Collaboration of a Medical School With a Special Forces Group on Annual Training: A Blueprint.

Collaboration on annual training between a medical school and a National Guard Special Forces Group can be accomplished with great benefit to both parties. The authors describe the involvement by the Edward Via College of Osteopathic Medicine in providing training for the 20th Special Forces Group Medical Sergeants of the Alabama Army National Guard.

Simulating Early Clinical Experiences With Surgical Procedures in the Anatomy Laboratory.

Background There is evidence to suggest that early exposure to clinical experiences could bolster a medical student's education and prepare them to tackle the problem-based learning encountered during clinical rotations. We hypothesized that incorporating common surgical procedures into the gross anatomy laboratory during preclinical years would enhance the anatomical learning experience for students. The incorporation of these procedures would not be disruptive to the normal conduct of the anatomy laboratory, nor result in exorbitant costs. Objectives The goal of a more integrated curriculum is to better enable medical students by providing them a unique learning experience, so that they may more readily recall the knowledge needed to deal with the complex problems of clinical work. Recognizing the importance of this concept, we have incorporated multiple common clinical procedures into our anatomy curriculum as a pilot program. Methods Seven common surgical procedures, including intraosseous needle insertion, venous cut-down, chest tube insertion, surgical cricothyroidotomy, core needle liver biopsy, appendectomy, and hysterectomy, were taught as a part of this study. Video instructions on each of the surgical procedures were provided before each corresponding laboratory. Surveys were distributed to study participants to measure their satisfaction with the procedures and whether or not it was disruptive to the allotted laboratory time. Results Both students and faculty who were sampled in the study reported that they were satisfied with the procedures (96.5% and 100%, respectively), that the procedures did not interfere with laboratory times (96% and 100%), and that the procedures facilitated clinical learning (98% and 100%). Conclusion This study demonstrated that providing a novel surgical teaching program to medical students was beneficial to their education and non-disruptive to the conventional anatomy curriculum. This exercise further facilitates osteopathic education by demonstrating how structure and function organize surgical practice. The integration of Edward Via College of Osteopathic Medicine, Auburn Campus's (VCOM-AC's) surgical procedures into other medical school anatomy courses can yield more prepared and confident students as they venture into their clinical rotations.

Evaluation of surgical educational videos available for third year medical students.

Objectives: In this study we evaluated 40, top recommended, laparoscopic appendectomy and laparoscopic cholecystectomy videos located on public domain websites using eight criteria created by a panel of third year medical students and general surgeons. We hypothesized that there is a lack of quality, thorough educational laparoscopic surgical videos appropriate for third year medical students to review in preparation for the Surgery rotation.Methods: Utilizing a panel, which included four third year medical students and two general surgeons, we created an 'ideal medical student educational video checklist.' This checklist included 8 vital criteria. We selected 40, top recommended, videos available on YouTube and Google Video search engines, using 'laparoscopic cholecystectomy' and 'laparoscopic appendectomy' as key terms. Each video was evaluated by four third year medical students individually, using a binary system 'meets' or 'does not meet' each criterion. Individual scores were averaged, producing a single score for each video.Results: 0/40 (0%) of the videos met all eight of the criteria. 26/40 (65%) of the videos did not meet half of the criteria. The top performing videos 7/40 (17%) only met 5/8 criteria. Conclusions: We identified a lack of quality and thorough educational surgical videos appropriate for third year medical students and a need for improved online video based instruction. Our checklist can be utilized as a guide for anyone creating surgical videos for medical student education in the future.

Garlic Burn to the Face.

Topical burns from the use of garlic have been reported rarely in the medical literature. Most cases have resulted from the use of naturopathic or home remedy treatments. A 20-year-old male military Servicemember presented to a military wound care clinic 7 days after applying a homemade topical preparation of garlic to the zygomatic region of the right side of his face. The patient had consulted the Internet for treatment of a minor skin lesion in that area. He created a garlic paste, applied it to the affected area, and covered it with a dressing. Twelve hours later, he noted an intense burning sensation where he had applied the garlic paste. After the initial blistering, the patient recovered without any additional treatment. Second-degree burns were an unintended consequence of the use of garlic as a home remedy.

Humanitarian care by a forward surgical team in afghanistan.

BACKGROUND: The mission of a Forward Surgical Team (FST) is to provide immediate lifesaving surgery to wounded U.S. and coalition forces. The degree of humanitarian surgical care provided to civilians is a topic of controversy. METHODS: From May 2011 to November 2011, the surgeons of the 126th FST provided humanitarian surgical care to Afghan civilians. RESULTS: The FST surgeons provided 553 surgical evaluations on 511 Afghan civilians. Of the patients, 95% were male and 38% were children. Forty percent of the clinic visits involved wound care and 20% involved a general surgery diagnosis. Seventeen percent involved an orthopedic diagnosis and 23% involved various surgical subspecialty diagnoses. Of the patients, 11% required a procedure necessitating the use of anesthesia. Interviews with Afghan patients and civic leaders identified a positive impact. CONCLUSION: This is the first report of humanitarian surgical care provided by surgeons of a FST in Afghanistan. Time and resource investment was minimal with no evidence of a negative impact on the primary mission of the FST.

Bladder stones in Afghan children.

OBJECTIVES: Military surgeons have been providing humanitarian care in Afghanistan since 2002. There are scant published reports on the details of that care. We report here the experience of deployed U.S. Army general surgeons in the management of an endemic problem, bladder stones in Afghan children. METHODS: A retrospective review was performed of pediatric patients presenting to an International Security Assistance Force humanitarian clinic over a 12-month period from October 2010 to November 2011. Symptoms at presentation, diagnostic modalities, and treatment provided were analyzed. The general surgeons of the 126th Forward Surgical Team (FST) provided surgical consultations for this military humanitarian clinic on a remote base in western Afghanistan. RESULTS: Eight male pediatric patients of an average age of 4 years presented with dysuria and underwent further evaluation. In five patients, the use of a portable ultrasound machine led to the diagnosis of bladder stones. Three other patients presented with ultrasound exams from an Afghan clinic. Four patients underwent surgical removal of their bladder stones by the FST and 4 four patients, including one with a recurrent bladder stone, were referred to a distant Afghan Regional Hospital. No short-term complications occurred in the five patients available for follow-up. CONCLUSIONS: Military surgeons providing humanitarian care in rural areas of Afghanistan, and humanitarian surgeons serving in endemic areas, can expect to encounter multiple cases of bladder stones in pediatric patients. Dysuria is a typical presenting symptom. The FST has the resources to diagnose and treat this disorder. If accessible, Afghan regional hospitals can provide curative surgery.

Compliance with antimalaria chemoprophylaxis in a combat zone.

Compliance with malaria chemoprophylaxis by military service members (MSMs) is notoriously low, ranging from 30% to 56%. Our objective was to determine the rate of compliance and reasons for non-compliance with malaria chemoprophylaxis among healthy US MSMs in Afghanistan. An eight-question, anonymous online survey was used to collect data regarding the compliance of healthy MSMs with malaria chemoprophylaxis. E-mail surveys were sent to 1,200 MSMs; 528 (44%) MSMs completed the survey. One-time daily doxycycline was the most commonly prescribed chemoprophylaxis (90%); 60% (N = 318) responded that they were compliant with their chemoprophylaxis as prescribed, whereas 40% (N = 221) indicated that they were not compliant. Compliance with daily dosing was 61% and weekly dosing was 38%. The most common reasons for non-compliance were gastrointestinal effects (39%), forgetfulness (31%), and low perception of risk (24%). Malaria chemoprophylaxis compliance by healthy MSMs in Afghanistan is poor. Side effects, forgetfulness, and lack of education are contributing factors. Commanders bear the primary responsibility for the health of their soldiers, and the individual MSM bears personal responsibility; however, additional public health interventions could possibly have a positive impact on prevention.

Improving compliance with malaria chemoprophylaxis in Afghanistan.

OBJECTIVE: Historically, compliance with malaria chemoprophylaxis by military service members (MSM) has been notoriously low, ranging from 30 to 56%. Since 2002, 28 to 85 cases per year of malaria have occurred in MSM deployed to Afghanistan. During their deployment to Afghanistan, the authors identified a low compliance rate with malaria chemoprophylaxis. A performance improvement project was developed to improve compliance. METHODS: In July 2011, a performance improvement plan was developed to improve malaria chemoprophylaxis compliance in MSM arriving on a remote base in western Afghanistan. The plan included a 15-minute briefing and a medical consultation for MSM who had discontinued their chemoprophylaxis because of side effects. At the conclusion of their deployment, the MSM were surveyed on their compliance. RESULTS: Ninety-four MSM attended the briefings. Eighty (85%) MSM completed the survey in October 2011. Ninety-eight percent were taking doxycycline (n = 78). Ninety percent (n = 72) reported that they were compliant with their chemoprophylaxis. One entire unit (n = 29) was identified to be critically short of doxycycline, which initiated an emergency order for medication. Two noncompliant soldiers requested a consultation concerning side effects and were able to continue their chemoprophylaxis. CONCLUSION: Personalized in-theater briefings and consultations by knowledgeable providers may improve compliance with malaria chemoprophylaxis in MSM in Afghanistan.

Management of the mangled face by a forward surgical team.

A mangled face is an uncommon injury that can occur in a combat zone as a result of blunt trauma, penetrating trauma or explosion injury. Despite the patient?s dramatic disfigurement, attention needs to focus on the basic ABC?s of initial trauma management. We present an injured Afghan civilian with a severe facial injury. Our approach to airway management, breathing evaluation and hemorrhage control are described. In addition we utilized two emergency hemorrhage control modalities that are usually associated with other areas of the body, a circumferential compression sling and a laparotomy sponge packing.

Variable application and misapplication of cricoid pressure.

BACKGROUND: In 1961, Sellick described a three-finger technique of cricoid pressure used to prevent gastric regurgitation during induction of anesthesia. The "Sellick maneuver" is now used worldwide. The authors have observed great variability in the application of cricoid pressure by health care providers and have suspected that misapplication occurs. The objectives of this observational study were to determine how many different techniques of cricoid pressure were being used and to identify the reasons for such variability of technique. METHODS: During a 30-month period, the authors observed 32 health care providers applying cricoid pressure at five hospitals. The technique and the professional degree of the person performing the maneuver were recorded. We also reviewed five national courses that provide airway management training to determine which technique of cricoid pressure was being taught. RESULTS: Ten different techniques of cricoid pressure were identified in 32 observations. We identified cases in which pressure was mistakenly applied to the thyroid cartilage and sternocleidomastoid muscles. The original three-finger Sellick technique was rarely used (3 of 32). A review of five national training courses revealed that none provide specific cricoid pressure training. CONCLUSION: This observational study demonstrates that there is great variability in the application of cricoid pressure, identifying 10 different techniques in 32 observations. Misapplication does occur with possible patient harm. We suggest four possible reasons for this variability of technique. The authors use the three-finger cricoid pressure technique as originally described by Sellick and thought that this technique is effective, easy to teach, and safely keeps the fingers in the midline of the cricoid cartilage.

Torsion of the epididymis.

Anomalies of the epididymis are most commonly associated with an undescended testis but also found occasionally in a normally descended testis. Our 11-year-old patient presented with an acute scrotum and Doppler ultrasound that suggested epididymitis. Painful symptoms required scrotal exploration with the finding of a torsion and infarction of the epididymis. The etiology of the torsion was an abnormal attachment of the epididymis to the testis. Torsion of the epididymis has not previously been reported.

Revision of circumcision in children: Report of 56 cases.

BACKGROUND/PURPOSE: Circumcision is the most commonly performed surgical procedure in the United States today. Despite the large number of specialists who perform this procedure, only occasionally are the results unsatisfactory. The purpose of this study is to review the indications for circumcision revision, attempt to identify the specialists who are performing unsatisfactory circumcisions, describe the authors' surgical technique for circumcision revision, and review current coding and billing issues related to this procedure. METHODS: The authors reviewed the charts of 56 consecutive children who underwent circumcision revision over a 4-year period (1995 to 1999). They also reviewed their current coding and billing practices for this procedure. RESULTS: Children undergoing revision of circumcision ranged in age from 6 weeks to 11 years with a mean of 26.7 months. Redundant foreskin was the most common indication for circumcision revision. In 38 patients (68%) the authors were able to identify the specialist who performed the procedure. Pediatricians were most commonly identified (n = 26), followed by residents in training (n = 10) family physician (1), and nurse midwife (1). The authors were unable to identify the type of neonatal circumcision originally performed. Their surgical procedure was the conventional sleeve technique without variation in 55 cases. A gomco clamp was utilized in one patient under local anesthesia and resulted in significant difficulty in the performance of the revision. All patients had a satisfactory cosmetic outcome. There was one complication in a child who required a return to the operating room for postoperative bleeding and hematoma. In review of the authors coding practices they found that there was an appropriate diagnosis code available for redundant foreskin but a specific procedure code was lacking before 2002. The authors also found that midwives perform circumcisions throughout the United States. CONCLUSIONS: Considering the number of neonatal circumcisions performed in the United States, revision of circumcision uncommonly is required. The most common indication for circumcision revision is redundant foreskin. Although pediatricians were most commonly implicated in this study as the source of unsatisfactory circumcisions, that finding probably is more a reflection of local practices and referral patterns. Our recommended surgical procedure, the conventional sleeve technique, is familiar to pediatric surgeons, produces a satisfactory cosmetic result, and is easy to teach to residents and fellows. The authors do not recommend the use of a gomco clamp for circumcision revision. The authors do not feel that a circumcision revision should be delayed expecting that the child will grow into the redundant foreskin. Appropriate diagnosis codes have been available, but a new and more specific procedure code has just been introduced in 2002.

The Use of Argon Beam Coagulation in the Management of Bleeding from an Ulcerated Breast Lesion.

Skin ulceration is an uncommon, but serious manifestation of locally advanced breast cancer. When the ulcerations present with bleeding, they can be particularly difficult to treat. Cautery often fails because the electrode adheres to the skin and rebleeding begins when the instrument is pulled away. We present a case in which argon beam coagulation was used to achieve hemostasis in a bleeding breast ulceration.