Disparities in trauma care education: An observational study of the ATLS course within a national trauma system.

BACKGROUND: Disparities in trauma systems, including gaps between trauma center levels, affect patient outcomes. Advanced Trauma Life Support (ATLS) is a standard method of care that improves the performance of lower-level trauma systems. We sought to study potential gaps in ATLS education within a national trauma system. METHODS: This prospective observational study examined the characteristics of 588 surgical board residents and fellows taking the ATLS course. The course is required for board certification in adult trauma specialties (general surgery, emergency medicine, and anesthesiology), pediatric trauma specialties (pediatric emergency medicine and pediatric surgery), and trauma consulting specialties (all other surgical board specialties). We compared the differences in course accessibility and success rates within a national trauma system which includes seven level 1 trauma centers (L1TC) and twenty-three non-level 1 hospitals (NL1H). RESULTS: Resident and fellow students were 53% male, 46% employed in L1TC, and 86% were in the final stages of their specialty program. Only 32% were enrolled in adult trauma specialty programs. Students from L1TC had a 10% higher ATLS course pass rate than NL1H (p = 0.003). Trauma center level was associated with higher odds to pass the ATLS course, even after adjustment to other variables (OR = 1.925 [95% CI = 1.151 to 3.219]). Compared to NL1H, the course was two-three times more accessible to students from L1TC and 9% more accessible to adult trauma specialty programs (p = 0.035). The course was more accessible to students at early levels of training in NL1H (p < 0.001). Female students and trauma consulting specialties enrolled in L1TC programs were more likely to pass the course (OR = 2.557 [95% CI = 1.242 to 5.264] and 2.578 [95% CI = 1.385 to 4.800], respectively). CONCLUSIONS: Passing the ATLS course is affected by trauma center level, independent of other student factors. Educational disparities between L1TC and NL1H include ATLS course access for core trauma residency programs at early training stages. Some gaps are more pronounced among consulting trauma specialties and female surgeons. Educational resources should be planned to favor lower-level trauma centers, specialties dealing in trauma care, and residents early in their postgraduate training.

Post-POEM Contrast-Enhanced Swallow Study: Is It Always Necessary?

BACKGROUND: Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM. METHODS: A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated. RESULTS: One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS. CONCLUSIONS: The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS.

Succeeding in Continuing Trauma Education During a Pandemic.

BACKGROUND: Corona virus disease 2019 (Covid-19) impacted continuing medical education programs such as the Advanced Trauma Life Support (ATLS) course. Modifications made to medical training like teleconferencing could affect students' learning success. We sought to evaluate the effects of the American College of Surgeons modifications on success rates in passing the ATLS course. METHODS: This study evaluated 28 ATLS 10th edition courses educating 898 students at our region before and after Covid-19 modifications. Traditional two-day courses were performed in-person while modified courses were conducted with a one-day teleconference followed by a second in-person practical day. We compared the characteristics and course pass rates between the traditional and modified ATLS courses. RESULTS: Modified ATLS courses had significantly lower pass rates (81.0%; 95% confidence interval = [74.8-87.3]) compared to traditional ATLS courses (94.3%; [92.2-96.3]). CONCLUSIONS: Modifications to the ATLS course are associated with lower student pass. This is possibly due to ineffective knowledge consolidation. Better modifications to the course are required such as use of electronic learning tools with modification to course schedule or returning to the traditional course but with the use of Covid-19 vaccines and other protective measures. These suggestions should be considered and evaluated further by ATLS program leaders.

The POEM bottom-up technique for achalasia.

BACKGROUND: POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique. METHODS: A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied. RESULTS: POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group. CONCLUSIONS: As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.

New Trends in Terrorism-Related Injury Mechanisms: Is There a Difference in Injury Severity?

STUDY OBJECTIVE: The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set. METHODS: This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes. RESULTS: Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks. CONCLUSION: Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention.

Importance: Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion. Objective: To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention. Design, Setting, and Participants: Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015. Main Outcomes and Measures: Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score. Results: Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P < .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P < .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores. Conclusions and Relevance: Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

Combating terror: a new paradigm in student trauma education.

BACKGROUND: Other than the Advanced Trauma Life Support course, usually run for postgraduate trainees, there are few trauma courses available for medical students. It has been shown that trauma teaching for medical students is sadly lacking within the undergraduate curriculum. We stated that students following formal teaching, even just theory and some practice in basic skills significantly improved their management of trauma patients. METHODS: Hadassah-Hebrew University in Israel runs an annual 2-week trauma course for final-year medical students. The focus is on hands-on practice in resuscitation, diagnosis, procedures, and decision making. After engaging a combination of instructional and interactive teaching methods including practice on simulated injuries that students must assess and treat through the 2 weeks, the course culminates in a disaster drill where students work alongside the emergency services to rescue, assess, treat, and transfer patients. The course is evaluated with a written precourse and postcourse test, an Objective Structured Clinical Examination and detailed feedback from the drill. RESULTS: We analyzed student feedback at the end of each course during a 6-year period from 2007 to 2012. Correct answers for the posttest results were higher each year with good reliability as assessed by Chronbach's α and with significant variation from pretest scores assessed using paired-samples t tests. Best scores were achieved in knowledge acquisition and practical skills gained. Students were also asked whether the course contributed to self-preparedness in treating trauma patients, and this consistently achieved high scores. CONCLUSION: We believe that students benefit substantially from the course and gain lasting skills and confidence in trauma management, decision making, and organizational skills. The course provides students with the opportunity to learn and ingrain trauma principles along Advanced Trauma Life Support guidelines and prepares them for practice as safe doctors. We advocate the global implementation of a student trauma training course as a mandatory educational initiative and propose our course format as a model for similar courses.

[Single incision laparoscopic combined cholecystectomy, bilateral salpingo-oophorectomy and omentectomy].

Single Incision Laparoscopic Surgery (SILS) is gaining popularity as a modality in surgery which reduces the number and size of skin incisions. General surgeons and urologists were the first to implement this technique, however, recently gynecologists have also started performing SILS procedures. We present the case of a 70 year old female who underwent a combined SILS procedure which included cholecystectomy, bilateral oophorectomy and omentectomy. The procedure lasted 100 minutes and the patient was discharged home the day after the operation. No operative or post-operative complications were noted. In this case report we present the technical details and demonstrate the collaboration between different disciplines which enables performing this complex and demanding procedure.

Reusable single-port access device shortens operative time and reduces operative costs.

BACKGROUND: In recent years, single-port laparoscopy (SPL) has become an attractive approach for performing surgical procedures. The pitfalls of this approach are technical and financial. Financial concerns are due to the increased cost of dedicated devices and prolonged operating room time. Our aim was to calculate the cost of SPL using a reusable port and instruments in order to evaluate the cost difference between this approach to SPL using the available disposable ports and standard laparoscopy. METHODS: We performed 22 laparoscopic procedures via the SPL approach using a reusable single-port access system and reusable laparoscopic instruments. These included 17 cholecystectomies and five other procedures. Operative time, postoperative length of stay (LOS) and complications were prospectively recorded and were compared with similar data from our SPL database. Student's t test was used for statistical analysis. RESULTS: SPL was successfully performed in all cases. Mean operative time for cholecystectomy was 72 min (range 40-116). Postoperative LOS was not changed from our standard protocols and was 1.1 days for cholecystectomy. The postoperative course was within normal limits for all patients and perioperative morbidity was recorded. Both operative time and length of hospital stay were shorter for the 17 patients who underwent cholecystectomy using a reusable port than for the matched previous 17 SPL cholecystectomies we performed (p < 0.001). Prices of disposable SPL instruments and multiport access devices as well as extraction bags from different manufacturers were used to calculate the cost difference. Operating with a reusable port ended up with an average cost savings of US$388 compared with using disposable ports, and US$240 compared with standard laparoscopy. CONCLUSION: Single-port laparoscopic surgery is a technically challenging and expensive surgical approach. Financial concerns among others have been advocated against this approach; however, we demonstrate herein that using a reusable port and instruments reduces operative time and overall operative costs, even beyond the cost of standard laparoscopy.

Defining the need for blood and blood products transfusion following suicide bombing attacks on a civilian population: a level I single-centre experience.

INTRODUCTION: Knowledge of patterns of blood use in the care of mass casualty settings is important for preparedness of medical centre resources and for maximising survival when blood supplies are limited. Our objectives were to review of our experience with the use of blood products and define the utilisation of blood transfusion following suicide bombing attacks. PATIENTS AND METHODS: We conducted a retrospective analysis of blood and blood product transfusion following civilian bombing attacks at a level I trauma centre in Jerusalem, Israel from 2000 to 2005. The study group consisted of 137 patients who were admitted following 17 suicide bombing attacks which were carried out in Jerusalem during the 5-year period. Demographic data, number of units of blood and blood products transfused and the need for massive transfusions were recorded and analyzed. RESULTS: Fifty-three patients received blood transfusions (38.7%). There were 33 males (62.2%) with a median ISS of 13 (range 4-25). These 53 patients received 524 PRBC, 42 WB, and 449 FFP. The mean number of PRBC transfused/admitted patient was 3.82 units (range 0-59). Thirty patients (21.9%) received 236 PRBC (45% of total PRBC) at the first 2h. The ratio of ordered to transfused blood was 946:524. The FFP:PRBC ratio for all transfused patients was 1:1.17. The number of PRBC transfused per attack correlated with the number of patients admitted per attack. The most commonly transfused blood type was A (52.3%). Only 18 units of uncrossed-matched blood were transfused (3.3% of total). 14 patients (10.2%) received massive transfusions. These patients received 399 PRBC (76.1% of total units transfused) and the average number of PRBC transfused was 28.5/patient (10-59). CONCLUSIONS: More than 1/3 of casualties admitted following civilian bombing attacks received transfusions, most in the first 2h. Large-scale attacks will require more blood and blood products than small-scale attacks. Twice the number of PRBC ordered than transfused reflects a known trend for over-triage during the initial assessment following bombing attacks. One tenth of patients received massive transfusion.

A novel totally internal laparoscopic liver retractor.

INTRODUCTION: Minimally invasive surgery is still in evolution. Throughout the past two decades numerous devices have been developed to enable safer and faster procedures, including anastomosis creating devices, energy sources, and superior imaging. However, retraction capabilities were put aside and currently, organ laparoscopic retraction is based on standard laparoscopic tools. In the era of minimizing the number of ports and shrinking their size, our aim was to develop internal retraction device that could be placed in the peritoneal cavity through a standard trocar, positioned for adequate retraction, and left in place for the entire procedure. These devices would obviate the need for inserting ports dedicated for retraction only and hence contribute to the reduction of the number of incisions. Herein, we present our initial experience with a novel internal liver retractor. MATERIALS AND METHODS: The Endolift retractor is a simple telescopic rod that has anchoring claws at each end. It can be inserted using 5 mm standard trocar using a dedicated applier and anchored to the peritoneum beside the liver edges thereby lifting the undersurface of the liver and exposing the organs underneath. To achieve retraction of the left lateral segment, the Endolift retractor is anchored lateral to the right diaphragmatic crus on 1 side and lateral to the falciform ligament on the other. RESULTS: A total of 14 operations were performed using the Endolift retractor for liver retraction including antireflux procedure, robotic-assisted Heller's myotomy, bariatric procedures, and bile duct exploration. The left lobe of the liver was adequately retracted and enabled access to the operating field. Repositioning was easily performed with progression of the surgery when necessary. CONCLUSIONS: Internal retraction devices such as the Endolift retractor for liver retraction are one step further in minimizing trauma to the abdominal wall during minimal invasive surgery. It obviates the need for extra incisions, frees up the surgeons' hands, and may enable performing complicated laparo-endoscopic single-site laparoscopy and natural orifice transluminal endoscopic surgery.

The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size?

Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure, yet there is no consensus on what bougie size is best for LSG. We reviewed the literature and assessed the relationship between the size of bougie used and the incidence of leak as well as weight loss parameters. We wanted to determine if there is an ideal bougie size for LSG. A search of the medical literature was undertaken. We limited the search to articles published in the last 5 years written in English and investigating humans. We analyzed 32 publications comprising 4,999 patients. We determined the frequency of staple line leaks as well as weight loss parameters in relation to bougie size. This study was exempt from our institutional review board. The use of bougies of 40 French (F) and larger was associated with a leak rate of 0.92% as opposed to 2.67% for smaller bougies (p < 0.05). Weight loss in percent of extra weight loss (%EWL) was 69.2% when a bougie of 40 F and larger was used, as opposed to 60.7% of EWL when smaller bougies were used (p = 0.29). LSG is becoming an important and common procedure. Larger sizing bougies are associated with a significant decrease in incidence of leak with no change in weight loss. Further studies are needed before an unequivocal decision on the optimal bougie size is made. A recommendation to use the smallest bougie possible should be avoided because the risks may outweigh the benefits.

Endovascular management of blunt renal artery trauma.

BACKGROUND: Renal artery injuries are rarely encountered in victims of blunt trauma. However, the rate of early diagnosis of such injuries is increasing due to increased awareness and the liberal use of contrast-enhanced CT. Sporadic case reports have shown the feasibility of endovascular management of blunt renal artery injury. However, no prospective trials or long-term follow-up studies have been reported. OBJECTIVES: To present our experience with endovascular management of blunt renal artery injury, and review the literature. METHODS: We conducted a retrospective study of 18 months at a level 1 trauma center. Search of our electronic database and trauma registry identified three patients with renal artery injury from blunt trauma who were successfully treated endovascularly. Data recorded included the mechanism of injury, time from injury and admission to revascularization, type of endovascular therapy, clinical and imaging outcome, and complications. RESULTS: Mean time from injury to endovascular revascularization was 193 minutes and mean time from admission to revascularization 154 minutes. Stent-assisted angioplasty was used in two cases, while angioplasty alone was performed in a 4 year old boy. A good immediate angiographic result was achieved in all patients. At a mean follow-up of 13 months the treated renal artery was patent in all patients on duplex ultrasound. The mean percentage renal perfusion of the treated kidney at last follow-up was 36% on DTPA renal scan. No early or late complications were encountered. CONCLUSIONS: Endovascular management for blunt renal artery dissection is safe and feasible if an early diagnosis is made. This approach may be expected to replace surgical revascularization in most cases.

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature.

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.