Etiology of fatal thoracic aortic injuries: Secondary data analysis.

OBJECTIVES: Motor vehicle crashes remain a leading cause of death in the United States (US). Thoracic aortic dissection due to blunt trauma remains a major injury mechanism, and up to 90% of these injuries result in death on the scene. The objective of this study is to understand the modern risk factors and etiology of fatal thoracic aortic injuries in the current US fleet. METHODS: Using a unique, linked, Fatality Analysis Reporting System (FARS) and Multiple Cause of Death (MCOD) database from 2000-2010, 144,169 drivers over 16 years of age who suffered fatal injuries were identified. The merged database provides an unparalleled fidelity for identifying thoracic aortic injuries due to motor vehicle accidents. Thoracic aortic injuries were defined by ICD-10 codes S250. Univariate and multivariate logistic regression models for presence of any thoracic aortic injuries were fitted. Age, gender, BMI weight categories, vehicle class, model year, crash type/direction, severity of crash damage, airbag deployment location, and seatbelt use, fatal injury codes, and location of injury were considered. Odds ratios (OR) and corresponding 95% confidence intervals (95%CI) are calculated. RESULTS: There were 2953 deaths (2.10%) related to thoracic aortic injuries that met the inclusion criteria. Nearside crashes were associated with an increased odds (OR = 1.42, 1.1-1.83), while rollover crashes (OR =.44,.29-.66) were associated with a reduced odds of fatal thoracic aortic injury. Using backward selection on the full multivariate model, the only significant model effects that remained were vehicle type, crash type, body region, and injury type. CONCLUSIONS: The increased prevalence of fatal thoracic aortic injury in nearside crashes, increasing age, and vehicle type provide some insight into the current US fleet. Important factors, including model year, had significantly lower levels of the injury in univariate analysis, demonstrating the effect of safety improvements in newer model vehicles. Further study of this fatal injury is warranted, including comparisons of those who survive the injury.

The benefits and tradeoffs for varied high-severity injury risk thresholds for advanced automatic crash notification systems.

OBJECTIVES: The objectives of this study are to (1) characterize the population of crashes meeting the Centers for Disease Control and Prevention (CDC)-recommended 20% risk of Injury Severity Score (ISS)>15 injury and (2) explore the positive and negative effects of an advanced automatic crash notification (AACN) system whose threshold for high-risk indications is 10% versus 20%. METHODS: Binary logistic regression analysis was performed to predict the occurrence of motor vehicle crash injuries at both the ISS>15 and Maximum Abbreviated Injury Scale (MAIS) 3+ level. Models were trained using crash characteristics recommended by the CDC Committee on Advanced Automatic Collision Notification and Triage of the Injured Patient. Each model was used to assign the probability of severe injury (defined as MAIS 3+ or ISS>15 injury) to a subset of NASS-CDS cases based on crash attributes. Subsequently, actual AIS and ISS levels were compared with the predicted probability of injury to determine the extent to which the seriously injured had corresponding probabilities exceeding the 10% and 20% risk thresholds. Models were developed using an 80% sample of NASS-CDS data from 2002 to 2012 and evaluations were performed using the remaining 20% of cases from the same period. RESULTS: Within the population of seriously injured (i.e., those having one or more AIS 3 or higher injuries), the number of occupants whose injury risk did not exceed the 10% and 20% thresholds were estimated to be 11,700 and 18,600, respectively, each year using the MAIS 3+ injury model. For the ISS>15 model, 8,100 and 11,000 occupants sustained ISS>15 injuries yet their injury probability did not reach the 10% and 20% probability for severe injury respectively. Conversely, model predictions suggested that, at the 10% and 20% thresholds, 207,700 and 55,400 drivers respectively would be incorrectly flagged as injured when their injuries had not reached the AIS 3 level. For the ISS>15 model, 87,300 and 41,900 drivers would be incorrectly flagged as injured when injury severity had not reached the ISS>15 injury level. CONCLUSIONS: This article provides important information comparing the expected positive and negative effects of an AACN system with thresholds at the 10% and 20% levels using 2 outcome metrics. Overall, results suggest that the 20% risk threshold would not provide a useful notification to improve the quality of care for a large number of seriously injured crash victims. Alternately, a lower threshold may increase the over triage rate. Based on the vehicle damage observed for crashes reaching and exceeding the 10% risk threshold, we anticipate that rescue services would have been deployed based on current Public Safety Answering Point (PSAP) practices.

Identifying pitfalls in chest tube insertion: improving teaching and performance.

OBJECTIVE: Chest tube thoracostomies are common surgical procedures, but little is known about how practitioners learn the skill. This study evaluates the frequency with which correctly performed tasks are executed by subjects during chest tube thoracostomies. DESIGN: In this prospective study, we developed a mobile-learning module, containing stepwise multimedia guidance on chest tube insertion. Next, we developed and tested a 14-item checklist, modeled after key skills in the module. Participants, defined as "novice" (fewer than 10 chest tubes placed) or "expert" (10 or more placed), were assigned to either the video or control group. A trained clinician used the checklist to rate participants while they inserted a chest tube on a TraumaMan simulator. SETTING: University of Miami, Miller School of Medicine, a tertiary care academic institution. PARTICIPANTS: Current medical students, residents, and the United States Army Forward Surgical Team members rotating through the institution. One hundred twenty-eight subjects entered and finished the study. RESULTS: One hundred twenty-eight subjects enrolled in the study; 86 (67%) were residents or US Army Forward Surgical Team members, 66 (77%) were novices, and 20 (23%) were experts. Novices most frequently connected the tube to suction (91%), adequately dissected the soft tissue (82%), and scrubbed or anesthetized appropriately (80%). They least frequently completed full finger sweeps (33%), avoided the neurovascular bundle (35%), and performed a controlled pleural puncture (39%). Comparing the novice video group with the novice control group, the video group was more likely to correctly perform a finger sweep (42%, p<0.001) and clamp the distal end of the chest tube (42%, p<0.001). Of all the steps, experts least frequently completed full finger sweeps (70%) and avoided the neurovascular bundle (75%). Comparing the expert video group with the expert control group, the video group was more likely to correctly perform finger sweeps, the incision, and clamping the distal chest tube (20%, p = not significant). CONCLUSIONS: Avoiding the neurovascular bundle, controlled pleural entry, and finger sweeps are most often performed incorrectly among novices. This information can help instructors to emphasize key didactic steps, possibly easing trainees' learning curve.

Usability of telepresence in a level 1 trauma center.

OBJECTIVES: Limited resources and the diminishing physician workforce in trauma require unique and innovative solutions. Our hypothesis is that telepresence by a remote physician is an appropriate application in an urban trauma setting. The purpose of this study is to assess user satisfaction and usability of a mobile telemedicine robot in trauma care. MATERIALS AND METHODS: A usability study of trauma patient assessments utilizing the Remote Presence-7 (RP-7) robot (InTouch Health, Santa Barbara, CA) with real-time, two-way communication between remote and local physicians was conducted at a Level 1 trauma center. Usability and acceptability was measured using survey questionnaires, open-ended feedback, and general observations. Comparisons were made between remote and local physician responses. RESULTS: One hundred fourteen patient encounters utilizing telepresence were performed. Remote and local physicians expressed a high level of satisfaction with the mobility (92% and 79%, respectively), communication (97% and 90%, respectively), and visual abilities (91% and 97%, respectively) of the RP-7 robot for remote consultation purposes. On average, 89% of remote and local physician participants rated their overall telemedicine experience as "excellent" or "above average." CONCLUSIONS: This study suggests that telepresence of a remote trauma surgeon may be a useful and functional adjunct in the trauma setting. Further development of these technologies could mitigate current and future concerns about gaps in rural and urban trauma care and critical care staffing shortages and during mass casualty or disaster scenarios.

Knowledge and usability of a trauma training system for general surgery residents.

BACKGROUND: Resident work-hour restrictions challenge educators to supplement residents' surgical education. We evaluated a computer-based trauma surgery system's ability to increase residents' surgical knowledge. METHODS: Modules on thoracic and abdominal surgical approaches were evaluated. Surgical residents with 1 or more years of experience completed the pretest, an interactive module, the post-test, and a usability survey. RESULTS: Fifteen participants completed both modules. Thoracic module pretest and post-test scores were 56 ± 11 (mean ± standard deviation) and 90 ± 10, respectively (P < .0001). Mean abdominal module scores were 48 ± 20 and 85 ± 14, respectively (P < .0001). The usability survey showed that 87% of participants would use these modules to supplement their trauma training, 93% could easily distinguish anatomic detail, and 100% thought that procedures were shown clearly. CONCLUSIONS: This novel computer-based trauma education training system improved residents' knowledge of anatomy, surgical incisions, exposures, and technique. As innovative didactic tools arise in postgraduate medical education, it is crucial to document their effects on educational processes, learning satisfaction, and knowledge outcomes.

Influence of social networking websites on medical school and residency selection process.

BACKGROUND: Social networking (SN) has become ubiquitous in modern culture. The potential consequences of revealing personal information through SN websites are not fully understood. OBJECTIVE: To assess familiarity with, usage of, and attitudes towards, SN websites by admissions offices at US medical schools and residency programmes. METHODS: A 26-question survey was distributed in autumn 2009 to 130 US medical school admissions officers and 4926 residency programme directors accredited by the Accreditation Council for Graduate Medical Education. RESULTS: A total of 600 surveys were completed, with 46 (8%) respondents who self-identified as reviewing only medical school applications, 511 (85%) who reported reviewing residency programme applications and 43 (7%) who reported reviewing both. 90/600 (15%) medical schools or programmes maintain profiles on SN websites and 381/600 (64%) respondents reported being somewhat or very familiar with searching individual profiles on SN websites. While a minority of medical schools and residency programmes routinely use SN websites in the selection process (53/600; 9%), more than half of respondents felt that unprofessional information on applicants' SN websites could compromise their admission into medical school or residency (315/600; 53%). CONCLUSIONS: SN websites will affect selection of medical students and residents. Formal guidelines for professional behaviour on SN websites might help applicants avoid unforeseen bias in the selection process.

Mobile learning module improves knowledge of medical shock for forward surgical team members.

OBJECTIVE: Acute trauma care is characterized by dynamic situations that require adequate preparation to ensure success for military health professionals. The use of mobile learning in this environment can provide a solution that standardizes education and replaces traditional didactic lectures. METHODS: A comparative evaluation with a pre-post test design regarding medical shock was delivered via either a didactic lecture or a mobile learning video module to U.S. Army Forward Surgical Team (FST) members. Participants completed a pretest, were randomly assigned to treatment group by FST, and then completed the post-test and scenario assessment. RESULTS: One-hundred and thirteen FST members participated with 53 in the mobile learning group and 60 in the lecture group (control). The percent mean score for the mobile learning group increased from 43.6 to 70 from pretest to post-test, with a scenario mean score of M = 56.2. The percent mean score for the control group increased from 41.5 to 72.5, with a scenario mean score of M = 59.7. The two-way analysis of variance mean score difference was 26.4 for the mobile learning group and 31.0 for the control, F = 2.18, (p = 0.14). CONCLUSIONS: Mobile learning modules, coupled with a structured assessment, have the potential to improve educational experiences in civilian and military settings.

Fatal falls in an ethnically diverse urban community: the link between demographic factors and the circumstances surrounding fatal falls.

OBJECTIVES: Fatal falls cause more than 15,000 deaths per year in the United States. Despite this, the circumstances surrounding fatal falls in elderly adults are poorly understood. It is unknown whether these circumstances differ across ethnicities, although Hispanic American individuals are at reduced risk for fatal falls. This study sought to describe fatal falls in an urban, predominantly Hispanic, and white non-Hispanic community and to determine the association of demographics with the circumstances surrounding these falls (proximate factors). METHODS: The death certificates and medical examiners' reports for all 328 elderly individuals experiencing a fatal fall in Miami-Dade County, FL, from 2005 to 2007 were reviewed for demographic and proximate factors such as the preceding activity and fall location. RESULTS: Fatal falls in elderly adults were experienced mostly by individuals living in the community (80%) and affected all demographic subgroups, although 80% occurred in individuals older than 74 years. Most fatal falls occurred at home (74%), indoors (75%), and during nonvigorous activities such as walking (58%) and these tended to affect the oldest elderly. In addition, a significant number of fatal falls occurred in public locations, outdoors, and during vigorous activity, with these falls tending to affect younger individuals living without family. Hispanic ethnicity was not associated with proximate factors. CONCLUSIONS: Fatal fall prevention is needed for elderly individuals living in the community and should target the oldest elderly adults living at home while helping to ensure that individuals who are living without family have the appropriate support. These data suggest that Hispanic individuals may benefit from prevention strategies developed in other populations.

Use of mobile learning module improves skills in chest tube insertion.

BACKGROUND: Just-In-Time Learning is a concept increasingly applied to medical education, and its efficacy must be evaluated. MATERIALS AND METHODS: A 3-minute video on chest tube insertion was produced. Consenting participants were assigned to either the video group, which viewed the video on an Apple® iPod Touch immediately before chest tube insertion, or the control group, which received no instruction. Every participant filled out a questionnaire regarding prior chest tube experience. A trained clinician observed participants insert a chest tube on the TraumaMan® task simulator, and assessed performance using a 14-item skills checklist. RESULTS: Overall, 128 healthcare trainees participated, with 50% in the video group. Participants included residents (34.4%, n = 44), medical students (32.8%, n = 42), and U.S. Army Forward Surgical Team members (32.8%, n = 42). Sixty-nine percent of all participants responded that they had never placed a chest tube, but 7% had placed more than 20. Only 25% of the participants had previously used TraumaMan®. Subjects who viewed the video scored better on the skills checklist than the control group (11.09 ± 3.09 versus 7.17 ± 3.56, P < 0.001, Cohen's D = 1.16). Medical students (9.33 ± 2.65 versus 4.52 ± 3.64, P < 0.001), Forward Surgical Team members (10.07 ± 2.52 versus 8.57 ± 3.22, P < 0.001), anesthesia residents (8.25 ± 2.56 versus 5.9 ± 2.23, P = 0.017), and subjects who had placed fewer than 10 chest tubes (9.7 ± 3 versus 6.6 ± 3.9, P < 0.001) performed significantly better with the video. CONCLUSIONS: The procedural animation video is an effective medium for teaching procedural skills. Embedding the video on a mobile device, and allowing trainees to access it immediately before chest tube insertion, may enhance and standardize surgical education for civilians and military personnel.

Training forward surgical teams: do military-civilian collaborations work?

UNLABELLED: The US Army and the Ryder Trauma Center (Jackson Memorial Hospital, Miami, Florida) teamed up to provide a training environment (ie, the Army Trauma Training Center) in which forward surgical teams can attend to gain critical teamwork and trauma technical skills to prepare for deployment to Iraq or Afghanistan. The purpose of this study was to gather trainee reactions to the military-civilian collaboration provided at ATTC after deployment to Iraq or Afghanistan. METHODS: Survey respondents were 135 US Army personnel (an approximately 50% response rate) who participated in the ATTC 2-week team training program between January 2005 and June 2007. The survey asked questions pertaining to their experience in the resuscitation unit and patient contact at the trauma center. RESULTS: Over 90% of participants agreed or strongly agreed that training in the resuscitation area was beneficial. A majority of participants also agreed or strongly agreed that the patient contact experience was sufficient (78.5%), was a good learning opportunity (90%), and that the experience was a good opportunity to apply what they had learned in their classroom training (over 80%). Areas of suggested improvement included the importance of clarifying roles between the ATTC trainees and the Ryder Trauma Center residents and interns. Trainees would have preferred an extension of the training as a whole, as they felt it was rushed in order to fit all training opportunities into the 2 weeks that they were in Miami. Finally, trainees noted the lack of injuries admitted to the trauma center which replicate injuries caused by blasts (ie, improvised explosive devices). CONCLUSIONS: The results of our efforts indicate that military-civilian collaborations do in fact work and are beneficial to both military and civilian medical providers. The opportunity to perform as a team in their respective roles, to respond to a variety of actual trauma patients, and access to civilian medical providers were beneficial. As mentioned, such collaborations are not without limitations. The good news is that most of the identified limitations will be corrected to ensure trainees get the best possible experience possible.