Quality Improvement Initiative to Increase Radial Artery Usage as a Second Arterial Conduit in Coronary Artery Bypass Grafting.

OBJECTIVES: Use of radial artery as a second arterial graft, compared to a saphenous vein, in coronary artery bypass grafting (CABG) can improve late outcomes. However, the radial artery remains underutilized. We initiated a quality improvement (QI) initiative to increase usage of radial artery grafts. METHODS: During our four-month lead period, we disseminated evidence for radial artery graft usage to surgeons, developed a radial artery decision-making algorithm, and adopted endoscopic harvesting. Our QI initiative was conducted over a six-month period and included a post-operative survey of decision-making for graft selection and obstacles to radial artery usage. RESULTS: Over the six-month study period, 247 patients received isolated CABG which included 98 (40%) with radial arteries as a second arterial graft and 144 (58%) with greater saphenous vein. Radial artery usage increased with QI initiative implementation by 67% compared to the six-months prior to the study period (60 radial arteries/252 isolated CABG, 24%) (P = 0.006). The survey response rate was 93% (231/247). Barriers to radial artery graft usage were poor quality target vessel or stenosis <80% (24%), patient age >75 years (20%), EF ≤ 35% (8%) and renal insufficiency/dialysis (7%). No patients experienced complications from radial artery harvest. CONCLUSIONS: Our institutional QI initiative was successful in 1) increasing usage of radial artery as a second arterial graft and 2) understanding barriers to radial artery graft usage. Implementation of a QI program can improve radial artery usage in CABG with low risk of patient morbidity from radial artery harvest.

Educational Strategies in Pediatric Trauma Resuscitation Across Disciplines: A Scoping Review.

INTRODUCTION: Trauma is the leading cause of death and disability in children. Differences in mechanism, injury pattern, severity, and physiology in this population distinguish pediatric trauma patients from adults. Educational techniques including simulation and didactics may improve pediatric readiness in this setting. We summarize the literature across disciplines, highlighting the curricular approaches, target provider population, educational content, content delivery method, and Kirkpatrick level for pediatric trauma resuscitation education. METHODS: The MEDLINE (via Ovid), Embase (via Elsevier), Cumulative Index to Nursing & Allied Health Literature Complete (via EBSCO), Education Database (via ProQuest), and Web of Science Social Science Citation Index and Science Citation Index (via Clarivate) were searched. We reviewed 90 manuscripts describing pediatric trauma resuscitation education programs. When available, target provider population, curricular content, delivery method, and Kirkpatrick level were obtained. RESULTS: Nurses (50%), residents (45%), and attending physicians (43%) were the most common participants. Airway management (25%), shock (25%), and general trauma (25%) were the most frequently taught concepts, and delivery of content was more frequently via simulation (65%) or didactics (52%). Most studies (39%) were Kirkpatrick Level 1. CONCLUSIONS: This review suggests that diverse strategies exist to promote pediatric readiness. Most training programs are interdisciplinary and use a variety of educational techniques. However, studies infrequently report examining the impact of educational interventions on patient-centered outcomes and lack detail in describing their curriculum. Future educational efforts would benefit from heightened attention to such outcome measures and a rigorous description of their curricula to allow for reproducibility.

Enhancing in situ biodegradation in groundwater using pump and treat remediation: a proof of concept and modelling analysis of controlling variables.

A remediation approach which uses pump and treatment (PAT) to enhance the biodegradation of organic contaminants by increasing dispersive mixing between plumes and groundwater was evaluated for a phenol-contaminated aquifer, using a reactive transport model which simulates kinetic reactions between an electron donor (ED) in the plume and electron acceptor (EA) in the groundwater. The influence of system design and operation was examined in six modelling scenarios. Injection or extraction of groundwater increases biodegradation above no action and the location, pumping rate, and distance between well(s) are important variables which influence biodegradation. An increase in pumping rate, distance of the wells from the plume centreline, and changing the flow direction increase dispersive mixing between the plume and groundwater. This increases plume spreading and the plume fringe interface, providing a greater flux of dissolved EAs for biodegradation. In general, injection of groundwater containing natural EAs enhances biodegradation more than extraction. The enhancement of biodegradation is sensitive to the relative fluxes of ED and EA, as controlled by the arrangement of the wells. In the best performing scenario, biodegradation was enhanced by 128%, compared with no action.

Roles, Responsibilities, and Expectations of Medical Students on Surgical Subinternships: A Modified Delphi Consensus Study.

PURPOSE: Surgical subinternships are important rotations for students preparing for a career in general surgery; however, these rotations often vary by institution and service. This modified Delphi study was conducted to reach a consensus set of roles, responsibilities, and expectations of fourth-year medical students on their surgical subinternships. METHOD: Candidate statements on roles, responsibilities, and expectations of subinterns were categorized into 7 domains: rotation structure, rounding and patient care, operating room conduct, technical skills, knowledge base, clinic, and professionalism. Expert panels were assembled of key stakeholders: program directors, clerkship directors, other education faculty, trainees, and recent subinterns. Three Delphi rounds were conducted from January to April 2023 to reach consensus defined a priori as a Cronbach α ≥ 0.8 and 80% or greater panel agreement. RESULTS: Forty-six expert panelists were recruited to participate in Delphi rounds, with 100%, 95.7%, and 97.8% response rates in the first, second, and third rounds, respectively. By the third round, 67 statements reached consensus as essential roles, responsibilities, and expectations of surgical subinterns. Key themes from these 67 statements included subinterns approximating the role of an intern with respect to work hours, patient care responsibilities, basic technical skills, and knowledge base. Panelists rated rounding and patient care as the most important domain, followed closely by professionalism. Additional key domains for evaluation in descending order were knowledge base, operating room conduct, clinic, and technical skills. By the third round, notable disagreements in the Delphi process included technical skills and rounding and patient care (93.3% and 88.9% agreement, respectively). CONCLUSIONS: This study provides a national consensus on core roles, responsibilities, and expectations for medical students completing surgical subinternships. Students can use these recommendations to prepare for subinternships, whereas faculty as well as residents and fellows can use them to evaluate applicants for general surgery residency positions.

Potential of stable isotope analysis to deduce anaerobic biodegradation of ethyl tert-butyl ether (ETBE) and tert-butyl alcohol (TBA) in groundwater: a review.

Understanding anaerobic biodegradation of ether oxygenates beyond MTBE in groundwater is important, given that it is replaced by ETBE as a gasoline additive in several regions. The lack of studies demonstrating anaerobic biodegradation of ETBE, and its product TBA, reflects the relative resistance of ethers and alcohols with a tertiary carbon atom to enzymatic attack under anoxic conditions. Anaerobic ETBE- or TBA-degrading microorganisms have not been characterized. Only one field study suggested anaerobic ETBE biodegradation. Anaerobic (co)metabolism of ETBE or TBA was reported in anoxic microcosms, indicating their biodegradation potential in anoxic groundwater systems. Non-isotopic methods, such as the detection of contaminant loss, metabolites, or ETBE- and TBA-degrading bacteria are not sufficiently sensitive to track anaerobic biodegradation in situ. Compound- and position-specific stable isotope analysis provides a means to study MTBE biodegradation, but isotopic fractionation of ETBE has only been studied with a few aerobic bacteria (εC -0.7 to -1.7‰, εH -11 to -73‰) and at one anoxic field site (δ2H-ETBE +14‰). Similarly, stable carbon isotope enrichment (δ13C-TBA +6.5‰) indicated TBA biodegradation at an anoxic field site. CSIA and PSIA are promising methods to detect anaerobic ETBE and TBA biodegradation but need to be investigated further to assess their full potential at field scale.

Spectroscopic and Microscopic Characterization of Microbial Biofouling on Aircraft Fuel Tanks.

Avoiding microbial contamination and biofilm formation on the surfaces of aircraft fuel tanks is a major challenge in the aviation industry. The inevitable presence of water in fuel systems and nutrients provided by the fuel makes an ideal environment for bacteria, fungi, and yeast to grow. Understanding how microbes grow on different fuel tank materials is the first step to control biofilm formation in aviation fuel systems. In this study, biofilms of Pseudomonas putida, a model Gram-negative bacterium previously found in aircraft fuel tanks, were characterized on aluminum 7075-T6 surfaces, which is an alloy used by the aviation industry due to favorable properties including high strength and fatigue resistance. Scanning electron microscopy (SEM) coupled with energy-dispersive X-ray (EDX) showed that extracellular polymeric substances (EPS) produced by P. putida were important components of biofilms with a likely role in biofilm stability and adhesion to the surfaces. EDX analysis showed that the proportion of phosphorus with respect to nitrogen is higher in the EPS than in the bacterial cells. Additionally, different morphologies in biofilm formation were observed in the fuel phase compared to the water phase. Micro-Fourier transform infrared spectroscopy (micro-FTIR) analysis suggested that phosphoryl and carboxyl functional groups are fundamental for the irreversible attachment between the EPS of bacteria and the aluminum surface, by the formation of hydrogen bonds and inner-sphere complexes between the macromolecules and the aluminum surface. Based on the hypothesis that nucleic acids (particularly DNA) are an important component of EPS in P. putida biofilms, the impact of degrading extracellular DNA was tested. Treatment with the enzyme DNase I affected both water and fuel phase biofilms─with the cell structure disrupted in the aqueous phase, but cells remained attached to the aluminum coupons.

Longitudinal Integrated Clerkships and Undergraduate Surgical Education: A Scoping Review and Gap Analysis.

OBJECTIVE: Longitudinal integrated clerkships (LICs) are an increasingly popular approach to medical student clinical education, and the literature describing them is expanding. Despite this, there is a lack of understanding for how surgery didactics and skills are currently taught as a part of the LIC curriculum. DESIGN: We conducted a scoping literature review in July 2022 using terms related to LIC and surgical education. Abstract and full-length text screening followed. Data extraction was completed in August 2022. Articles published in English, focused on LIC students, and discussed any element of LIC curriculum surgical education was included. SETTING: Scoping literature review. PARTICIPANTS: A total of 282 studies describing LICs were identified from the scoping literature review. After applying inclusion and exclusion criteria, 37 (13%) studies describing some element of surgical education were included. RESULTS: Of these 37 studies, the majority did not delve into pertinent details related to students' surgery experience, expectations, and surgical skills accomplishments. Four studies (11%) reported on the outpatient surgical experience, such as minimum required time that students were expected to be in the clinic, and 8 studies (22%) described the inpatient and operating room exposure. Only 1 study (3%) described the surgical floor management of surgical patients, including tasks like documentation and wound care, and 3 studies (8%) reported formal assessment of surgical skills, such as suturing technique. CONCLUSIONS: Our study highlights the paucity LIC literature examining the relationship between this curricular innovation and the unique needs of medical students on a surgical clerkship. Surgeon educators should embrace the opportunity to contribute LIC curriculum development and subsequent investigation into how this modality interfaces with the learning objectives of undergraduate surgical education. A formal description of essential curriculum components for all surgical LIC programs is needed to ensure appropriate surgical education across the varied LIC models.

Melon and rostral muscle morphology of Gervais' beaked whale (Mesoplodon europaeus): Alternating patterns of bilateral asymmetry.

Toothed whales utilize specialized nasal structures such as the lipid-rich melon to produce sound and propagate it into the aquatic environment. Very little nasal morphology of mesoplodont beaked whales has been described in the literature, and the anatomy of the melon and associated musculature of Gervais' beaked whale (Mesoplodon europaeus) remains undescribed. Heads of three (n = 3) Gervais' beaked whales were examined in detail via dissection as well as computed tomography (CT) and magnetic resonance imaging (MRI). Two additional Gervais' beaked whale individuals (n = 2) were studied via archived CT and MRI scans. Representative transverse dissection sections of the melon were processed for polarized light imaging to verify the presence of tendons inserting into the melon tissue. Three-dimensional (3D) CT reconstructions of the melon, rostral muscles, and associated structures were performed to assess morphology and spatial relationships. In all individuals, the melon's main body demonstrated a bilaterally asymmetrical, curvilinear geometry. This curvilinear shape was defined by a pattern of alternating asymmetry in the medial rostral muscles that projected into the melon's tissue. In transverse polarized light imaging, a network of tendons originating from these asymmetrical rostral muscle projections was observed permeating the melon's lipid tissue. This curvilinear melon morphology and associated asymmetrical musculature suggest a means of lengthening the lipid pathway within a relatively short dimensional footprint. In addition, the species-specific arrangement of muscular projections suggests complex fine-tuning of the melon's geometry during echolocation. Further studies may lend additional insight into the function of this unusual melon morphology.

Quality improvement strategies in pediatric ECMO.

Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.

Use of pediatric trauma simulations to facilitate exposure to pediatric trauma resuscitations during training.

BACKGROUND: Pediatric traumas are often high-acuity but are low-frequency compared to adult trauma activations. This is reflected in the relatively limited experience with these events during training. Although some principles of trauma resuscitation are similar between adults and children, there are also important differences in physiology, injury patterns, and presentation. Therefore, simulation can be used to supplement trainee exposure and enhance their ability to respond to these high-stakes events. METHODS: We developed a multidisciplinary pediatric trauma resuscitation simulation curriculum to increase exposure to pediatric traumas at our institution. The intervention includes monthly sessions in the pediatric resuscitation bays, during which multidisciplinary teams complete 2 full pediatric trauma resuscitation simulations. This is supplemented with formal debriefing, simulation-specific teaching, and standardized trauma cognitive aids. The comprehensiveness of trauma evaluations and resuscitation efforts are evaluated using our institutional structured trauma resuscitation observation tool, and post-simulation surveys are used to assess the impact of the teaching interventions. RESULTS: Nine simulation sessions were conducted with more than 100 participants, including surgical residents, emergency medicine residents, nursing staff, respiratory therapists, and medical students. Completeness of resuscitation efforts improved from 55% to 82% (P < .01) between initial and repeat simulations. Surveyed participants reported improvement in overall team performance on the Team Emergency Assessment Measure (P < .01). CONCLUSION: Implementing a multidisciplinary pediatric trauma simulation curriculum with structured teaching interventions and standardized trauma scripts promotes teamwork and strengthens trainees' ability to conduct comprehensive evaluations required for high-acuity pediatric traumas.

A National Comparison of Volume and Acuity for Adult and Pediatric Trauma: A Trauma Quality Improvement Program Cohort Study.

INTRODUCTION: Most injured children receive trauma care outside of a pediatric trauma center. Differences in physiology, dosing, and injury pattern limit extrapolation of adult trauma principles to pediatrics. We compare US trauma center experience with pediatric and adult trauma resuscitation. MATERIALS AND METHODS: We queried the 2019 Trauma Quality Improvement Program to describe the experience of US trauma centers with pediatric (<15 y) and adult trauma. We quantified blunt, penetrating, burn, and unspecified traumas and compared minor, moderate, severe, and critical traumas (ISS 1-8 Minor, ISS 9-14 Moderate, ISS 15-24 Severe, ISS 25+ Critical). We estimated center-level volumes for adults and children. Institutional identifiers were generated based on unique center specific factors including hospital teaching status, hospital type, verification level, pediatric verification level, state designation, state pediatric designation, and bed size. RESULTS: A total of 755,420 adult and 76,449 pediatric patients were treated for traumatic injuries. There were 21 times as many critical or major injuries in adults compared to children, 17 times more moderate injuries, and 6 times more minor injuries. Children and adults presented with similar rates of blunt trauma, but penetrating injuries were more common in adults and burn injuries were more common in children. Comparing center-level data, adult trauma exceeded pediatric for every severity and mechanism. CONCLUSIONS: There is relatively limited exposure to high-acuity pediatric trauma at US centers. Investigation into pediatric trauma resuscitation education and simulation may promote pediatric readiness and lead to improved outcomes.

Response of soil bacterial populations to application of biosolids under short-term flooding.

Biosolids are applied to agricultural land as a soil conditioner and source of crop nutrients. However, there is concern that bacteria from biosolids may become established in soils, particularly if that soil becomes water-logged. This study examined the microbial community of arable soils cultivated with barley under different applications of biosolids (0, 24t/ha, 48t/ha) in laboratory mesocosms which simulated a 10-day flood. Nutrients (P and N) and organic matter in the soil increased with application rate, but plant growth was not affected by biosolid application. The biosolids contained 10× more genetic material than the soil, with much lower bacterial diversity, yet application did not significantly change the taxonomy of the soil microbiome, with minor changes related to increased nutrients and SOM. Anaerobic conditions developed rapidly during flooding, causing shifts in the native soil microbiome. Some bacterial taxa that were highly abundant in biosolids had slightly increased relative abundance in amended soils during the flood. After flooding, soil bacterial populations returned to their pre-flood profiles, implying that the native microbial community is resilient to transient changes. The short-term changes in the microbiome of biosolid-amended soils during flooding do not appear to increase the environmental risk posed by biosolid application.

The Surgical Subinternship: A Unique Opportunity for Early Leadership Development.

Subinternships are formative rotations in the surgery-bound medical student's journey to surgical training. This experience allows for further exploration of career goals, plays an important evaluative role in the residency selection process, and offers ongoing opportunities for technical and non-technical development. The graduated responsibility experienced in this setting extends beyond what was experienced during the core surgical clerkship where students are first interfacing with the clinical environment. We review and reflect on the role of subinternships in developing the leadership skills that surgery-bound medical students will need to effectively lead interprofessional healthcare teams in the future.

Risk of Surgical Intervention in Children with Diagnoses of Cancer and Preoperative Malnutrition: A National Analysis.

BACKGROUND: Perioperative nutrition is a critical component of appropriate healing and recovery after surgery. We sought to identify perioperative risk in children with cancer and low preoperative hypoalbuminemia undergoing surgical intervention. METHODS: We queried the 2015-2019 NSQIP-Peds datasets for children with a primary diagnosis of renal or hepatic malignancy undergoing surgical resection. Postoperative outcomes were evaluated for comparative risk between patients with low albumin (albumin<3.0 g/dL) and normal albumin within 30 days of their surgical procedure. Univariate analysis and multivariable logistic regression were conducted to identify perioperative risk in patients with hypoalbuminemia. RESULTS: We identified 360 children with primary diagnosis of hepatic malignancy and 896 children with renal malignancy undergoing surgical resection. Of these, 77 children had hypoalbuminemia. Patients with renal or hepatic malignancy diagnosis and low albumin levels were more likely to experience postoperative dehiscence, need for TPN at discharge, postoperative bleeding or transfusion, unplanned reoperation, and unplanned readmission, based on univariate analysis (all P > 0.05). Postoperative bleeding, need for nutritional support at discharge, and unplanned readmission were each associated with hypoalbuminemia. CONCLUSION: We demonstrate that low preoperative albumin is associated with significant perioperative risk. More attention should focus on perioperative nutritional status of children with cancer who are undergoing major resections.

Impact of Ventricular Dominance on Long-Term Fontan Outcomes: A 25-year Single-institution Study.

BACKGROUND: The long-term impact of ventricular dominance on Fontan outcomes is controversial. This study examined this issue in a 25-year cohort. METHODS: Patients undergoing the Fontan operation at a single institution (Duke University Medical Center, Durham, NC) from October 1998 to February 2022 were reviewed. Primary outcomes were transplant-free survival and Fontan failure (death, heart transplantation, takedown, protein-losing enteropathy, or plastic bronchitis). Secondary outcomes included hospital and intensive care lengths of stay. Kaplan-Meier methodology compared outcomes by ventricular dominance. Multiphase parametric risk hazard analysis identified risk factors for primary outcomes. RESULTS: There were 195 patients (104 right ventricular dominant) included in the study. Baseline characteristics were comparable. Perioperative survival was similar (right ventricular dominant, 98%; non-right ventricular dominant, 100%; P = .51). The proportion of patients experiencing death or heart transplantation was 8.7%, and the rate of Fontan failure was 11.8% during a median follow-up of 4.5 years (interquartile range, 0.3-9.8 years). Right ventricular-dominant patients had reduced transplant-free survival (10-year estimates: 80% [95% CI, 70%-91%] vs 92% [95% CI, 83%-100%]; P = .04) and freedom from Fontan failure (73% [95% CI, 62%-86%] vs 92% [95% CI, 83%-100%]; P = .04). Multiphase hazard modeling resolved 2 risk phases. The early phase spanned from surgery to approximately 6 months afterward. The late phase spanned from approximately 6 months after surgery onward. In multivariable analysis, right ventricular dominance was an independent risk factor for death or heart transplantation (parameter estimate, 1.3 ± 0.6; P = .04) and Fontan failure (1.1 ± 0.5; P = .04) during the second phase, with no significant first-phase risk factors. CONCLUSIONS: Right ventricular dominance was associated with long-term complications after Fontan procedures, including mortality, heart transplantation, and Fontan failure. This cohort may benefit from heightened surveillance in a multidisciplinary Fontan clinic after the perioperative period.

Improved survival and higher rates of surgical resection associated with hepatocellular carcinoma in children as compared to young adults.

Hepatocellular adenocarcinoma (HCC) is the second most common primary hepatic malignancy in children with a 5-year overall survival of 30%. Few studies have examined the similarities and differences between pediatric and adult HCC. This article aims to examine the relationship between tumor characteristics, treatments and outcomes in pediatric and adult patients with HCC. The 2019 National Cancer Database was queried for patients with HCC. Patients were stratified by age: pediatric <21 years (n = 214) and young adults 21 to 40 (n = 1102). Descriptive statistics and chi square were performed. The mean age at diagnosis was 15.5 years (SD 5.6) in the pediatric and 33 years (5.3) in the adult group. Children had a comparable rate of metastasis (30% vs 28%, P = .47) and increased fibrolamellar histology (32% vs 9%). Surgical resection was more common in children compared to adults (74% vs 62%, P < .001), children also had more lymph nodes examined (39% vs 19%, P < .001), positive lymph nodes (35% vs 17%, P = .02) and surgical resection when metastasis were present at diagnosis (46% vs 18%, P < .001). The 1-, 3- and 5-year overall survival was higher for pediatric patients than adults (81%, 65%, 55%, vs 70%, 54%, 48%). Despite higher prevalence of fibrolamellar histology, greater number of positive lymph nodes and comparable rates of metastasis at diagnosis, children with HCC have improved overall survival compared to adults. Age did not significantly contribute to survivorship, so it is likely that the more aggressive surgical approach contributed to the improved overall survival in pediatric patients.

Minimally Invasive Approach for Cardiac Hemangioma Resection in a Teenager.

Cardiac hemangiomas are a rare tumor traditionally resected by median sternotomy. We performed a minimally invasive right ventricular cardiac hemangioma resection via a left anterior mini-incision (LAMI). The procedure was without complication, and the patient was discharged on postoperative day 2. The LAMI has been used broadly by our team for operations involving the right ventricular outflow tract, as an alternative to median sternotomy. Here we show that it can also be used for the resection of a cardiac tumor.

Use of a Structured Observation Tool to Promote Medical Student Engagement in Trauma Resuscitations.

OBJECTIVE: We describe a novel approach to promoting medical student learning and engagement during trauma resuscitation with implementation of a structured observation and debriefing tool. DESIGN: In the context of a multifaceted quality improvement effort in our emergency room, we implemented a structured trauma observation tool (SOT) for medical students based on ATLS trauma guidelines. The SOT reflects the American College of Surgeons and Association for Surgical Education (ACS/ASE) trauma evaluation module for medical students. Two medical students from our quality improvement working group undertook a proof-of-concept study to determine whether the SOT facilitated accurate observations of trauma resuscitations and promoted educational debriefs with precepting providers. Results were encouraging, so the tool was implemented for elective use on surgical clerkships. Clerkship students who used the SOT were given the opportunity to share its impact on their experience. Institutional Review Board approval was obtained under Pro00109569. SETTING: A large level 1 trauma center at an academic hospital in the southeastern United States. PARTICIPANTS: An interdisciplinary working group including surgeons, emergency medicine physicians, nurses, and students developed the observation tool. Two medical students from this team showed that the tool was effective at guiding observations and facilitating debriefs prior to its broader implementation on the general surgery clerkship. RESULTS: A total of 630 resuscitation tasks were observed during 15 trauma activations prior to implementation on the surgery clerkship. There was over 97% agreement between students observations and evaluating physicians self-reporting on which tasks were completed. Tasks on which there was disagreement were discussed to aid student learning. The tool was implemented for elective use on the surgery clerkship where students reported positive experiences. CONCLUSIONS: Early data suggest that this structured observation tool facilitates accurate trauma assessment observations and provides an opportunity for high-yield debriefs with the evaluating physician. This promotes student comprehension of ATLS principles. The SOT is being implemented as a pedagogic tool for students on the surgery clerkship to guide their observations, improve comprehension of decisions made in a hyperacute setting, and offer real time feedback as part of their learning in the trauma bay. The tool appears to be a valuable supplement which supports the ACS/ASE curriculum.