The simulated Trauma Patient Teaching Module--does it improve student performance?

BACKGROUND: Student feedback from the old TEAM (Trauma Evaluation and Management) program prompted introduction of simulated trauma patient models in the new program. Performance after the new and old programs was compared to assess the impact of the simulated patient models. METHODS: Final year medical students randomly assigned to control and experimental groups completed a 20-item trauma multiple choice questionnaire examination (MCQE). The experimental groups attended the old or new TEAM program before completing a second MCQE and the control groups completed the same post-test without the TEAM programs. We used paired t tests for within and unpaired t tests for between group comparisons of the control and experimental groups' performances on the MCQ pre- and post-tests. On a 1 to 5 scale, students graded if objectives were met; trauma knowledge improved; trauma skills improved; overall satisfaction; and if TEAM should be mandatory. RESULTS: Post-test scores increased significantly after both the old and new programs but the increase was statistically significantly greater after the new program. In the old TEAM, 51.6% rated improvement in trauma skills at 4 or greater compared with 97.3% in the new program. A large percentage of students in the old program requested more hands-on teaching. Of students, 85% scored honors pass mark after completion of the new TEAM format, and no honors pass marks were achieved after completion of the old TEAM format. CONCLUSION: Simulated trauma patient models were rated highly and improved both trauma skills and knowledge. Wider application of these teaching models is suggested.

Surgically treated cerebral aneurysms in south Trinidad: twenty years experience 1986-2005.

INTRODUCTION: For many years the treatment of cerebral aneurysms was surgical - clipping or wrapping. In recent years however, interventional radiology is available with techniques of coiling and stenting. The current treatment of any aneurysm is based on a combination of interventional and surgical techniques and in many cases the final treatment is interventional. It may be useful to document surgically treated aneurysms at San Fernando General Hospital serving a population area of half million in south Trinidad in the twenty years 1986-2005 before the advent of interventional radiology in Trinidad which became available in late 2005

Transsphenoidal pituitary tumour surgery in Trinidad and Tobago - Poster abstract

OBJECTIVE: To determine whether the transsphenoidal approach for pituitary tumours is advantageous over the traditional transcranial approach. DESIGN andMETHODS: Retrospective analysis of consecutive patients who underwent transsphenoidal (TS) and transcranial (TC) procedures for pituitary tumor during January 1998 to September 1999. Age, gender, presenting symptoms, preoperative findings, endocrine and imaging studies, operative procedure, complications,outcome, hospital stay, cost and patient satisfaction were recorded and analyzed. RESULTS: There was atotal of 15 cases (8 TS and 7 TC). The male to female ratio was 1:2, with an age range 10 to 71 years.All presented with visual impairment, 10 with headaches and 5 with hyperprolactinaemia. Average operative time for TS procedure was 2 hr 55 min and for TC, 2 hr 12 min. Average hospital stay for TS cases was 5.3 days whereas TC patients stayed for 5.7 days. Average cost of hospitalization (excluding fees for the surgeons and anaesthetists) for TS patients was significantly lower than for the TC patients (p<0.001). Patient satisfaction mean index for TS cases was 4.125 while it was 3.71 for TC cases. Three TS patients had excellent satisfaction. There were no mortalities. CONCLUSION: The TS approach has certain advantages compared to the TC approach in the management of pituitary tumors. TS approach is recommended in selected cases in our setting in Trinadad and Tobago. (Au)

Spinal injury in South Trinidad - rationale for a spinal unit - Pster abstract

OBJECTIVE: To determine the quantum and patterns of serious spinal injury in a population of half a million persons in South Trinidad and to determine if there is a need for a spinal unit. DESIGN and METHOD: Charts of all cases of serious spinal injury from January 1991 to December 1995 were reviewed and data collected on demographic and injury details, neurologic deficit, admitting and managing units, management, complications, duration of stay and outcome. RESULTS: There were 160 cases mainly in the third to fifth decades, male:female 3:1. Labourers outnumbered sedentary workers 2:1 and more than 1/3 fell from heights. Injuries were in the lumbo-sacral spine (50 percent), cervical (33 percent) and thoracic (25 percent) areas. Neurologic deficit was present in 38 cases and 16 other had potentially disabling injuries. The majority (112) were admitted to orthopaedics; 26 to general surgery and 37 cases were referred to neurosurgery and 32 cases were managed jointly by orthopaedics and neurosurgery. Management was by cervical collars, calipers 5, Minerva jackets 10, plaster jackets 88 and surgical treatment 17. Complication were mainly pressure sores and urinary tract infections. Mortality was 5, all quadriplegic. Hospital stay averaged 21.5 days. CONCLUSIONS: In South Trinadad from 1991-1995 a total of 54 cases of spinal injury had neurological deficit or potentially disabling injury and might have benefited from a spinal unit with joints management by specialists in several disciplines including nurses, technicians and social workers. A unit of 4-6 beds may be appropriate. (Au)

Comparison of performance of interns completing the old (1993) and new interactive (1997) Advanced Trauma Life Support courses

BACKGROUND: The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as its major change. The impact of this change is assessed in this study. METHODS: We compared two matched groups of 16 interns completing either the old (group I) or new (group II) ATLS course. Cognitive skills (40 standard ATLS questions plus 10 additional questions on airway and shock) and clinical trauma management skills (four trauma objective structured clinical examinations [OSCEs] on simulated trauma patients) were tested. OSCE station scores (standardized to a maximum of 20), priority scores (graded 1-7), organized approach global passing grades (graded 1-5), and initial assessment test station scores (graded 1-5) were compared. RESULTS: Using ATLS criteria, three interns failed in each group. Post-ATLS examination quesiton scores were similar (84.5 +/- 6.9 for group I, 85.9 +/- 7.1 for group II); scores for the airway and shock questions were higher but not different between the two groups. The four OSCE station mean scores varied between 13.9 +/- 2.0 and 15.4 +/- 2.1 for group I and were higher (P < 0.05) for group II (17.9 +/- 1.6 to 19.1 +/- 1.0). Priority scores were similar (group I, 6.3 +/- 1.1; group II, 6.4+/- 1.2), but approach scores (3.9 +/- 0.1 for group I and 4.9 +/- 0.8 for group II). There were 8 honors grades in group I and 40 (p < 0.05) in group II. Interactive teaching, adult education principles, opportunities for discussion, provision of feedback, and stimulation of self-learning were rated more highly in the new course. CONCLUSION: Using standard ATLS pass criteria, performance after the new and old ATLS courses was similar. Superior performances were measured using OSCE methodology for clinical trauma management skills after the new compared with the old ATLS course in this population of interns.(Au)

Effect of basic prehospital trauma life support program on cognitive and trauma management skills

We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45 +/- 9.4 percent vs. 48.4 +/- 8.9 percent for groups I and II respectively), but the post-PHTLS scores were higher in group I (80.4 +/- 5.9 percent) than in group II (52.6 +/- 4.9 percent). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group II (range 8.0 - 11.1). The overall mean pre-PHTLS score for all four stations was 8.3 +/- 2.1 for group I and 8.8 +/- 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 +/- 2.7 (p < 0.05) compared to 9.1 +/- 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 +/- 0.9 for group I and 1.2 +/- 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 +/- 1.1. Group II (1.1 +/- 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 +/- 1.0 for group I and 1.9 +/- 1.2 for group II (NS) compared to 4.2 +/- 0.9 (p < 0.05) in group I and 2.0 +/- 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.(Au)

Impact of the prehospital trauma life support programme in Trinidad and Tobago

The impact of the Prehospital Trauma Life Support (PHTLS) programme, introduced in Trinidad and Tobago in 1992, was assessed by questionnaires completed by 26 medical personnel (MP); 71 ambulance personnel (AP); and 50 non ambulance paramedical personnel (NAP). Of the 23 MP, 45 AP and 38 NAP who were aware of the programme, 19 (82.6 percent) MP, 40(88.9 percent) AP and 25 (65.8 percent) NAP were able to differentiate personnel that had taken the PHTLS programme based on their performance. 32 (71.1 percent) of the AP were PHTLS trained. 24 (53.3 percent) and 4 (9 percent) of the AP identified poor equipment and poor supervision, respectively, as reasons for difficulty in applying PHTLS principles. Improvements observed among those completing the PHTLS programme were: improved resuscitation techniques by 20 (86.9 percent) MP, 38 (84.4 percent) AP and 27 (71.1 percent) NAP; better vital signs recording by 8 (34.8 percent) MP, 27 (60 percent) AP and 8 (21.1 percent) NAP; improved immobilization by 23 (100 percent) MP, 40 (88.9 percent) AP and 33 (86.8 percent) NAP: better haemorrhage control by 22 (95.6 percent) MP, 40 (88.9 percent) AP and 24 (63.2 percent) NAP; appropriate splinting of fractures by 23 (100 percent) MP, 40 (88.9 percent) AP and 32 (84.2 percent) NAP: and increased utilization of oxygen by 15 (65.2 percent) MP, 31 (68.9 percent) AP and 21 (55.3 percent) NAP. 32 (71.1 percent) AP with PHTLS training indicated improvement in their ability to resuscitate and transport trauma victims, with 42 (93.3 percent) reporting improvement in overall prehospital care. Medical, paramedical and ambulance personnel all perceive a significant positive impact of PHTLS training on prehospital trauma care. Although improvements in supervision, documentation and equipment are still required, improved trauma resuscitative techniques after PHTLS training should improve trauma patient outcome in Trinidad and Tobago. (AU)

Improving trauma care in Trinidad and Tobago

Indentification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago. (AU)

Improving trauma care in Trinidad and Tobago

Indentification of trauma as a major cause of morbidity and mortality in Trinidad and Tobago prompted the establishment of a training programme aimed at improving trauma care in this developing country. An Advanced Trauma Life Support (ATLS) programme for physicians, funded through the Canadian International Development Agency resulted in a statistically significant improvement of in-hospital trauma patient outcome at the Port-of-Spain General Hospital (observed to expected mortality ratio of 3.16 pre-ATLS compared to 1.94 post ATLS). A recent analysis of all motor vehicle injuries for a shorter period did not confirm this positive impact of the ATLS programme, primarily because a large number of these patients died in the pre-hospital period. Pre-hospital trauma care therefore required urgent attention to complement the positive in-hospital impact of the ATLS programme. A second training programme (the Pre-Hospital Trauma Life Support or PHTLS) for paramedical personnel was thus instituted in 1990. Over 250 physicians have been trained in the ATLS programme and to date over 100 paramedical personnel have been trained in the PHTLS programme. Attempts have also been made to equip the ambulances with more appropriate resuscitative devices in order to improve pre-hospital care. The combination of the PHTLS and the ATLS programme should result in further improvement in the care of patients sustaining major injuries in Trinidad and Tobago.

Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country

Over a 9-year period (July 1981-December 1985--pre-ATLS period; January 1986-June 1990-post-ATLS period), the hospital charts of 813 trauma patients with ISS > or = 16 were reviewed (n = 413, pre-ATLS and n = 400, post-ATLS) in order to assess the impact of the ATLS program. The freqeuncy of endotracheal intubation (ET), nasogastric tube insertion (NG), intravenous access(i.V.), Foley catheterization of the bladder (Foley) and chest tube insertion (CT) were compared by Pearson Chi-square analysis. Overall, pre-ATLS vs. post-ATLS frequencies ( percent) were 83.5 vs. 65.3 for ET, 97.3 vs 98.0 for i.v., 74.6 vs. 96.3 for Foley, 68.3 vs. 91.3 for NG, and 18.4 vs. 47.0 for CT. In the emergency room these frequencies ( percent) were 26.1 vs. 36.4 for ET, 98.8 vs. 98.7 for i.v., 11.0 vs. 97.1 for Foley 3.2 vs. 95.9 for NG, and 3.9 vs for CT. The differences in the application of these life saving procedures between the pre-ATLS and the post ATLS periods were statistically significant (p < 0.05) except i.v. access, which showed no difference between the pre-ATLS and post-ATLS groups. Of the patientys with severe chest injuries (AIS > or = 3) 87.7 percent and chest tubes post ATLS (94.4 percent in ER) compared with 48>1 percent pre ATLS (3.2 percent in ER). These differences were associated with significant improvement in trauma patient outcome post ATLS. We conclude that the frequency of lifesaving interventions, particularly in the ER, was increased post ATLS (AU Truncated at 250 words)

Fat embolism in Trinidad and Tobago - abstract

The fat embolism syndrome is under-diagnosed because of low suspicion and this study was done to increase physician awareness and improve management. In the 6 years, 1984-1989 at San Fernando General Hospital, Trinidad, there were 10 cases - 1,2,2,1,1 and 3 in the years, respectively. Six were in the 3rd decade and all male, motor vehicle accidents accounted for 9 and a fall for one. There was poor attention to on-site immobilisation and sometimes delay in patients' transfer to hospital. Diagnosis was usually made on the 2nd or 3rd day. Eight patients had femoral fractures, one a bilateral, one a tibial and one a radial fracture. Soft tissue injury was common. Symptoms were alteration in level of consciousness in 9 with progression to coma in 3. Four had respiratory distress, 8 had conjunctival petechial haemorrhages, 3 respiratory crepitations and rhonchi and 2 tachycardia. Six had elevated temperature profile and gm/100ml haemoglobin was less than 10 and haematocrit less than 30 ml/100 ml in 4. Platelet count was normal in 6 tested. Treatment was with oxygen, antibiotics and steroids (Decadron or hydrocortisone), plaster immobilisation of the tibia and radius, skeletal traction in the 6 with femoral fractures and internal Kuntschner (K-nail) fixation was done in 5 at 12-19 days post injury. One had early K-nail at 12 hours post surgery. Nine showed complete recovery; however, complications of respiratory distress, siezures and renal failure resulted in one mortality. Sufficient facilities for arterial blood gasses and other parameters were not available for diagnosis and monitoring treatment. Treatment outcome was good because of aggressive management of oxygen, antibiotics and steriods. Long bone fractures need to be fixed early to reduce the incidence of fat embolism (AU)

Heredofamilial neurological syndromes in Trinidad and Tobago - abstract

The only report in the literature of heredofamilial neurological syndromes (HNS) in Trinidad and Tobago was Beaubrun's study of Huntington's chorea (Beaubrun, 1965). This study of HNS in Trinidad and Tobago comprised all patients seen at the Port-of-Spain General Hospital (1980 - mid 1985), the San Fernando General Hospital (mid 1985 - 1989), together with those seen in private practice. The diagnosis and genealogy were verified. A wide variety of HNS was encountered and included amyotrophic lateral sclerosis [4 cases in 2 generations] olivopontocerebellar degeneration [9 in 3 generations], multiple sclerosis [2 in 2 generations], neurofibromatosis [3 in 3 generations], Crouzon's syndrome [2 in 3 generations], biparietal foramina [17 in 3 generations], a neurological syndrome referred to as "ptosis plus syndrome" [9 in 3 generations] and familial tremor [4 in 2 generations]. In addition there were 2 siblings each with cerebral gliomas and intracranial meningioma with familial occurrence of seizures, many cases of carpal tunnel syndrome in 1 family, and familial cases of Huntington's chorea. Mode of genetic transmission seemed to be autosomal dominant in all pedigrees, sometimes with incomplete penetrance or expressivity (AU)

A neurosurgical profile - abstract

Neurosurgical disease patterns, trends and workload in a hospital with 30 years' neurosurgical experience, serving a population of 1/3 milion were studied to assess, provide guidelines for more cost-effective patient care and to provide data for the development of neurosurgical facilities in developing areas. At the San Fernando General hospital, Trinidad, 1979-1988, there was a general increase in total hospital admissions (approximately 48,000/yr), neurosurgical admissions (73 to 161/yr), transfers to the neurosurgical unit (39 to 76/yr), new clinic patients (170 to 269/yr), consultations (181 to 351/yr), neuro-radiological procedures (44 to 105/yr), and surgical procedures (32 to 140 yr). There was an increase in bed occupancy rate (68 percent to 87 percent) and a reduction in the length of stay per patient (16 to 11 days), and in deaths (from a peak of 20 to 13/yr). There was a decrease in invasive studies with the advent of computerized axial tomographic scanning and magnetic resonance imaging, and myelograms showed a sharp rise due in part to newer water soluble contrast media. Surgical procedures showed a trend to more definite cranial surgery with a sharp rise in spinal surgery - laminectomy. There was and increase in the relative value score and factor which take case complesity into consideration. The commonest condition was head trauma followed by cervical spondylosis, brain tumours, seizures, spinal fractures, herniated lumbar disc, hydrocephalus and congenital anomalies and spinal tumours (AU)

Computerised axial tomography and magnetic resonance imaging bridging the gap - abstract

Since 1983, computerised axial tomography (CAT) has been the mainstay of neurological imaging in Trinidad and Tobago. In 1988, magnetic resonance imaging (MRI) became available in nearby South America. This study was done to examine the capabilities, limitations and pitfalls of CAT scanning and to provide guidelines for patients referral for MRI. The most recent 2,000 head and 68 body CAT scans performed from 1984 to 1988 were reviewed. Abnormalities were seen in 759 (38 percent) of head scans: tumours 262 (34.5 percent), cerebral atrophy 128 (17 percent), ischaemic infarcts 121 (16 percent), intracranial haemorrhage 105 (14 percent), hydrocephalus 42 (5.5 percent), traumatic cerebral contusions 40 (5 percent), infection 36 (5 percent) and vascular malformations 14 (2 percent). Abnormalities were seen in 45 (66 percent) body scans: spinal lesions 20 (44 percent), and lesions of the pancreas 8, liver 8, kidneys 4, adrenals 2, and 1 each in the lung, oesophagus and spleen. CAT scanning, however, was sometimes unable to resolve diagnostic dilemmas, and in 1988, 32 patients were referred for 22 head and 10 spine MRI studies. MRI head abnormalities were tumours 4, absceses 3 (1 in the brain stem), and 1 each of subdural haematoma, demyelinating disease and hydrocephalus. There were 12 normal head MRI studies. MRI spine abnormalities (7) were lumbar disc herination, cervical spondylosis 2, and syringomyelia 1, and 3 studies were normal. CAT scan limitations were most apparent with bone artefacts in the posterior and temporal fossae and the pituitary region, isodense subdural collections, differentiating enhancing infarcts from tumour and in demyelinating disease. MRI did not have these limitations and had the advantage of direct multiplanar (coronal and sagittal) imaging, superior tissue type differentiation, no ionizing radiation or allergenic contrast media. MRI is especially useful in imaging pituitary, parasellar and brain stem lesions, the spine and spinal cord, the heart, abdominal viscera, and joints. Its realtive disadvantages include slower scan times, danger to patients with indwelling ferromagnetic material, claustrophobia and higher equipment cost (AU)

The role of water-soluble contrast myelography implications for the Caribbean - abstract

Since 1985, water-soluble contrast medium has been used for myelography in Trinidad; it has distinct advantages over the traditional oily medium. It is rapidly excreted in the urine so that it does not need removal. A smaller (20-22 gauge) spinal needle is used; less trauma causes less CSF leakage and hence less post-spinal headache. The needle is removed after contrast injection, allowing easier patient manipulation. The low viscosity contrast also gives a better view of the thecal sac, spinal cord and nerve roots; further, it can traverse a lesion enabling both cephalad and caudal margin delineation. Fluoroscopy is not absolutely necessary as the 5-30 degree head up postero-anterior and obliques show a lumber lesion. Further, it can be used as an outpatient procedure and allows for enhanced CT scanning. There were 57 cases in the 3 years from 1985 to 1987 (7, 15, 35): 30 at San Fernando, 12 at Port-of-Spain and 15 in private clinics. The 36 males and 21 females were aged 23 to 62 years; 54 had low-back syndrome, 2 suspected thoracic and the other suspected cervical lesions. Metrizamide (Amipaque) was used in 44 cases and Iohexo (Omnipaque) in 13. Visualization was good to excellent in all cases. Complications were headaches in 3, vomiting in 1 and seizures in another. In the latter patient, the contrast passed intracranially during the Trendelenburg tilting for thoracic visualisation. Twice some contrast was injected epidurally without complication. However, this comprised visualisation. Extreme care was taken in proper patient hydration, gentle motion in the procedure and the 15-30 degree head up position for 24 hours post-myelogram. There is advantageous ease of performance, rarity of complications, outpatient performance and lack of necessity for fluoroscopy in areas where this is not available. It is advised for use in developing territories where the common problem of back pain and suspected lower spinal lesions can be more easily investigates (AU)