Anesthesiology Fellowships in the Military Health System: An Education Analysis of the Supply and Demand.

INTRODUCTION: Evidence indicates that desire for fellowship training is most influenced by personal interest, enhancement of career options, and a specific interest in an academic medicine career. The overall objective of this study is to evaluate anesthesiology fellowship interest and its potential impact on military retention and other outcomes. We hypothesized that current fellowship training accessibility is outpaced by the interest for fellowship training and that additional factors will be associated with the desire for fellowship training. METHODS: This prospective cross-sectional survey study was approved as Exempt Research by the Brooke Army Medical Center Institutional Review Board in November 2020. Participants were eligible to complete the online voluntary survey if they were active duty anesthesiologists. Anonymous surveys were administered via the Research Electronic Data Capture System from December 2020 to January 2021. Aggregated data were evaluated using univariate statistics, bivariate analyses, and a generalized linear model. RESULTS: Seventy-four percent of general anesthesiologists (those without fellowship training) were interested in pursuing future fellowship training versus 23% of subspecialist anesthesiologists (those currently in fellowship training or have completed fellowship training), odd ratio 9.71 (95% CI, 4.3-21.7). Of subspecialist anesthesiologists, 75% indicated serving in a nongraduate medical education (GME) leadership position (e.g., service/department chief), with 38% serving in a GME leadership position (e.g., program or associate program director). Almost half (46%) of subspecialist anesthesiologists reported being "extremely likely" to serve ≥20 years, versus 28% of general anesthesiologists. CONCLUSIONS: There is a high demand among active duty anesthesiologists for fellowship training, which in turn, may improve military retention. The demand for fellowship training is outpaced by what the Services currently offer, including training in Trauma Anesthesiology. Leveraging this interest in subspecialty fellowship training, particularly when the skills align with combat casualty care-related requirements, would greatly benefit the Services.

Maintaining Surgical Readiness While Deployed to Low-Volume Military Treatment Facilities: A Pilot Program for Clinical and Operational Sustainment Training in the Deployed Environment.

INTRODUCTION: Maintaining readiness among Army surgeons is increasingly challenging because of declining operative experience during certain deployments. Novel solutions should be considered. MATERIALS AND METHODS: A pilot program was conducted to rotate surgical teams from a military treatment facility with a low volume of combat casualty care to one with a higher volume. Pre- and postrotation surveys were conducted to measure relative operative experience, trauma experience, and perceived readiness among rotators. RESULTS: Operative volumes and trauma volumes were increased and that perceived readiness among rotators, especially those with the fewest previous deployments, was improved. CONCLUSIONS: Maintaining readiness among Army surgeons is a difficult task, but a combination of increased trauma care while in garrison, as well as increased humanitarian care during deployments, may be helpful. Additionally, rotating providers from facilities caring for few combat casualties to facilities caring for more combat casualties may also be feasible, safe, and helpful.

Advanced Resuscitative Care in Tactical Combat Casualty Care: TCCC Guidelines Change 18-01:14 October 2018.

TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interventions are designated Advanced Resuscitative Care (ARC) and may enable casualties with severe NCTH to survive long enough to reach the care of a surgeon. Although Special Operations units are now using whole blood far-forward, this capability is not routinely present in other US combat units at this point in time. REBOA is not envisioned as care that could be accomplished by a unit medic working out of his or her aid bag. This intervention should be undertaken only by designated teams of advanced combat medical personnel with special training and equipment.

Using high-fidelity patient simulation and an advanced distance education network to teach pharmacology to second-year medical students.

The feasibility and acceptance of an Advanced Distance Education Network (ADEN) in bringing the simulated operating room (OR) to second-year medical students learning the pharmacology of anesthetic drugs is reviewed. A MedSim-Eagle (Binghamton, NY) full-scale mannequin simulator was used. Using an ADEN, students were linked in real time to a simulated OR where the anesthesiologist instructor was using a MedSim-Eagle patient simulator to present for discussion the physiologic effects of volatile anesthetics on cardiac output (CO), heart rate (HR), mean arterial pressure (MAP), and systemic vascular resistance (SVR). The use of simulation to present basic science principles of isoflurane and halothane's effect on CO, HR, MAP, and SVR in a clinical setting via an ADEN is feasible. Student acceptance of this method of education is high, as measured by a post-exercise survey. Ninety-five percent of students felt this exercise was a valuable use of their time; 93% felt the ADEN-delivered clinical simulation presentation contributed to their understanding of the pharmacology of anesthesia. Eighty-three percent of students preferred this integrated clinically oriented review to a didactic review of the material, and 92% of students who had experienced previous small group hands-on session simulation felt the ADEN-delivered session was the same or better.

A multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities.

STUDY OBJECTIVE: To reinforce concepts presented in the lectures; understand the complexity and speed of casualty and information generation during a Weapons of Mass Destruction and Terrorism (WMD/T) event; experience the novelty of combined weapons' effects; recognize the time course of the various chemical, biological, and radiation agents; and make challenging decisions with incomplete and conflicting information. SETTINGS: Two environments simulated simultaneously: one a major trauma center emergency room (ER) with two patient simulators and several human actors; the other an Emergency Operations Command Center (EOC). TARGET AUDIENCE: Students for this course included: clinicians, scientists, military and intelligence officers, lawyers, administrators, and logistic personnel whose jobs involve planning and executing emergency response plans to WMD/T. SIMULATION SCRIPT: A WMD/T attack in Washington, D.C., has occurred. Clinical students performed in their real life roles in the simulated ER, while nonclinical students did the same in the simulated EOC. Six ER casualties with combined WMD/T injuries were presented and treated over 40 minutes. In the EOC, each person was given his or her role title with identification tag. The EOC scenario took cues from the action in the ER via two television (TV) news feeds and telephone calls from other Emergency Operations Assets. PERFORMANCE EXPECTATIONS: Students were expected to actively engage in their roles. Student performances were self-evaluated during the debriefing. DEBRIEFING: The two groups were reunited and debriefed utilizing disaster crisis resource management tools. ASSESSMENT OF EFFECTIVENESS: Students answered an 18-point questionnaire to help evaluate the usefulness and acceptance of multimodality patient simulation. LESSONS LEARNED: Large-scale multimodality patient simulation can be used to train both clinicians and nonclinicians for future events of WMD/T. Students accepted the simulation experience and thought that scenario was appropriately realistic, complex, and overwhelming. Difficulties include the extensive man-hours involved in designing and presenting the live simulations. EOC-only sessions could be staged with only a few video cassette recorders, TVs, telephones, and callers.

Using High-Fidelity Patient Simulation and an Advanced Distance Education Network to Teach Pharmacology to Second-Year Medical Students.

The feasibility and acceptance of an Advanced Distance Education Network (ADEN) in bringing the simulated operating room (OR) to second-year medical students learning the pharmacology of anesthetic drugs is reviewed. A MedSim-Eagle (Binghamton, NY) full-scale mannequin simulator was used. Using an ADEN, students were linked in real time to a simulated OR where the anesthesiologist instructor was using a MedSim-Eagle patient simulator to present for discussion the physiologic effects of volatile anesthetics on cardiac output (CO), heart rate (HR), mean arterial pressure (MAP), and systemic vascular resistance (SVR). The use of simulation to present basic science principles of isoflurane and halothane's effect on CO, HR, MAP, and SVR in a clinical setting via an ADEN is feasible. Student acceptance of this method of education is high, as measured by a post-exercise survey. Ninety-five percent of students felt this exercise was a valuable use of their time; 93% felt the ADEN-delivered clinical simulation presentation contributed to their understanding of the pharmacology of anesthesia. Eighty-three percent of students preferred this integrated clinically oriented review to a didactic review of the material, and 92% of students who had experienced previous small group hands-on session simulation felt the ADEN-delivered session was the same or better.

A Multidisciplinary Approach to Teach Responses to Weapons of Mass Destruction and Terrorism Using Combined Simulation Modalities.

STUDY OBJECTIVE: To reinforce concepts presented in the lectures; understand the complexity and speed of casualty and information generation during a Weapons of Mass Destruction and Terrorism (WMD/T) event; experience the novelty of combined weapons' effects; recognize the time course of the various chemical, biological, and radiation agents; and make challenging decisions with incomplete and conflicting information. SETTINGS: Two environments simulated simultaneously: one a major trauma center emergency room (ER) with two patient simulators and several human actors; the other an Emergency Operations Command Center (EOC). TARGET AUDIENCE: Students for this course included: clinicians, scientists, military and intelligence officers, lawyers, administrators, and logistic personnel whose jobs involve planning and executing emergency response plans to WMD/T. SIMULATION SCRIPT: A WMD/T attack in Washington, D.C., has occurred. Clinical students performed in their real life roles in the simulated ER, while nonclinical students did the same in the simulated EOC. Six ER casualties with combined WMD/T injuries were presented and treated over 40 minutes. In the EOC, each person was given his or her role title with identification tag. The EOC scenario took cues from the action in the ER via two television (TV) news feeds and telephone calls from other Emergency Operations Assets. PERFORMANCE EXPECTATIONS: Students were expected to actively engage in their roles. Student performances were self-evaluated during the debriefing. DEBRIEFING: The two groups were reunited and debriefed utilizing disaster crisis resource management tools. ASSESSMENT OF EFFECTIVENESS: Students answered an 18-point questionnaire to help evaluate the usefulness and acceptance of multimodality patient simulation. LESSONS LEARNED: Large-scale multimodality patient simulation can be used to train both clinicians and nonclinicians for future events of WMD/T. Students accepted the simulation experience and thought that scenario was appropriately realistic, complex, and overwhelming. Difficulties include the extensive man-hours involved in designing and presenting the live simulations. EOC-only sessions could be staged with only a few video cassette recorders, TVs, telephones, and callers.

Developing meaningful metrics of clinical productivity for military treatment facility anesthesiology departments and operative services.

Comparing clinical productivity is important for strategic planning and the evaluation of resource allocation in any large organization. This process of benchmarking performance allows for the comparison of groups with similar characteristics. However, this process is often difficult when comparing the operative service productivity of large and small military treatment facilities because of the significant heterogeneity in mission focus and case complexity. However, in this article, we describe the application of a new method of benchmarking operative service productivity based on normalizing data for operating room sites, cases, and total American Society of Anesthesiologists units produced per hour. We demonstrate how these benchmarks allow for valid comparisons of operative service productivity among these military treatment facilities and how the data could be used in expanding or contracting operating locations. In addition, these benchmarks are compared with those derived from the use of this system in the civilian sector.

Pyruvate prevents poly-ADP ribose polymerase (PARP) activation, oxidative damage, and pyruvate dehydrogenase deactivation during hemorrhagic shock in swine.

The inadequate availability of fuel substrates and sharp decline in cellular ATP have been implicated in a cascade of events associated with cell death and organ failure during hemorrhagic shock (HS). In this in vivo swine model of severe prolonged HS, the effect of exogenous pyruvate administration on various markers of cell damage in brain and liver was examined. Thirty minutes after the start of controlled arterial hemorrhage, 30% sodium pyruvate, 10% saline, or 0.9% saline was administered via jugular vein. Four hours after the initiation of hemorrhage, tissue samples from brain and liver were obtained and examined for the cellular and molecular markers of cellular damage. Results of our study suggest that pyruvate prevents loss of total NAD content, cleavage of poly-ADP ribose polymerase (PARP), and inhibits lipid peroxidation in both the brain and liver of swine during prolonged severe HS. We conclude that there are multiple mechanisms by which pyruvate can possibly prevent cell damage caused during HS.