Methods of advanced wound management for care of combined traumatic and chemical warfare injuries.

OBJECTIVE: Chemical warfare agents are potential threats to military personnel and civilians. The potential for associated traumatic injuries is significant. Damage control surgery could expose medical personnel to agents contaminating the wounds. The objectives of this study were to demonstrate efficacy of surgical decontamination and assess exposure risk to attending personnel. METHODS: Weanling pigs were randomly assigned to 2 of 4 debridement tools (scalpel, Bovie knife, Fugo Blade, and Versajet Hydrosurgery System). Penetrating traumatic wounds were created over the shoulder and thigh and then exposed to liquid sulfur mustard (HD) for 60 minutes. Excisional debridement of the injuries was performed while vapors over each site were collected. Gas chromatography was used to measure HD in samples of collected vapors. Unbound HD was quantified in presurgical wound swabs, excised tissues, and peripheral tissue biopsies following solvent extraction. RESULTS: Excisional debridement produced agent-free wound beds (surgical decontamination). A significant amount of HD vapor was detected above the surgical fields with each tool. Apart from the Versajet producing significantly lower levels of HD detected over thigh wounds compared with those treated using the scalpel, there were no differences in the amount of agent detected among the tools. All measured levels significantly exceeded established safety limits. Vesicating levels of unbound HD were extracted from excised tissue. There was no measured lateral spreading of HD beyond the surgical margins. CONCLUSIONS: There is significant occupational exposure risk to HD during surgical procedures designed to stabilize agent-contaminated wounds. If appropriate protective measures are taken, surgical decontamination is both effective and safe.

Validation of SimPL -- a simulator for diagnostic peritoneal lavage training.

This study describes a comparison between an animal model and a haptic enabled, needle based, graphical user interface simulator (SimPL), for teaching Diagnostic Peritoneal Lavage (DPL). Forty novice medical students were divided into two groups and then trained to perform a DPL on either a pig or the SimPL. All subjects completed a pre and post test of basic knowledge and were tested by performing a DPL on a TraumaMan mannequin and evaluated by two trauma surgeons blinded to group. The results showed significant improvement over baseline knowledge in both groups but more so in the SimPL group. The simulator group performed better on site selection (p<0.001) and technique (p<0.002) than those who trained on a pig. The finding that a simulator is superior to an animal model for teaching an important skill to medical students has profound implications on future training and deserves further study.

Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training.

BACKGROUND: Human patient simulation (HPS) has been used since 1969 for teaching purposes. Only recently has technology advanced to allow application to the complex field of trauma resuscitation. The purpose of our study was to validate an advanced HPS as an evaluation tool of trauma team resuscitation skills. METHODS: The pilot study evaluated 10 three-person military resuscitation teams from community hospitals that participated in a 28-day rotation at a civilian trauma center. Each team consisted of physicians, nurses, and medics. Using the HPS, teams were evaluated on arrival and again on completion of the rotation. In addition, the 10 trauma teams were compared with 5 expert teams composed of experienced trauma surgeons and nurses. Two standardized trauma scenarios were used, representing a severely injured patient with multiple injuries and with an Injury Severity Score of 41 (probability of survival, 50%). Performance was measured using a unique human performance assessment tool that included five scored and eight timed tasks generally accepted as critical to the initial assessment and treatment of a trauma patient. Scored tasks included airway, breathing, circulation, and disability assessments as well as overall organizational skills and a total score. The nonparametric Wilcoxon test was used to compare the military teams' scores for scenarios 1 and 2, and the comparison of the military teams' final scores with the expert teams. A value of p < 0.05 was considered significant. RESULTS: The 10 military teams demonstrated significant improvement in four of the five scored (p < or = 0.05) and six of the eight timed (p < or = 0.05) tasks during the final scenario. This improvement reflects the teams' cumulative didactic and clinical experience during the 28-day trauma refresher course as well as some degree of simulator familiarization. Improved final scores reflected efficient and coordinated team efforts. The military teams' initial scores were worse than the expert group in all categories, but their final scores were only lower than the expert groups in 2 of 13 measurements (p < or = 0.05). CONCLUSION: No studies have validated the use of the HPS as an effective teaching or evaluation tool in the complex field of trauma resuscitation. These pilot data demonstrate the ability to evaluate trauma team performance in a reproducible fashion. In addition, we were able to document a significant improvement in team performance after a 28-day trauma refresher course, with scores approaching those of the expert teams.