-care-capable technology platform that can run a rapid (<15 minute), quantitative antibody test with a sample of 10 µl of whole blood from a fingerstick. The test we validated on this platform measures the concentration of anti-RBD IgG in Binding Antibody Units per milliliter (BAU/mL) per WHO Reference Standard NIBSC 20/136. In this paper, we present studies used to characterize the Brevitest anti-RBD IgG assay and evaluate its clinical performance, lower limits of measurement, precision, linearity, interference, and cross-reactivity. The results demonstrate the ability of this assay to measure a patient's anti-RBD IgG concentration. This information, together with models developed from recent COVID-19 vaccine clinical trials, can provide a means of assessing the current level of immune protection of an individual or community against COVID-19 infection.

The AAST prospective observational multicenter study of the initial experience with reversal of direct oral anticoagulants in trauma patients.

BACKGROUND: Drug-specific agents for the reversal of direct oral anticoagulants (DOACs) were recently approved. We hypothesized that the approval of these reversal agents would lead improved outcomes for trauma patients taking DOACs. METHODS: A multicenter, prospective (2015-2018), observational study of all adult trauma patients taking DOACs who were admitted to one of fifteen participating trauma centers was performed. The primary outcome was mortality. RESULTS: For 606 trauma patients on DOACs, those reversed were older (78 vs. 74, p = 0.007), more severely injured (ISS: 16 vs. 5, p < 0.0001), had more severe head injuries (Head AIS: 2.9 vs. 1.3, p < 0.0001), and higher mortality (11% vs. 3%, p = 0.001). Patients who received drug-specific agents (idarucizumab, andexanet alfa) had higher mortality (30% vs. 8%, p = 0.04) than those reversed with factor concentrates. However, the low usage of drug-specific reversal agents limits our ability to assess their efficacy and safety. CONCLUSIONS: DOAC reversal was not independently associated with mortality. At present, the overall usage of drug-specific reversal agents is too sparing to meaningfully assess outcomes in trauma.

Surgical Simulation: Markers of Proficiency.

OBJECTIVE: Surgical simulation has become an integral component of surgical training. Simulation proficiency determination has been traditionally based upon time to completion of various simulated tasks. We aimed to determine objective markers of proficiency in surgical simulation by comparing novel assessments with conventional evaluations of technical skill. DESIGN: Categorical general surgery residents completed 10 laparoscopic cholecystectomy modules using a high-fidelity simulator. We recorded and analyzed simulation task times, as well as number of hand movements, instrument path length, instrument acceleration, and participant affective engagement during each simulation. Comparisons were made to Objective Structured Assessment of Technical Skill (OSATS) and Accreditation Council for Graduate Medical Education Milestones, as well as previous laparoscopic experience, duration of laparoscopic cholecystectomies performed by participants, and postgraduate year. Comparisons were also made to Fundamentals of Laparoscopic Surgery task times. Spearman's rho was utilized for comparisons, significance set at >0.50. SETTING: University of Missouri, Columbia, Missouri, an academic tertiary care facility. PARTICIPANTS: Fourteen categorical general surgery residents (postgraduate year 1-5) were prospectively enrolled. RESULTS: One hundred forty simulations were included. The number of hand movements and instrument path lengths strongly correlated with simulation task times (ρ 0.62-0.87, p < 0.0001), FLS task completion times (ρ 0.50-0.53, p < 0.0001), and prior real-world laparoscopic cholecystectomy experience (ρ -0.51 to -0.53, p < 0.0001). No significant correlations were identified between any of the studied markers with Accreditation Council for Graduate Medical Education Milestones, Objective Structured Assessment of Technical Skill evaluations, total previous laparoscopic experience, or postgraduate year level. Neither instrument acceleration nor participant engagement showed significant correlation with any of the conventional markers of real-world or simulation skill proficiency. CONCLUSIONS: Simulation proficiency, measured by instrument and hand motion, is more representative of simulation skill than simulation task time, instrument acceleration, or participant engagement.

Case Difficulty, Postgraduate Year, and Resident Surgeon Stress: Effects on Operative Times.

OBJECTIVE: We aimed to evaluate resident operative times in relation to postgraduate year (PGY), case difficulty and resident stress while performing a single surgical procedure. DESIGN: We prospectively examined operative times for 268 laparoscopic cholecystectomies, and analyzed relationships between PGY, case difficulty, and resident surgeon stress utilizing electrodermal activity. Each case operative times were divided into 3 separate time periods. Case Start and End times were recorded, as well as the time between the start of the operation and the time until the cystic structures were divided (Division). Case difficulty was determined by multiple trained observers with a high inter-rater concordance. SETTING: University of Missouri, a tertiary academic medical institution. PARTICIPANTS: All categorical general surgery residents at our institution. RESULTS: For each operative time period examined during laparoscopic cholecystectomy, operative time increased, with each incremental increase in difficulty resulting in approximately 130% longer times. Minimal differences in operative times were seen between PGY levels, except during the easiest cases (Start-End times: 38.5 ± 10.4 minutes vs 34.2 ± 10.8 minutes vs 28.9 ± 10.9 minutes, p 0.002). Resident stress poorly correlated with operative times regardless of case difficulty (Pearson coefficient range 0.0-0.22). CONCLUSIONS: Operative times are longer with increasing case difficulty. PGY level and resident surgeon stress appear to have minimal to no correlation with operative times, regardless of case difficulty.

Clearing the cervical spine in patients with distracting injuries: An AAST multi-institutional trial.

BACKGROUND: Single institution studies have shown that clinical examination of the cervical spine (c-spine) is sensitive for clearance of the c-spine in blunt trauma patients with distracting injuries. Despite an unclear definition, most trauma centers still adhere to the notion that distracting injuries adversely affect the sensitivity of c-spine clinical examination. A prospective AAST multi-institutional trial was performed to assess the sensitivity of clinical examination screening of the c-spine in awake and alert blunt trauma patients with distracting injuries. METHODS: During the 42-month study period, blunt trauma patients 18 years and older were prospectively evaluated with a standard c-spine examination protocol at 8 Level 1 trauma centers. Clinical examination was performed regardless of the presence of distracting injuries. Patients without complaints of neck pain, tenderness or pain on range of motion were considered to have a negative c-spine clinical examination. All patients with positive or negative c-spine clinical examination underwent computed tomography (CT) scan of the entire c-spine. Clinical examination findings were documented prior to the CT scan. RESULTS: During the study period, 2929 patients were entered. At least one distracting injury was diagnosed in 70% of the patients. A c-spine injury was found on CT scan in 7.6% of the patients. There was no difference in the rate of missed injury when comparing patients with a distracting injury to those without a distracting injury (10.4% vs. 12.6%, p = 0.601). Only one injury missed by clinical examination underwent surgical intervention and none had a neurological complication. CONCLUSIONS: Negative clinical examination may be sufficient to clear the cervical spine in awake and alert blunt trauma patients, even in the presence of a distracting injury. These findings suggest a potential source for improvement in resource utilization. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Finding Them a Spot: A Successful Preliminary Match Curriculum.

PURPOSE: Nondesignated preliminary residents (N-DPRs) in General Surgery face difficult challenges of overcoming failure to match and quickly reentering the match again with little time to significantly improve their application. Programs with N-DPRs should take seriously their responsibility for helping these residents obtain a successful career path just as they do for their categorical residents. This study evaluates an intervention to improve the matching of N-DPRs into desired positions. METHODS: We evaluated the match results of N-DPRs at a single institution over an 8-year period. The first 4 years served as the historical control (Group 1), while the following 4 years of N-DPRs underwent a focused intervention (Group 2). Group 2 underwent an 8-step process: (1) a phone call shortly after supplemental offer and acceptance program (SOAP) to discuss strategy, (2) a 1-hour N-DPR specific orientation, (3) targeted meetings to identify reasons for an unsuccessful match, and personal statement revision in July, (4) mock interviews in August, (5) mid-interview cycle meetings to review strategy and trajectory, (6) meetings in January to prioritize rank lists, (7) meetings the week before the match to discuss plan if match is unsuccessful, and (8) meeting on Monday of Match Week. We determined the N-DPRs initial choice of specialty, specialty obtained after their N-DPR year, and career choice changes that occurred during their preliminary years for both groups. Comparisons and statistical analysis were then completed. RESULTS: There were 40 N-DPRs in the program over the last 8 years. Group 1, the 4 years before the curriculum, had only 13 of the 16 (81%) N-DPRs obtain a desired position. Group 2, the 4 years following intervention, had all 24 (100%) N-DPRs obtain a desired position. This was a significant improvement (number needed to treat (NNT) = 5.38, p = 0.027). There were no significant differences between groups in regard to the N-DPRs maintaining their original specialty of choice (44% vs 50%). CONCLUSIONS: The implementation of an N-DPR curriculum significantly improved the probability of N-DPRs to obtain desired positions. Over half of the N-DPRs obtained a position in a specialty different from what they originally applied. Programs should consider aiding N-DPRs in navigating toward a different career path.

Laparoscopic Management of Penetrating Thoracoabdominal Trauma.

BACKGROUND: Traumatic thoracoabdominal injuries can involve multiple organs and multiple cavities, which increases the complexity of surgical management. Traditionally, these injuries required laparotomy and thoracotomy. However, minimally invasive intervention may be reasonable for stable patients. MATERIALS AND METHODS: We present a case of a thoracoabdominal gunshot wound resulting in multiorgan, multicavity injury to the lung, diaphragm, and liver. We performed hepatorrhaphy and diaphragm repair, and addressed a retained hemothorax through a transabdominal laparoscopic approach. RESULTS: The patient tolerated the procedure well. He required no further procedures, and had no evidence of retained hemothorax or bile leak from the liver injury. After a short stay in the hospital, the patient recovered uneventfully. CONCLUSIONS: In hemodynamically stable patients, the transabdominal laparoscopic approach is a feasible and effective approach to penetrating thoracoabdominal trauma.

Inadequacy of Algorithmic Ventilator-Associated Pneumonia Diagnosis in Acute Care Surgery.

Clinical utility of algorithms to diagnose ventilator-associated pneumonia (VAP) in surgical patients has not been established. We aimed to test the diagnostic accuracy of two established methods to reliably diagnose VAP in acutely ill and injured surgical patients. After institutional review board approval, we prospectively collected data on 508 mechanically ventilated acute care surgery patients. Microbiologic samples were taken daily from all patients. Demographics, clinical, laboratory, and radiographic data were collected. The Johanson Criteria (JC) and Clinical Pulmonary Infection Score (CPIS) were calculated and analyzed. Sensitivity, specificity, and positive predictive values (PPV) and negative predictive value (NPV) were calculated in comparison to positive respiratory cultures. Of the 508 patients, 312 (61.4%) were acutely injured; emergent general surgery was performed in 141 (27.8%) patients, and 54 (10.6%) underwent elective operation. Positive respiratory cultures were identified in 198 (39%) of the 508 patients. JC diagnosed VAP in 291 (57.3%) patients (sensitivity 82.8%, specificity 59%, PPV 56.4%, NPV 84.3%, accuracy 68.3%). The CPIS resulted in 189 (37.2%) VAP diagnoses (sensitivity 61.1%, specificity 78.1%, PPV 64%, NPV 75.9%, and accuracy 71.5%). To address the inaccuracy of the algorithms, concordance testing was performed on the data to evaluate correlation between the algorithmic VAP diagnosis criteria and respiratory culture data. Nonconcordance with culture data diagnosis was identified with both JC (rho 0.41) and CPIS (rho 0.41). Sensitivity, specificity, PPV and NPV, and accuracy of both established clinical formulas was unacceptably low in acute care surgery patients.

Pulmonary Contusion in Mechanically Ventilated Subjects After Severe Trauma.

BACKGROUND: Pulmonary contusions are thought to worsen outcomes. We aimed to evaluate the effects of pulmonary contusion on mechanically ventilated trauma subjects with severe thoracic injuries and hypothesized that contusion would not increase morbidity. METHODS: We conducted a single-center, retrospective review of 163 severely injured trauma subjects (injury severity score ≥ 15) with severe thoracic injury (chest abbreviated injury score ≥ 3), who required mechanical ventilation for >24 h at a verified Level 1 trauma center. Subject data were analyzed for those with radiographic documentation of pulmonary contusion and those without. Statistical analysis was performed to determine the effects of coexisting pulmonary contusion in severe thoracic trauma. RESULTS: Pulmonary contusion was present in 91 subjects (55.8%), whereas 72 (44.2%) did not have pulmonary contusions. Mean chest abbreviated injury score (3.54 vs 3.47, P = .53) and mean injury severity score (32.6 vs 30.2, P = .12) were similar. There was no difference in mortality (11 [12.1%] vs 9 [12.5%], P > .99) or length of stay (16.29 d vs 17.29 d, P = .60). Frequency of ventilator-associated pneumonia was comparable (43 [47.3%] vs 32 [44.4%], P = .75). Subjects with contusions were more likely to grow methicillin-sensitive Staphylococcus aureus in culture (33 vs 10, P = .004) as opposed to Pseudomonas aeruginosa in culture (6 vs 13, P = .003). CONCLUSIONS: Overall, no significant differences were noted in mortality, length of stay, or pneumonia rates between severely injured trauma subjects with and without pulmonary contusions.

Laboratory measures of coagulation among trauma patients on NOAs: results of the AAST-MIT.

BACKGROUND: Warfarin is associated with poor outcomes after trauma, an effect correlated with elevations in the international normalized ratio (INR). In contrast, the novel oral anticoagulants (NOAs) have no validated laboratory measure to quantify coagulopathy. We sought to determine if use of NOAs was associated with elevated activated partial thromboplastin time (aPTT) or INR levels among trauma patients or increased clotting times on thromboelastography (TEG). METHODS: This was a post-hoc analysis of a prospective observational study across 16 trauma centers. Patients on dabigatran, rivaroxaban, or apixaban were included. Laboratory data were collected at admission and after reversal. Admission labs were compared between medication groups. Traditional measures of coagulopathy were compared with TEG results using Spearman's rank coefficient for correlation. Labs before and after reversal were also analyzed between medication groups. RESULTS: 182 patients were enrolled between June 2013 and July 2015: 50 on dabigatran, 123 on rivaroxaban, and 34 apixaban. INR values were mildly elevated among patients on dabigatran (median 1.3, IQR 1.1-1.4) and rivaroxaban (median 1.3, IQR 1.1-1.6) compared with apixaban (median 1.1, IQR 1.0-1.2). Patients on dabigatran had slightly higher than normal aPTT values (median 35, IQR 29.8-46.3), whereas those on rivaroxaban and apixaban did not. Fifty patients had TEG results. The median values for R, alpha, MA and lysis were normal for all groups. Prothrombin time (PT) and aPTT had a high correlation in all groups (dabigatran p=0.0005, rivaroxaban p<0.0001, and apixaban p<0.0001). aPTT correlated with the R value on TEG in patients on dabigatran (p=0.0094) and rivaroxaban (p=0.0028) but not apixaban (p=0.2532). Reversal occurred in 14%, 25%, and 18% of dabigatran, rivaroxaban, and apixaban patients, respectively. Both traditional measures of coagulopathy and TEG remained within normal limits after reversal. DISCUSSION: Neither traditional measures of coagulation nor TEG were able to detect coagulopathy in patients on NOAs. LEVEL OF EVIDENCE: Level IV.

Objective Measurement of Clinical Competency in Surgical Education Using Electrodermal Activity.

OBJECTIVE: Within the realm of surgical education, there is a need for objective means to determine surgical competence and resident readiness to operate independently. We propose a novel, objective method of assessing resident confidence and clinical competence based on measurement of electrodermal activity (EDA) during live surgical procedures. We hypothesized that with progressive training, EDA responses to the stress of performing surgery would exhibit decline, elucidating an objective correlate of clinical competence. DESIGN: EDA was measured using galvanic skin response sensors worn by residents performing laparoscopic cholecystectomy on sequential live human patients over an 8-month period. Baseline, phasic (peak) and tonic EDA responses were measured as a fractional change from baseline. SETTING: University of Missouri, Columbia, Missouri, an academic tertiary care facility. PARTICIPANTS: Fourteen categorical general surgery residents and 5 faculty surgeons were voluntarily enrolled and participated through completion. RESULTS: Tonic fractional change (FCTONIC) was highest in PGY3 residents compared with postgraduate year (PGY) 1 and 2 residents (7.199 vs. 2.100, p = 0.004, 95% CI: 8.58-1.61 and PGY4 and 5 residents (7.199 vs. 2.079, p = 0.002, 95% CI: 8.38-0.29). Phasic fractional change in EDA (FCPHASIC) exhibited a progressive decline across resident training levels, with PGY1 and 2 residents having the highest response, and faculty displaying the lowest FCPHASIC responses. Statistical differences were seen between FCPHASIC faculty and PGY4 and 5 (3.596 vs. 6.180, p = 0.004, 95% CI: 0.80-4.36), PGY4 and 5, and PGY3 (6.180 vs. 15.998, p = 0.003, 95% CI: 3.33-16.3), as well as among all residents and faculty (13.057 vs. 3.596, p = 0.004, 95% CI: 15.8-3.1). CONCLUSION: Phasic EDA changes decrease with increasing clinical competence. For those participants with the lowest and highest levels of competence, tonic EDA changes are minimal. Tonic EDA changes follow an inverse-U shape with differing levels of clinical competence.