A distinct immune cytokine profile is associated with morning cortisol and repeated stress.

OBJECTIVE: The objective of this study was to investigate possible immune cytokine trends throughout a week-long surgical simulation mass-casualty training session in order to determine the effects of stress inoculation on the immune system. METHODS: Thirty-seven military medical students participated in a hyper-realistic surgical simulation training event conducted at Strategic Operations site in San Diego, California. Salivary samples were collected every morning of the stress training exercise for 4 consecutive days. Cortisol, along with a panel of 42 immune cytokines, was measured using multiplex enzyme-linked immunosorbent assays from Eve Technologies. The determined concentrations were averaged and plotted on a scatter plot, and then points were fit to a second-order polynomial trendline of best fit to measure. RESULTS: The cytokines epidermal growth factor, growth-related oncogene-α, interleukin (IL)-1α, and platelet-derived growth factor-AA followed a noted pattern of cortisol decrease throughout the week. In addition, cytokines IL-27, granulocyte colony stimulating factor, IL-10, and IL-13 demonstrated a late peak, followed by a return to baseline at the conclusion of training. Finally, the cytokine monocyte chemoattractant protein-1 displayed a decline throughout the week followed by an increase on the last day of stress training. CONCLUSIONS: Altogether, these results help to identify important biomarkers that may help to improve long-term stress adaptation and prevent post-traumatic stress disorder following exposure to repeated stress.

Exploring the relationship of supernumerary recurrent renal calculi formation and tick-borne infections: a case report.

A 51-year-old male with a history of Cacchi-Ricci disease and long-standing infection with various species of Borrelia, Babesia, and Bartonella presented with recurrent symptoms of right-sided flank pain. Numerous renal calculi were identified on imaging. The etiology of the calculi had not been previously elucidated. Symptoms intermittently date back to 2002 when uric acid stones were identified. Subsequent calculi analysis revealed calcium oxalate stones. Despite the commonality of nephrolithiasis in patients with Cacchi-Ricci disease, the extreme number of calculi and recurrent presentation of symptoms persisted despite a plethora of medical evaluations, dietary changes, and hereditary testing. This case raises questions of etiology including possible immune deficiency and whether his uncommon microbial history contributes to recurrent stone formation.

Start-of-day oculomotor screening demonstrates the effects of fatigue and rest during a total immersion training program.

BACKGROUND: Investigating changes in sleep and fatigue metrics during intensive surgical and trauma skills training, this study explored the dynamic association between oculomotor metrics and fatigue. Specifically, alterations in these relations over extended stress exposure, the influence of time of day, and the impact of fatigue exposure on sleep metrics were examined. METHODS: Thirty-nine military medical students participated in 6 days of immersion, hyper-realistic, and high-stress experiential casualty training. Participants completed surveys assessing the state of sleepiness with oculomotor tests performed each morning and evening, analyzing eye movement and pupillary change to characterize fatigue. Participants wore Fitbit TM devices to measure overall time asleep and time in each sleep stage during the training. RESULTS: Fitbit data showed increased average minutes in rapid eye movement, deep sleep, and less time in light sleep from day 1 to day 4. The microsaccade peak velocity-to-displacement ratio exhibited a morning decrease but not in afternoon sessions, indicating repeated but temporary effects of accumulated fatigue. There were no findings regarding pupil reactivity to illumination changes. CONCLUSION: This study describes characteristics of fatigue measured by rapid and individually calibrated oculomotor tests. It demonstrates oculomotor relationships to fatigue in start-of-day testing, providing a direction for timing for optimal fatigue testing. These data suggest that improved sleep could signal resilience to fatigue during afternoon testing. Further investigation with more participants and longer duration is warranted. A deeper understanding of the interrelationships between training, sleep, and fatigue could improve surgical and military fitness.

Correlation analysis of salivary cytokines and hormones with resiliency.

BACKGROUND: Frequent exposure to acute stress increases risk of suicide, posttraumatic stress disorder, and other stress-related disorders. Neuroendocrine and immunologic dysregulation associated with stress may underlie predispositions to psychological disorders and inflammatory disease processes in individuals, such as first-responders and other healthcare professionals, who function in high stress situations. The Hardiness Resilience Gauge (HRG) can be used to psychometrically measure resilience, a psychological modifier of the stress response. Using the HRG alongside salivary biomarker profiling, may help to identify low resilience phenotypes and allow mitigation and early therapeutic interventions. There is a paucity of knowledge regarding biomarkers of resilience. This study aims to evaluate the relationship between factors of resilience with salivary biomarker levels and fluctuations during and following acute stress. METHODS: Sixty-three first responders underwent a standardized stress-inducing training exercise, providing salivary samples before (prestress), immediately after (post-stress), and 1 hour after the event (recovery). The HRG was administered before (initial) and after (final) the event. Multiplex ELISA panels quantified 42 cytokines and 6 hormones from the samples, which were analyzed for relationships to psychometric factors of resilience measured by the HRG. RESULTS: Several biomarkers correlated with psychological resilience following the acute stress event. The HRG scores correlated ( p < 0.05) with a select set of biomarkers with moderate-to-strong correlations (|r| > 0.3). These included EGF, GROα, PDGFAA, TGFα, VEGFA, interleukin (IL)1Ra, TNFα, IL18, cortisol, FGF2, IL13, IL15, and IL6. Interestingly, fluctuations of EGF, GROα, and PDGFAA in post-stress compared with recovery were positively correlated with factors of resilience, which were negatively correlated from the pre-stress to post-stress period. CONCLUSION: This exploratory analysis discovered a small subset of salivary biomarkers that are significantly correlated with acute stress and resilience. Further investigation of their specific roles in acute stress and associations with resiliency phenotypes is warranted.

Cytokine fluctuation during acute stress is correlated to life trauma.

BACKGROUND: Multiple studies have demonstrated that human neurobiology and behavior are inextricably linked to the activity of our immune systems. Trauma is associated with a multitude of immune system changes; reflecting this, posttraumatic stress disorder (PTSD) is often comorbid with immune-related conditions such as autoimmune disorders. To further investigate this phenomenon, we tested our hypothesis that cytokine fluctuations during and after an acute stress response correlates with experienced life trauma. METHODS: Using a prospective observational approach, this cohort study measured biomarker profiles in firefighter participants (n = 63), with 9 participants having prior PTSD diagnoses and 54 without prior PTSD diagnoses. In addition, life trauma scores were determined from all participants using the Life Events Checklist 5 (LEC-5) survey. Baseline salivary biomarker concentrations were determined, along with levels immediately before, immediately after, and 1 hour following a standardized stressful training event. Biomarkers measured using these salivary samples included 42 cytokines and 6 steroid and thyroid hormones. The concentrations of these markers were then correlated, using Pearson correlation coefficients, with the participants' LEC-5 scores. t Tests were also performed to compare cytokine values between the populations with and without prior PTSD diagnosis. RESULTS: Included in the cytokine panel were interleukin (IL)-8, IL-10, IL-1B, GCSF, IL1-Ra, Groα, IFNa2, PDGFAA, and VEGF, all of which demonstrated positive correlation at various time points in individuals with increased severity of LEC-5 scores (and thus increased experienced life trauma). Concentrations of Groα, PDGFAA, IL1-Ra, IL-1a, Mip1a, IL-1a, IL-6, Mip1b, TNFα, and TGFα were also found to be significantly altered at various time points in participants with prior PTSD diagnoses, demonstrating some overlap with the LEC-5 Pearson correlations. CONCLUSION: The results support our hypothesis and demonstrate that LEC-5 scores are indeed significantly correlated to cytokine concentrations and fluctuations surrounding a stress test. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level IV.

A Mixed Methods Investigation on the Relationship Between Perceived Self-Regard, Self-Efficacy, and Commitment to Serve Among Military Medical Students.

INTRODUCTION: Routinely faced with potentially traumatizing situations, resilience is critical for military physicians. However, related studies are limited in scope. The current study distinctively combines hyper-realistic immersion training for military medical students with emotional intelligence and hardiness measures. With self-reflection shown to improve performance, qualitative inquiry was concurrently conducted in a mixed methodology approach to provide a uniquely comprehensive perspective on the resilience training needs of this population. MATERIALS AND METHODS: Thirty-four osteopathic military medical students participated in a week-long training simulating real-life combat and mass casualty events. The Emotional Quotient-Inventory 2.0 (EQ-i 2.0) and Hardiness Resilience Gauge were administered as pre- and post-test measures. Paired t-tests were used to determine statistically significant gains, and a multiple case study analysis of a six-student focus group allowed for the synchronization of quantitative and qualitative data. Institutional Review Board approval for the study was obtained through Rocky Vista University with a reciprocal agreement with Touro University California's Institutional Review Board. All students participating in the study received written informed consent. RESULTS: Qualitative findings for this study aligned with this current year's findings of statistically significant results in the improvement of the Overall EQ-i and Overall Hardiness. Qualitative responses thematically analyzed demonstrated environmental realism, adaptation, increased awareness, and positive interpersonal and clinical outlook. Notable increases occurred in all EQ-i domains except Decision-Making and Stress Tolerance. The Self-Perception domain saw significant increases in Self-Regard and Emotional Self-Awareness while Well-Being and Optimism simultaneously improved. CONCLUSION: This unique pilot study showed that quantitative and qualitative results aligned, supporting the finding that a safe trauma-related training environment can improve the confidence and resilience in military medical students. The goal of this training was to promote resilience and mitigate trauma. Results demonstrate improved self-efficacy and enhanced commitment. Increases in self-awareness and confidence made participants more inclined to see their worth and strengthened their sense of duty as described in their qualitative responses. Pervasive gains suggest that the training aligned well with its purpose, and the methods employed enhanced participant experience. Long-term follow-up studies are needed to assess outcome sustainability.

Principal component analysis of salivary cytokines and hormones in the acute stress response.

The acute stress response is characterized by activation of multiple interconnected systems in the body, resulting in the release of a flood of hormones and immune mediators into circulation. In addition to detection of these molecules in the serum, saliva can serve as a source of these markers as well and can be collected in a non-invasive way. The complete profile of salivary biomarkers associated with the hypothalamic pituitary adrenal/gonadal axes and the immune system during the acute stress response has not been fully elucidated. In a cohort of 62 first responders engaged in a stress training exercise, we set out to determine patterns of cytokine, chemokine and hormone shifts during the acute stress response. Salivary samples were collected immediately before (pre-stress), immediately after (post-stress) and 1 h after the stress test (recovery). Multiplex ELISA panels of 42 cytokines and 6 steroid and thyroid hormones were used to determine concentrations of these biomarkers during the three aforementioned time points. Principal components analysis was conducted to determine patterns in the large data sets collected. In our ≥0.3 loading principal components analysis, for pre-stress vs. post, post-stress vs. recovery and pre-stress vs. recovery, a total of three, four and three factors accounted for 56.6, 68.34, and 61.70% of the biomarker variation for each phase respectively. In the ≥0.7 loading principal components analysis, three, four and three factors were found for pre-stress vs. post, post-stress vs. recovery and pre-stress vs. recovery stages, respectively. Of note, in our ≥0.3 loading principal components analysis, MCP1 was present in all three factors from pre-stress to post-stress, and fractalkine was found to be in all four factors post-stress vs. recovery and pre vs. recovery from stress. Additionally, hormones testosterone, estradiol, T4 and T3 grouped together consistently in the same factor for all phases of acute stress in both ≥0.3 and ≥0.7 principal components analysis. Overall, our results identified specific patterns of immune markers and hormones that shift during acute stress and warrant further investigation to understand their mechanistic role in regulating the stress response.

Website Usability Analysis of U.S. Military Residency Programs.

INTRODUCTION: The Military Match is the residency matching system for medical students attending the Uniformed Services University of Health Sciences, and the students were funded by the Health Professions Scholarship Program through the U.S. Army, Air Force, and Navy. To evaluate and compare military residency programs, students use residency program websites. Often, the residency program's website serves as a key source, or the only point of reference, when considering residency options, especially during times when face-to-face interactions are limited.This report aims to provide a systematic evaluation of military residency programs and their websites. MATERIALS AND METHODS: Utilizing a previously published website usability scoring system, military residency programs were categorized to objectively and quantitatively analyze their websites. Usability was divided into four categories for quantifiable analysis: accessibility, marketing, content quality, and technology. The methodology for this analysis was replicated from published reports that have examined healthcare website usability. Each website was analyzed and scored in four categories: accessibility, content quality, marketing, and technology. A "General Usability" score was calculated for each website using a composite of the key factors within the four categories. An overall score was generated utilizing the weighted percentage across all four categories. To address deficiencies of the original methodology, a secondary analysis was performed on the listed websites utilizing an automated methodology for website usability. RESULTS: A comprehensive list of 125 Accreditation Council for Graduate Medical Education U.S. Military residency program websites was compiled. Of these, 96 programs and 106 websites were evaluated. The primary analysis employing usability methodology identified technology as the highest ranked category with a score of 0.749 (SD ± 0.039) (SE 0.005) (P < .05). Marketing and content quality were the lowest scoring categories with mean scores of 0.414 (SD ± 0.054) (SE 0.006) and 0.428 (SD ± 0.229) (SE 0.027), respectively (P < .05). There was no significant difference in overall usability rankings or scores among the 96 residency program websites across the three branches (P < .05).Secondary analysis with the new usability methodology demonstrated military residency websites to exhibit more external backlinking compared to internal backlinking (P < 0.05) and no social media backlinking to any of the 106 analyzed websites. When comparing the three services, the Army had significantly lower external backlinking ranking 43.4 (P < .05) and overall backlinking ranking 56.4 (P < 0.05) when compared to the Navy (mean 48.8 and 71.7, and 43.4). There were no other differences in backlinking rankings across the three branches. CONCLUSIONS: Residency websites have become a primary way to communicate information to applicants. By assessing the overall usability of the various military residency websites, we determined the effectiveness of these websites to relay information to prospective students interested in applying for military residency. We predict that by improving website accessibility, residency programs increase their effectiveness at communicating information to potential applicants and increase interest in military residency programs.

Robotically applied hemostatic clamping for care-under-fire: harnessing bomb robots for hemorrhage control.

BACKGROUND: Early hemorrhage control after interpersonal violence is the most urgent requirement to preserve life and is now recognized as a responsibility of law enforcement. Although earlier entry of first responders is advocated, many shooting scenes remain unsafe for humans, necessitating first responses conducted by robots. Thus, robotic hemorrhage control warrants study as a care-under-fire treatment option. METHODS: Two bomb disposal robots (Wolverine and Dragon Runner) were retrofitted with hemostatic wound clamps. The robots' ability to apply a wound clamp to a simulated extremity exsanguination while controlled by 4 experienced operators was tested. The operators were randomly assigned to perform 10 trials using 1 robot each. A third surveillance robot (Stair Climber) provided further visualization for the operators. We assessed the success rate of the application of the wound clamp to the simulated wound, the time to application of the wound clamp and the amount of fluid loss. We also assessed the operators' efforts to apply the wound clamp after an initial attempt was unsuccessful or after the wound clamp was dropped. RESULTS: Remote robotic application of a wound clamp was demonstrated to be feasible, with complete cessation of simulated bleeding in 60% of applications. This finding was consistent across all operators and both robots. There was no difference in the success rates with the 2 robots (p = 1.00). However, there were differences in fluid loss (p = 0.004) and application time (p < 0.001), with the larger (Wolverine) robot being faster and losing less fluid. CONCLUSION: Law enforcement tactical robots were consistently able to provide partial to complete hemorrhage control in a simulated extremity exsanguination. Consideration should be given to using this approach in care-under-fire and care-behind-the-barricade scenarios as well as further developing the technology and doctrine for robotic hemorrhage control.

Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest.

AIM: Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence. METHODS: A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR). RESULTS: Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients. CONCLUSION: Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA.

Delayed care in myocardial infarction and ischemic stroke patients during the COVID-19 pandemic.

COVID-19 has profound direct health consequences, however secondary effects were much broader as rates of hospital visits steeply declined for non-COVID-19 concerns, including myocardial infarction (MI) and stroke, with patients choosing to wait longer before symptoms convince them to seek medical attention. Thus, patients where ischemia leads to tissue loss should be a major concern. METHODS: The months of March to June 2019 and 2020 were compared to each other at 4 Denver area hospitals. Reduction in overall ED visits and an increase in patient refusal for emergency transport were clear in the data collected. During this period in 2019, 49 MI and 90 stroke patients were admitted. In 2020 this was 40 and 90 respectively. All were matched for age and gender. For MI patients ejection fraction and door to EKG and intervention times were measured. For stroke patients last known well time, time to evaluation, and modified Rankin scores were measured. RESULTS: 254 (8.12%) patients refused emergency services transportation before the pandemic compared to 479 (18.35%) during the pandemic (p-value <0.001, chi square test). In the MI cohort, no significant difference was detected in measured ejection fraction (48% vs 49% p-value = 0.682). Additionally, no significant difference was detected between door to EKG time or door to MI intervention time. During the pandemic 8 (22%) expired with an MI prior to discharge, compared to 2 (4%) before the pandemic. The stroke cohort Door to Evaluation Time, Time since last well known, and modified Rankin scores were all found to have insignificant differences. DISCUSSION: ED volume was significantly lower during the early stages of the pandemic. During this time however only death from cardiac events increased, in spite of similar ejection fractions at discharge. The cause of this remains unclear as ejection fraction similarities make it less attributable to loss of tissue than to other factors. Patient behavior significantly changed during the pandemic, making this a likely source of the increase in mortality seen.

Emotional intelligence, cortisol and α-amylase response to highly stressful hyper-realistic surgical simulation of a mass casualty event scenario.

Lifetime exposure to stress leads to risk of suffering from cumulative detrimental physiological and psychological ailments. Due to the nature of healthcare and exposure to trauma, medical professionals are particularly susceptible to the negative impacts of high stress environments. emotional intelligence plays a role in ameliorating the risk of being negatively impacted by these stressors. As such, there is special interest to develop and implement training interventions for medical personnel that would allow them to improve emotional intelligence potential with the goal of enabling them to handle stress better and mitigate burnout. A hyper-realistic surgical simulation training session, replicating the intensity of a Mass-Casualty Event scenario, was implemented to allow medical professionals to experience this in real time. Overall, the training led to increased emotional intelligence, correlating with decreased hypothalamus-pituitary-adrenal axis and sympathetic nervous system stress biomarkers, cortisol and α-amylase. This novel training provides, at least, short-term improvements in emotional intelligence that is reflected with a physiological response. These results guide the ongoing effort to develop therapeutic tools to improve long term stress management, mitigate burnout and reduce post-traumatic stress risk after an exposure to a Mass-Casualty event scenario.

Medical Students Immersed in a Hyper-Realistic Surgical Training Environment Leads to Improved Measures of Emotional Resiliency by Both Hardiness and Emotional Intelligence Evaluation.

BACKGROUND: Burnout is being experienced by medical students, residents, and practicing physicians at significant rates. Higher levels of Hardiness and Emotional Intelligence may protect individuals against burnout symptoms. Previous studies have shown both Hardiness and Emotional IntelIigence protect against detrimental effects of stress and can be adapted through training; however, there is limited research on how training programs affect both simultaneously. Therefore, the objective of this study was to define the association of Hardiness and Emotional Intelligence and their potential improvement through hyper realistic immersion simulation training in military medical students. METHODS: Participants in this study consisted of 68 second year medical students representing five medical schools who were concurrently enrolled in the United States military scholarship program. During a six day hyper-realistic surgical simulation training course, students rotated through different roles of a medical team and responded to several mass-casualty scenarios. Hardiness and Emotional Intelligence were assessed using the Hardiness Resilience Gauge (HRG) and the Emotional Quotient Inventory (EQ-I 2.0) respectively, at two time points: on arrival (pre-event) and after completion of the course (post-event). RESULTS: Hardiness and Emotional Intelligence scores and sub scores consistently improved from pre-event to post-event assessments. No difference in training benefit was observed between genders but differences were observed by age where age was more often associated with Emotional Intelligence. In addition, factor analysis indicated that the HRG and EQ-I 2.0 assessment tools measured predominately different traits although they share some commonalities in some components. CONCLUSION: This study indicates that Hardiness and Emotional Intelligence scores can be improved through immersion training in military medical students. Results from this study support the use of training course interventions and prompt the need for long term evaluation of improvement strategies on mitigating burnout symptoms.

Strategies to improve communication in telementoring in acute care coordination: a scoping review.

Background: Telementoring facilitates the coordination of advanced medical care in rural, remote or austere environments. Because the interpersonal element of telementoring has been relatively underexplored, we conducted a scoping review to identify strategies to improve communication in telementoring. Methods: Two independent reviewers searched all English-language articles in MEDLINE and Scopus from 1964 to 2017, as well as reference lists of relevant articles to identify articles addressing telementored interactions between health care providers. Search results were gathered in June 2017 and updated in January 2018. Identified articles were categorized by theme. Results: We identified 144 articles, of which 56 met our inclusion criteria. Forty-one articles focused on improving dispatcher-directed cardiopulmonary resuscitation (CPR). Major themes included the importance of language in identifying out-of-hospital cardiac arrest and how to provide instructions to enable administration of effective CPR. A standardized approach with scripted questions was associated with improved detection of out-of-hospital cardiac arrest, and a concise script was associated with improved CPR quality compared to no mentoring, unscripted mentoring or more complex instructions. Six articles focused on physician-physician consultation. Use of a handover tool that highlighted critical information outperformed an unstructured approach regarding transmission of vital information. Nine articles examined telementoring in trauma resuscitation. A common theme was the need to establish an understanding between mentor and provider regarding the limitations of the provider and his or her environment. Conclusion: The available data suggest that standardization coupled with short, concise validated scripts could improve efficacy, safety and engagement. Improvements will require multidisciplinary input, practice and deliberate efforts to address barriers.

Contexte: Le mentorat en ligne facilite la coordination des soins médicaux de pointe dans les environnements ruraux, éloignés ou rudimentaires. Toutefois, le facteur relationnel de ce type d'interaction est resté plutôt sous-exploré. C'est pourquoi nous avons réalisé une revue exploratoire pour dégager des stratégies d'amélioration de la communication en contexte de mentorat en ligne. Méthodes: Deux réviseurs indépendants ont cherché à recenser les articles portant sur les interactions de mentorat en ligne entre professionnels de la santé parmi tous les articles de langue anglaise publiés entre 1964 et 2017 indexés dans les bases de données MEDLINE et Scopus, ainsi que dans les listes bibliographiques des articles pertinents. Les résultats de recherche ont été recueillis en juin 2017 et actualisés en janvier 2018, et les articles recensés ont été regroupés par thèmes. Résultats: Nous avons retenu 144 articles, dont 56 répondant à nos critères d'inclusion. De ce total, 41 portaient sur l'amélioration de la réanimation cardiorespiratoire (RCR) dirigée par un répartiteur. Parmi les thèmes principaux, on retrouve l'importance du langage dans l'identification des arrêts cardiaques hors de l'hôpital, ainsi que la manière de fournir des instructions permettant de pratiquer une RCR efficace. Une approche normalisée avec des questions scénarisées a été associée à une meilleure détection des arrêts cardiaques hors de l'hôpital, alors qu'un scénario concis a été associé à une amélioration de la qualité de la RCR comparativement à une approche sans mentorat, avec mentorat non scénarisé ou avec des instructions plus complexes. Six des articles retenus portaient sur la consultation de type médecin­médecin. Ils ont conclu que l'utilisation d'un outil de transfert mettant en évidence l'information importante était plus efficace qu'une approche non structurée pour la transmission de renseignements vitaux. Finalement, 9 articles portaient sur le mentorat en ligne en réanimation traumatologique. Un des thèmes communs de ces articles était le besoin d'établir une compréhension mutuelle entre mentors et professionnels en ce qui concerne les restrictions de ces derniers et de leur environnement. Conclusion: Les données disponibles semblent indiquer que la normalisation associée à des scénarios courts, concis et éprouvés pourrait améliorer l'efficacité, la sécurité et l'engagement. Cependant, toute amélioration nécessitera un encadrement multidisciplinaire, de la pratique et des efforts délibérés pour surmonter les obstacles.

The Effect of Hyper-Realistic Trauma Training on Emotional Intelligence in Second Year Military Medical Students.

INTRO: This project expanded upon previous exploration of emotional intelligence during the habituation for military second year medical students undergoing high-stress simulation with trauma and surgical skill training. The objective was to interpret emotional intelligence data before and after hyper-realistic immersion trauma training and to include a larger sample size than previously investigated. METHODS: Fifty increasingly intense mass casualty scenarios with simulated Emergency Department (ED) and Operating Room (OR) procedures were performed while students lived as if deployed in an Afghan village. Students rotated through a variety of roles in both the ED and the OR throughout the weeklong program. Second year medical students completed the EQ-i 2.0 Model for Emotional Intelligence on the first and last day of the intensive surgical skills week. Three different cohorts from three different graduating classes were followed with a total sample size of 96. Emotional intelligence in this model is defined as a combination of 5 domains each with three subdomains. RESULTS: A statistical analysis of the EQ data shows significant improvement in almost every subdomain of Emotional Intelligence from pre to post testing. The total EQ score was significantly higher with an average improvement of 3.95 points. All of the subdomains, except for emotional expression, empathy, and problem solving significantly improved following the intensive skills course. A 3 factor ANOVA including year and gender was also performed. R2 of the change in pre to post scores was around 90%, indicating practical significance in the score improvements. CONCLUSION AND IMPACT: Total emotional intelligence significantly improved from pre to post scores as well as each of the 5 domains and most subdomains. Scores improved an average of 4 points after only a 5-day training course. This training led to the most improvement in the self-perception and stress management categories. Medicine, especially high stress specialties like surgery and trauma, require physicians who are able to make decisions at a moment's notice and cope well with stressful situations. It is essential that individuals develop these intangible skills, which can be measured by emotional intelligence. Further research is needed to determine the long-term impacts of the increased emotional intelligence seen with hyper-realistic training. Some specific areas to investigate include physician performance and emotional wellbeing.

Hyper-realistic and immersive surgical simulation training environment will improve team performance.

BACKGROUND: Surgical trauma care requires excellent multidisciplinary team skills and communication to ensure the highest patient survival rate. This study investigated the effects of Hyper-realistic immersive surgical team training to improve individual and team performance. A Hyper-realistic surgical training environment is defined as having a high degree of fidelity in the replication of battlefield conditions in a training environment, so participants willingly suspend disbelief that they become totally immersed and eventually stress inoculated in a way that can be measured physiologically. METHODS: Six multispecialty member US Navy Fleet Surgical/US Army Forward Surgical Teams (total n=99 evaluations) underwent a 6-day surgical training simulation using movie industry special effects and role players wearing the Human Worn Surgical Simulator (Cut Suit). The teams were immersed in trauma care scenarios requiring multiple complex interventions and decision making in a realistic, fast-paced, intensive combat trauma environment. RESULTS: Hyper-realistic immersive simulation training enhanced performance between multidisciplinary healthcare team members. Key efficacy quantitative measurements for the same simulation presented on day 1 compared with day 6 showed a reduction in resuscitation time from 24 minutes to 14 minutes and critical error decrease from 5 to 1. Written test scores improved an average of 21% (Medical Doctors 11%, Registered Nurses 25%, and Corpsman/Medics 26%). Longitudinal psychometric survey results showed statistically significant increases in unit readiness (17%), combat readiness (12%), leadership quality (7%), vertical cohesion (7%), unit cohesion (5%), and team communication (3%). An analysis of salivary cortisol and amylase physiologic biomarkers indicated an adaptive response to the realistic environment and a reduction in overall team stress during performance evaluations. CONCLUSIONS: Hyper-realistic immersive simulation training scenarios can be a basis for improved military and civilian trauma training. LEVEL OF EVIDENCE: Level III.

Assessing Surgical Task Load and Performance: A Comparison of Simulation and Maritime Operation.

INTRODUCTION: This study examined the effects of simulated and actual vessel motion at high seas on task load and surgical performance. METHODS: This project was performed in phases. Phase I was a feasibility study. Phase II utilized a motion base simulator to replicate vessel motion. Phase III was conducted aboard the U.S. Naval Ship Brunswick. After performing surgical tasks on a surgical simulation mannequin, participants completed the Surgical Task Load Index (TLX) designed to collect workload data. Simulated surgeries were evaluated by subject matter experts. RESULTS: TLX scores were higher in Phase III than Phase II, particularly at higher sea states. Surgical performance was not significantly different between Phase II (84%) and Phase III (89%). Simulated motions were comparable in both phases. CONCLUSIONS: Simulated motion was not associated with a significant difference in surgical performance or deck motion, suggesting that this simulator replicates the conditions experienced during surgery at sea on the U.S. Naval Ship Brunswick. However, Surgical TLX scores were dramatically different between the two phases, suggesting increased workload at sea, which may be the result of time at sea, the stress of travel, or other factors. Surgical performance was not affected by sea state in either phase.

The next nine minutes: Lessons learned from the large-scale active shooter training prior to the STEM school shooting.

OBJECTIVE: As the incidence of active shooters increase, local emergency response has also changed. South Metro Fire Rescue coordinated a series of hyper-realistic active shooter simulation drills involving multiple agencies. METHODS: "The Next Nine Minutes" was one of the largest active shooter drills performed to date with 904 personnel that were trained in 18 mass casualty active shooter drills. Evaluation was from point of injury to and including care in the operating room (OR), and evaluation of real-time system logistics. RESULTS: A total of 126 patients in Cut Suits® received a total of 479 procedures such as needle decompressions, cricothyrotomies, tourniquets, wound packs, and chest tubes. Central to this exercise, law enforcement (LE) established a warm zone from the initial shooting. EMS was able to move into the facility, locate casualties, extract the first victim, move them to a casualty collection point (CCP), and transport them to safety within 12 minutes. CONCLUSIONS: Strengths and weaknesses were identified in prehospital and in-hospital care. These included what roles agencies play in a true event, specific timing in establishing areas such as the warm zone and CCP, transportation, and logistics at the accepting hospitals. Only after the barriers to success were identified and addressed did the timing of casualty movement drastically improve. Lessons learned from this training were ultimately used to save lives at the STEM School, Highlands Ranch, and Colorado Shooting. This in situ immersion training should be practiced as a whole system.

Efficacy of Medical Operations and Layout Planning Onboard Nontraditional US Navy Vessels at High Seas.

INTRODUCTION: Attempting to expedite delivery of care to wounded war fighters, this study aimed to quantify the ability of medical and surgical teams to perform lifesaving damage control and resuscitation procedures aboard nontraditional US Navy Vessels on high seas. Specifically, it looked at the ability of the teams to perform procedures in shipboard operating and emergency rooms by analyzing motion of personnel during the procedures. METHODS: One hundred and twelve damage control and resuscitation procedures were performed during a voyage of the US Naval Ship Brunswick in transit from Norfolk, Virginia, to San Diego, California. The ability of personnel to perform these procedures was quantified by the use of motion link analysis designed to track the movement of each participant as they completed their assigned tasks. RESULTS: The link analysis showed no significant change in the number of movements of participants from the beginning to the end of the study. However, there was a learning effect observed during the study, with teams completing tasks faster at the end of the study than at the beginning. CONCLUSION: This shows that the working conditions aboard the US Naval Ship Brunswick were satisfactory for the assigned tasks, indicating that these medical operations may be feasible aboard nontraditional US Navy vessels.

Comparison of a Novel Trainer to a Traditional Swine Model for Training Providers in Lateral Canthotomy and Cantholysis.

RESEARCH OBJECTIVE: Military personnel are at greater risks of head and facial traumas and permanent blindness from orbital compartment syndrome in modern warfare. Rapid treatment must be implemented with a low-risk surgical remedy: lateral canthotomy and cantholysis (LCC). Traditional training of LCC is primarily performed using an animal tissue trainer (ATT); however, limitations to these types of trainers exist. Therefore, our research objectives were focused on highlighting the effectiveness, benefits, and vision-saving potential of learning LCC on a synthetic trainer. METHODS: Participants included 22 second-year medical students and 6 healthcare professionals. A pre-quiz assessed baseline knowledge. Next, an experienced ophthalmologist provided an overview and instruction. Subjects were randomized to either the synthetic trainer or the ATT and then switched to the other model for comparison. After performing LCC procedures on both models, a post-quiz and survey were administered. RESULTS: Participants found the synthetic trainer easier to use than the ATT model (p < 0.01). There was no statistically significant preference (p = 0.23), or preference of practical eye anatomy (p = 0.26) between the trainers. Post-quiz results demonstrated an overall improvement from pre-quiz scores for participants (p < 0.001). CONCLUSIONS: The synthetic trainer is comparable to the traditional swine model for training LCC procedures, and should be considered as a future training platform.