Initial Assessment of a Regional Military-Civilian Partnership on Trauma Surgery Skills Sustainment.

INTRODUCTION: Trauma surgery skills sustainment and maintenance of combat readiness present a major problem for military general surgeons. The Military Health System (MHS) utilizes the knowledge, skills, and abilities (KSA) threshold score of 14,000 as a measure of annual deployment readiness. Only 9% of military surgeons meet this threshold. Most military-civilian partnerships (MCPs) utilize just-in-time training models before deployment rather than clinical experiences in trauma at regular intervals (skills sustainment model). Our aim is to evaluate an established skills sustainment MCP utilizing KSAs and established military metrics. MATERIALS AND METHODS: Three U.S. Navy active duty general surgeons were embedded into an urban level-1 trauma center taking supervised trauma call at regular intervals prior to deployment. Operative density (procedures/call), KSA scores, trauma resuscitation exposure, and combat casualty care relevant cases (CCC-RCs) were reviewed. RESULTS: During call shifts with a Navy surgeon present an average 16.4 trauma activations occurred; 32.1% were category-1, 27.6% were penetrating, 72.4% were blunt, and 33.8% were admitted to the intensive care unit. Over 24 call shifts of 24 hours in length, 3 surgeons performed 39 operative trauma cases (operative density of 1.625), generating 11,683 total KSA points. Surgeons 1, 2, and 3 generated 5109, 3167, and 3407 KSA points, respectively. The three surgeons produced a total of 11,683 KSA points, yielding an average of 3,894 KSA points/surgeon. In total, 64.1% of operations fulfilled CCC-RC criteria. CONCLUSIONS: Based on this initial evaluation, a military surgeon taking two calls/month over 12 months through our regional skills sustainment MCP can generate more than 80% of the KSA points required to meet the MHS KSA threshold for deployment readiness, with the majority being CCC-RCs. Intangible advantages of this model include exposure to multiple trauma resuscitations while possibly eliminating just-in-time training and decreasing pre-deployment requirements.

Repeat Head CT? Not Necessary for Patients with a Negative Initial Head CT on Anticoagulation or Antiplatelet Therapy Suffering Low-Altitude Falls.

Anticoagulation and antiplatelet (ACAP) medications are increasingly prescribed to patients at high risk for falls. Many trauma centers have developed protocols for obtaining repeat head CT (HCT) for patients with low-altitude falls on ACAP therapy. We assess the need for routine scheduled repeat HCT in this population. Prospective, observational analysis of all low-altitude fall (<6 feet) patients on ACAP therapy evaluated at a Level II trauma center. All low-altitude fall patients with visible or suspected head trauma received an initial HCT. Patients were admitted and repeat HCT was obtained 12 hours later or earlier if acute neurologic decline developed. Chi-squared, Fischer exact, t, and Wilcoxon rank-sum tests were used. Statistical significance was defined as P < 0.05. Total of 1501 patients enrolled suffering low-altitude falls with initial HCT. Among them 1379(91.2%) were negative and 122(8.1%) were initially positive for intracranial hemorrhage. Mean age was 79.9 ± 11.4 years, 61 per cent were female and 85 per cent had visible head trauma at presentation. One hundred ninety-nine were excluded secondary to not receiving repeat HCT. Of the 1180 patients with normal initial HCT who underwent repeat HCT, only 7 (0.51%) had delayed intracranial hemorrhage. None of these patients required surgery, major changes in medical management or suffered head trauma-related mortality; 69 per cent were taking aspirin (acetylsalicylic acid, ASA), 19 per cent warfarin, 17 per cent clopidogrel, 6 per cent other anticoagulants, and 11 per cent were on combination therapy. Repeat HCT for patients on any ACAP therapy after low-altitude fall with a negative initial HCT is not necessary. Thorough neurologic examination and close monitoring is as effective as obtaining a repeat HCT.

Symptomatic lymphoepithelial cyst of the pancreas: successful treatment without pancreatic resection.

Lymphoepithelial cysts (LECs) of the pancreas are rare benign lesions with unknown pathogenesis. LECs are true cysts that mimic pseudocysts and cystic neoplasms making diagnosis challenging. We report a case of a symptomatic LEC of the pancreas in a 67-year-old man who had severe epigastric pain. Workup including computed tomography and endoscopic ultrasound were non-diagnostic. The patient underwent attempted surgical resection; however, the mass was unresectable. The mass was enucleated and drained, and pathology returned LEC. The patient underwent a normal postoperative course and remained symptom free. Most LECs are diagnosed after an extensive pancreatic resection for suspicious cystic masses. The aim of this report is to show that operative management of LECs should not be limited to pancreatic resections. Excision and enucleation of LEC of the pancreas is a better alternative than an extensive pancreatic resection. Preoperative diagnosis of LECs appears to be the limiting factor.