Evaluation of urological and gynecological surgeons as force multipliers for mass Casualty trauma care.

BACKGROUND: The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients. METHODS: Urological (6), gynecological surgeons (6), senior (PGY5) general surgery residents (6), and non-trauma trained general surgeons (8) completed a rigorous trauma training program (ASSET+). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures pre/post mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent, accurate completion of all procedural components within a realistic time window (90%). RESULTS: General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Pre-training, general surgery and urology participants outperformed gynecologists for overall procedural abilities. Post-training, only general surgeons met the 90% benchmark. Post-hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures, however knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training. CONCLUSION: For physiologically stable patients with traumatic injuries to the abdomen, pelvis or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level III/IV.

Paediatric percutaneous bone anchored hearing aid implant failures: Comparing the experience of a tertiary centre with a systematic review of the literature and meta-analysis.

BACKGROUND: Despite the proven audiological benefits of Percutaneous Bone Anchored Hearing Aids (BAHAs) in paediatric patients with conductive or mixed hearing loss, their adoption has been limited due to concerns over implant failure and associated complications. This paper conducts a systematic review and meta-analysis to assess the prevalence of implant failure in paediatric populations, combined with a case series from our tertiary referral centre. METHODS: A comprehensive literature search identified 562 articles, from which 34 were included in the review, covering 1599 implants in 1285 patients. Our retrospective case series included consecutive patients from our tertiary referral centre who underwent percutaneous BAHA implantation from 2003-2019. RESULTS: Meta-analysis revealed an overall implant failure rate of 11%, predominantly attributed to traumatic extrusion. Our retrospective case series comprised 104 implantations in 76 patients, with a 4.8% failure rate. DISCUSSION: Factors contributing to the lower-than-expected failure rates in the case series likely included consistent use of 4 mm fixtures from a single manufacturer and older age at implantation. The study underscores the need for standardised reporting formats in bone conduction implants research, given the systematic review's limitations in study design heterogeneity, especially with the expected rise in the adoption of novel active devices.

Clinical Readiness: Can Providers Learn to Perform Lower Leg Fasciotomy Through a Tablet-based Augmented Reality Surgical Training Environment?

INTRODUCTION: The uses of on-demand, interactive tablet-based surgical training environments are of interest as potential resources for both the acquisition and maintenance of rarely performed, critical procedures for expeditionary surgical care. This study examined the effectiveness of a tablet-based augmented reality (AR) procedural training environment for lower leg fasciotomy with a cohort of novice surgical trainees in (1) procedural knowledge, (2) tablet-based procedural skills, (3) tablet-based procedural time, and (4) procedural performance on a cadaver. We hypothesized that engaging with the AR procedural training would increase procedural knowledge and tablet-based skills and procedural time. We hypothesized that the tablet-based AR training environment would be insufficient to acquire the ability to perform lower leg fasciotomy on a cadaver. MATERIALS AND METHODS: This study was approved as exempt by the Institutional Review Board at USU. Surgical interns, sub-interns, and independent duty corpsman (n = 30) with no prior lower leg fasciotomy experience voluntarily participated. Tablet-based training activities included pre-training assessment, engagement with instruction, interactive procedural practice, and post-training assessment. Tablet-based knowledge assessment included 17 multiple choice questions covering concepts, reasoning, and judgment associated with the procedure. Tablet-based procedural completion and time were assessed within the training environment. Within 1 week of completing the tablet activities, participants were assessed by fellowship-trained trauma surgeons while performing cadaver-based lower leg fasciotomy. Statistical analysis included paired t-tests and effect size (Cohen's d). Statistical significance was set at P < .05. RESULTS: Tablet-based AR procedural training significantly improved procedural knowledge (P < .001), tablet-based procedural skills (P < .001), and reduced tablet-based procedural time (P < .002). Effect sizes were very large for tablet-based procedural knowledge (d = 1.75) and skills (d = 3.2) and small (d = 0.42) for procedural time. There were no significant effects of procedural knowledge, tablet-based procedural skills, or time on cadaver-based performance. No participant was able to accurately and independently complete lower leg fasciotomy procedure on a cadaver. CONCLUSIONS: Tablet-based AR procedural training improved procedural knowledge and tablet-based skills; however, those gains did not transfer to the ability to perform the procedure on a cadaver. The tablet's limited AR interface did not support the acquisition of requisite surgical technique, tissue handling, and decision-making in novice surgical trainees. Experienced surgeons may have different outcomes because their mature understanding of surgical constructs would allow extrapolation of abilities to other procedural contexts. Further investigation of the tablet-based training environments for surgical care is necessary before distributing such resources to support clinical readiness.

Metabolomic Signatures Differentiate Immune Responses in Avian Influenza Vaccine Recipients.

BACKGROUND: Avian influenza viruses pose significant risk to human health. Vaccines targeting the hemagglutinin of these viruses are poorly immunogenic without the use of adjuvants. METHODS: Twenty healthy men and women (18-49 years of age) were randomized to receive two doses of inactivated influenza A/H5N1 vaccine alone (IIV) or with AS03 adjuvant (IIV-AS03) one month apart. Urine and serum samples were collected on day 0 and on days 1, 3, and 7 following first vaccination and subjected to metabolomics analyses to identify metabolites, metabolic pathways, and metabolite clusters associated with immunization. RESULTS: Seventy-three differentially abundant (DA) serum and 88 urine metabolites were identified for any post-vaccination day comparison. Pathway analysis revealed enrichment of tryptophan, tyrosine and nicotinate metabolism in urine and serum among IIV-AS03 recipients. Increased urine abundance of 4-vinylphenol sulfate on Day 1 was associated with serologic response based on hemagglutination inhibition responses. In addition, 9 DA urine metabolites were identified in participants with malaise compared to those without. CONCLUSIONS: Our findings suggest that tryptophan, tyrosine, and nicotinate metabolism are upregulated among IIV-AS03 recipients compared with IIV alone. Metabolites within these pathways may serve as measures of immunogenicity and may provide mechanistic insights for adjuvanted vaccines.

Leading Graduate Medical Education in the Face of Uncertainty.

Leading through uncertainty poses significant challenges. The COVID-19 pandemic, the Afghanistan withdrawal, and the implementation of a new electronic medical records system led to massive shortages of health care workers throughout the Military Health System (MHS). This case describes the leadership challenges of a surgical residency program director during uncertain times.

Simple signage and targeted education can lead to process improvement in acute appendicitis care.

INTRODUCTION: An institution-wide protocol for uncomplicated acute appendicitis was created to improve compliance with best practices between the emergency department (ED), radiology and surgery. Awareness of the protocol was spread with the publication of a smartphone application and communication to clinical leadership. On interim review of quality metrics, poor protocol adherence in diagnostic imaging and antimicrobial stewardship was observed. The authors hypothesised that two further simple interventions would result in more efficient radiographic diagnosis and antimicrobial administration. MATERIALS AND METHODS: Surgery residents received targeted in-person education on the appropriate antibiotic choices and diagnostic imaging in the protocol. Signs were placed in the emergency and radiology work areas, immediately adjacent to provider workstations highlighting the preferred imaging for patients with suspected appendicitis and the preferred antibiotic choices for those with proven appendicitis. Protocol adherence was compared before and after each intervention. RESULTS: Targeted education was associated with improved antibiotic stewardship within the surgical department from 30% to 91% protocol adherence before/after intervention (p<0.005). Visible signs in the ED were associated with expedited antimicrobial administration from 50% to 90% of patients receiving antibiotics in the ED prior to being brought to the operating room before/after intervention (p<0.005). Diagnostic imaging after the placement of signs showed improved protocol adherence from 35% to 75% (p<0.005). CONCLUSION: This study demonstrates that smartphone-based applications and communication among clinical leadership achieved suboptimal adherence to an institutional protocol. Targeted in-person education reinforcement and visible signage immediately adjacent to provider workstations were associated with significantly increased adherence. This type of initiative can be used in other aspects of acute care general surgery to further improve quality of care and hospital efficiency.

Use of Levetiracetam for Post-Traumatic Seizure Prophylaxis in Combat-Related Traumatic Brain Injury.

INTRODUCTION: Post-traumatic seizure (PTS) prophylaxis is recommended in patients with traumatic brain injury (TBI) at high risk for PTSs, but consensus on the optimal pharmacologic therapy has not yet been established. Levetiracetam is frequently used for seizure prophylaxis in combat-related TBI, but its efficacy and safety in this patient population has not yet been described. METHODS: A retrospective cohort of 687 consecutive casualties transferred to the CONUS from October 2010 to December 2015 was analyzed. Seventy-one patients with combat-related injuries and radiographic evidence of skull fractures or intracranial hemorrhage were included. Data collection included demographics and injury characteristics including initial Glasgow Coma Scale, computed tomography findings, interventions, and 6-month Glasgow Outcome Score. RESULTS: All patients in this cohort were male, with an average age of 25 (median 24; Interquartile range (IQR) 4.5) and an average Injury Severity Score of 28 (median 27; IQR 15). The most common mechanism of injury was explosive blast (76%). Penetrating TBI was common (51%). Most patients (88.7%) were administered seizure prophylaxis. Of these, the majority (61/63) received levetiracetam, and the additional two were administered phenytoin. The remaining 11.3% of patients were deemed not to require seizure prophylaxis. The incidence of seizures while on prophylaxis was low (2.8%) and occurred in patients who suffered transcranial gunshot wounds and ultimately died. No serious adverse effects were attributed to levetiracetam. CONCLUSIONS: Levetiracetam appears to be a safe and effective medication for PTS prophylaxis in combat casualties. The rate of PTSs in combat-related TBI on appropriate prophylaxis is low.

The last days: The medical response of United States and allied military teams during the Afghanistan Exodus.

OBJECTIVES: The objective of this study is to describe the United States and allied military medical response during the withdrawal from Afghanistan. BACKGROUND: The military withdrawal from Afghanistan concluded with severe hostilities resulting in numerous civilian and military casualties. The clinical care provided by coalition forces capitalized on decades of lessons learned and enabled unprecedented accomplishments. METHODS: In this retrospective, observational analysis, casualty numbers, and operative information was collected and reported from military medical assets in Kabul, Afghanistan. The continuum of medical care and the trauma system, from the point of injury back to the United States was captured and described. RESULTS: Prior to a large suicide bombing resulting in a mass casualty event, the international medical teams managed distinct 45 trauma incidents involving nearly 200 combat and non-combat civilian and military patients over the preceding 3 months. Military medical personnel treated 63 casualties from the Kabul airport suicide attack and performed 15 trauma operations. US air transport teams evacuated 37 patients within 15 hours of the attack. CONCLUSION: Lessons learned from the last 20 years of combat casualty care were successfully implemented during the culmination of the Afghanistan conflict. Ultimately, the effort, teamwork, and system adaptability exemplify not only the attitudes and character of service members who provide modern combat casualty care but also the paramount importance of the battlefield learning health care system. A continued posture to maintain military surgical preparedness in unique environments remain crucial as the US military prepares for the future.Retrospective observational analysis. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

Rare Hypermucoviscous Klebsiella pneumoniae Liver Abscess in an Active Duty Male Requiring Partial Liver Resection for Definitive Treatment.

Antibiotics and drainage have largely replaced hepatic resection for the treatment of liver abscesses in the modern era; however, in cases caused by a rare strain of Klebsiella pneumoniae with a hypermucoviscous phenotype, more aggressive hepatic resection may be required. The patient is a 34-year-old male who presented to Landstuhl Regional Medical Center with a week of epigastric pain. His workup revealed a 6 cm liver abscess with growth to 10 cm in 48 hours. He underwent multiple drainage procedures at Landstuhl and then was transferred to Walter Reed where further surgical drainage was performed. Initial cultures demonstrated K. pneumoniae. He clinically improved and was able to discharge after a 2 week hospitalization. His final remaining surgical drain was removed as an outpatient, but 48 hours after removal, he was admitted to the intensive care unit in septic shock. Imaging revealed a 12 cm liver abscess, and cultures verified hypermucoviscous Klebsiella. After multidisciplinary discussion and counseling, he underwent an open right partial hepatectomy. Postoperatively he gradually recovered from his sepsis and major operation and then returned to his home in Landstuhl. This is a case of a rare hypermucoviscous variant of K. pneumoniae causing a liver abscess resistant to multiple drainage procedures, ultimately requiring open hepatic surgical resection for source control. This remains a last-resort option in the treatment of liver abscesses and should be considered early when caused by this rare strain of Klebsiella.

Development, refinement, and characterization of a nonhuman primate critical care environment.

BACKGROUND: Systemic inflammatory response remains a poorly understood cause of morbidity and mortality after traumatic injury. Recent nonhuman primate (NHP) trauma models have been used to characterize the systemic response to trauma, but none have incorporated a critical care phase without the use of general anesthesia. We describe the development of a prolonged critical care environment with sedation and ventilation support, and also report corresponding NHP biologic and inflammatory markers. METHODS: Eight adult male rhesus macaques underwent ventilation with sedation for 48-96 hours in a critical care setting. Three of these NHPs underwent "sham" procedures as part of trauma control model development. Blood counts, chemistries, coagulation studies, and cytokines/chemokines were collected throughout the study, and histopathologic analysis was conducted at necropsy. RESULTS: Eight NHPs were intentionally survived and extubated. Three NHPs were euthanized at 72-96 hours without extubation. Transaminitis occurred over the duration of ventilation, but renal function, acid-base status, and hematologic profile remained stable. Chemokine and cytokine analysis were notable for baseline fold-change for Il-6 and Il-1ra (9.7 and 42.7, respectively) that subsequently downtrended throughout the experiment unless clinical respiratory compromise was observed. CONCLUSIONS: A NHP critical care environment with ventilation support is feasible but requires robust resources. The inflammatory profile of NHPs is not profoundly altered by sedation and mechanical ventilation. NHPs are susceptible to the pulmonary effects of short-term ventilation and demonstrate a similar bioprofile response to ventilator-induced pulmonary pathology. This work has implications for further development of a prolonged care NHP model.

Protocols for single-cell RNA-seq and spatial gene expression integration and interactive visualization.

There is a wealth of software that utilizes single-cell RNA-seq (scRNA-seq) data to deconvolve spatial transcriptomic spots, which currently are not yet at single-cell resolution. Here we provide protocols for implementing Seurat and Giotto packages to elucidate cell-type distribution in our example human ureter scRNA-seq dataset. We also describe how to create a stand-alone interactive web application using Seurat libraries to visualize and share our results. For complete details on the use and execution of this protocol, please refer to Fink et al. (2022).1.

Content validity test of a safety checklist for simulated participants in simulation-based education in the United Kingdom: a methodological study

PURPOSE: Simulation training is an ever-growing means of healthcare education and often involves simulated participants (SPs), commonly known as actors. Simulation-based education (SBE) can sometimes endanger SPs, and as such we have created a safety checklist for them to follow. This study describes how we developed the checklist through a quality improvement project, and then evaluated feedback responses to assess whether SPs felt our checklist was safe. METHODS: The checklist was provided to SPs working in an acute trust simulation service when delivering multidisciplinary SBE over 4 months. Using multiple plan­do­study­act cycles, the checklist was refined by reflecting on SP feedback to ensure that the standards of the safe simulation were met. We collected 21 responses from September to December 2021 after SPs completed an SBE event. RESULTS: The responses showed that 100% of SPs felt safe during SBE when using our checklist. The average "confidence in safety" rating before using the checklist was 6.8/10, which increased significantly to 9.2/10 after using the checklist (P<0.0005). The checklist was refined throughout the 4 months and implemented in adult and pediatric SBE as a standard operating procedure. CONCLUSION: We recommend using our safety checklist as a standard operating procedure to improve the confidence and safety of SPs during safe and effective simulations.

Single-cell and spatial mapping Identify cell types and signaling Networks in the human ureter.

Tissue engineering offers a promising treatment strategy for ureteral strictures, but its success requires an in-depth understanding of the architecture, cellular heterogeneity, and signaling pathways underlying tissue regeneration. Here, we define and spatially map cell populations within the human ureter using single-cell RNA sequencing, spatial gene expression, and immunofluorescence approaches. We focus on the stromal and urothelial cell populations to enumerate the distinct cell types composing the human ureter and infer potential cell-cell communication networks underpinning the bi-directional crosstalk between these compartments. Furthermore, we analyze and experimentally validate the importance of the sonic hedgehog (SHH) signaling pathway in adult progenitor cell maintenance. The SHH-expressing basal cells support organoid generation in vitro and accurately predict the differentiation trajectory from basal progenitor cells to terminally differentiated umbrella cells. Our results highlight the essential processes involved in adult ureter tissue homeostasis and provide a blueprint for guiding ureter tissue engineering.

Cellular microRNAs correlate with clinical parameters in multiple injury patients.

INTRODUCTION: The pathophysiology of the inflammatory response after major trauma is complex, and the magnitude correlates with severity of tissue injury and outcomes. Study of infection-mediated immune pathways has demonstrated that cellular microRNAs may modulate the inflammatory response. The authors hypothesize that the expression of microRNAs would correlate to complicated recoveries in polytrauma patients (PtPs). METHODS: Polytrauma patients enrolled in the prospective observational Tissue and Data Acquisition Protocol with Injury Severity Score of >15 were selected for this study. Polytrauma patients were divided into complicated recoveries and uncomplicated recovery groups. Polytrauma patients' blood samples were obtained at the time of admission (T0). Established biomarkers of systemic inflammation, including cytokines and chemokines, were measured using multiplexed Luminex-based methods, and novel microRNAs were measured in plasma samples using multiplex RNA hybridization. RESULTS: Polytrauma patients (n = 180) had high Injury Severity Score (26 [20-34]) and complicated recovery rate of 33%. MicroRNAs were lower in PtPs at T0 compared with healthy controls, and bivariate analysis demonstrated that variations of microRNAs correlated with age, race, comorbidities, venous thromboembolism, pulmonary complications, complicated recovery, and mortality. Positive correlations were noted between microRNAs and interleukin 10, vascular endothelial growth factor, Acute Physiology and Chronic Health Evaluation, and Sequential Organ Failure Assessment scores. Multivariable Lasso regression analysis of predictors of complicated recovery based on microRNAs, cytokines, and chemokines revealed that miR-21-3p and monocyte chemoattractant protein-1 were predictive of complicated recovery with an area under the curve of 0.78. CONCLUSION: Systemic microRNAs were associated with poor outcomes in PtPs, and results are consistent with previously described trends in critically ill patients. These early biomarkers of inflammation might provide predictive utility in early complicated recovery diagnosis and prognosis. Because of their potential to regulate immune responses, microRNAs may provide therapeutic targets for immunomodulation. LEVEL OF EVIDENCE: Diagnostic Tests/Criteria; Level II.

Risk Factors for Urgent or Emergent Cholecystectomy Mid-workup for Symptomatic Cholelithiasis.

BACKGROUND: Patients who undergo cholecystectomy often do so for diagnoses related to the sequelae of gallstones. Many patients present acutely, requiring urgent removal due to complications of cholelithiasis. This study aims to characterize the patient population likely to present acutely during ongoing workup for cholelithiasis to better identify those who may benefit from expedited care. METHODS: Medical records of all adult patients who underwent cholecystectomy for indications related to cholelithiasis between 2015 and 2016 were reviewed retrospectively. Qualitative data was analyzed using Chi square test and quantitative data was analyzed using independent t-tests. RESULTS: One hundred and seventy-four cholecystectomies were performed. Overall, 74.2% of the procedures were done electively while 25.8% were done urgently. And 42.2% of patients who underwent acute surgical intervention had evidence of prior workup. Patients requiring urgent intervention during ongoing diagnostic evaluation were more likely to have initially presented to an emergency department (ED) than another provider (68.4% vs 31.3%, P < .001) and had an odds ratio of 4.7 for undergoing acute intervention if they initially presented to the ED. They also tended to be more temporally remote from their initial diagnosis (119 ± 142 vs 74.6 ± 68.2 days, P < .19) relative to those who underwent elective operations. DISCUSSION: Patients who require urgent intervention during ongoing workup for cholelithiasis have prolonged courses of care and present to the ED more often for initial evaluation when compared to those who undergo elective intervention. These findings suggest that an emphasis on expedited workup of cholelithiasis and early surgical referral may be warranted, especially for those who initially present in the ED.

The coronavirus disease clavicle study: a predictor of future trauma trends.

Background: Clavicle fractures are a common presentation to the emergency department after falls and sporting injuries. During 2020, the coronavirus disease 2019 (COVID-19) pandemic brought with it a long period of social isolation, resulting in a change of behavior patterns and, in return, the presentation of fractures to our local hospitals. The effects of this global pandemic on the presentation and management of clavicles were noted with particular interest to the change in mechanism and its future implications. Methods: We performed a longitudinal observational study in 10 hospitals in the North West of England, reviewing all patients presenting with a clavicle fracture during 6 weeks in the first peak of COVID-19 pandemic and compared these with the same period in 2019. Collection points included the patient demographics, fracture characteristics, mechanism of injury, and management. Results: A total of 427 clavicle fractures were assessed with lower numbers of patients presenting with a clavicle fracture during the COVID-2020 period (n = 177) compared with 2019 (n = 250). Cycling-related clavicle fractures increased 3-fold during the pandemic compared with the 2019 control group. We also noted an overall increase in clavicle fractures resulting from higher energy trauma as opposed to low energy or fragility fracture. We also found a faster time to surgery in the COVID cohort by 2.7 days on average when compared with 2019. Conclusions: Government restrictions and the encouragement of social distancing led to behavioral changes with a vast increase in cyclists on the road. This created a significant rise in clavicle fractures related to this activity. This is likely to be further driven by the government pledge to double cyclists on the road by 2025 in the United Kingdom. We forecast that this increase in cyclists, a behavior change accelerated by the pandemic, is a reliable predictor for future trauma trends.

Upper-Extremity Vascular Exposures for Trauma: Comparative Performance Outcomes for General Surgeons and Orthopedic Surgeons.

INTRODUCTION: As combat-related trauma decreases, there remains an increasing need to maintain the ability to care for trauma victims from other casualty events around the world (e.g., terrorism, natural disasters, and infrastructure failures). During these events, military surgeons often work closely with their civilian counterparts, often in austere and expeditionary contexts. In these environments, the primary aim of the surgical team is to implement damage control principles to avert blood loss, optimize oxygenation, and improve survival. Upper-extremity vascular injuries are associated with high rates of morbidity and mortality resulting from exsanguination and ischemic complications; however, fatalities may be avoided if hemorrhage is rapidly controlled. In austere contexts, deployed surgical teams typically include one general surgeon and one orthopedic surgeon, neither of which have acquired the expertise to manage these vascular injuries. The purpose of this study was to examine the baseline capabilities of general surgeons and orthopedic surgeons to surgically expose and control axillary and brachial arteries and to determine if the abilities of both groups could be increased through a focused cadaver-based training intervention. METHODS: This study received IRB approval at our institution. Study methods included the use of cadavers for baseline assessment of procedural capabilities to expose and control axillary and brachial vessels, followed by 1:1 procedural training and posttraining re-assessment of procedural capabilities. Inferential analyses included ANOVA/MANOVA for within- and between-group effects (P < .05). Effect sizes were calculated using Cohen's d. RESULTS: Study outcomes demonstrated significant differences between the baseline performance abilities of the two groups, with general surgeons outperforming orthopedic surgeons. Before training, neither group reached performance benchmarks for overall or critical procedural abilities in exposing axillary and brachial vessels. Training led to increased abilities for both groups. There were statistically significant gains for overall procedural abilities, as well as for critical procedural elements that are directly associated with morbidity and mortality. These outcomes were consistent for both general and orthopedic surgeons. Effect sizes ranged between medium (general surgeons) and very large (orthopedic surgeons). CONCLUSION: There was a baseline capability gap for both general surgeons and orthopedic surgeons to surgically expose and control the axillary and brachial vessels. Outcomes from the course suggest that the methodology facilitates the acquisition of accurate and independent vascular procedural capabilities in the management of upper-extremity trauma injuries. The impact of this training for surgeons situated in expeditionary or remote contexts has direct relevance for caring for victims of extremity trauma. These outcomes underscore the need to train all surgeons serving in rural, remote, expeditionary, combat, or global health contexts to be able to competently manage extremity trauma and concurrent vascular injuries to increase the quality of care in those settings.