An Informed Consent Program Enhances Surgery Resident Education.

OBJECTIVE: First-year residents often obtain informed consent from patients. However, they typically receive no formal training in this area before residency. We wished to determine whether an educational program would improve residents' comfort with this process. DESIGN: Our institution created an informed consent educational program, which included a didactic component, a role-play about informed consent, and a simulation exercise using standardized patients. Residents completed surveys before and after the intervention, and responses to survey questions were compared using the signed-rank test. SETTING: This study took place at Temple University Hospital, a tertiary care institution in Philadelphia, PA. PARTICIPANTS: First-year surgery and emergency medicine residents at Temple University Hospital in 2014 participated in this study. Thirty-two residents completed the preintervention survey and 27 residents completed the educational program and postintervention survey. RESULTS: Only 37.5% had ever received formal training in informed consent before residency. After participating in the educational program, residents were significantly more confident that they could correctly describe the process of informed consent, properly fill out a procedure consent form, and properly obtain informed consent from a patient. Their comfort level in obtaining informed consent significantly increased. They found the educational program to be very effective in improving their knowledge and comfort level in obtaining informed consent. In all, 100% (N = 27) of residents said they would recommend the use of the program with other first-year residents. CONCLUSIONS: Residents became more confident in their ability to obtain informed consent after participating in an educational program that included didactic, role-play, and patient simulation elements.

"Permissive hypoventilation" in a swine model of hemorrhagic shock.

BACKGROUND: Many penetrating trauma patients in severe hemorrhagic shock receive positive pressure ventilation (PPV) upon transport to definitive care, either by intubation (INT) or bag-valve mask (BVM). Using a swine hemorrhagic shock model that simulates penetrating trauma, we proposed that severely injured patients may have better outcomes with "permissive hypoventilation," where manual breaths are not given and oxygen is administrated passively via face mask (FM). We hypothesized that PPV has harmful physiologic effects in severe low-flow states and that permissive hypoventilation would result in better outcomes. METHODS: The carotid arteries of Yorkshire pigs were cannulated with a 14-gauge catheter. One group of animals (n = 6) was intubated and manually ventilated, a second received PPV via BVM (n = 7), and a third group received 100% oxygen via FM (n = 6). After placement of a Swan-Ganz catheter, the carotid catheters were opened, and the animals were exsanguinated. The primary end point was time until death. Secondary end points included central venous pressure, cardiac output, lactate levels, serum creatinine, CO2 levels, and pH measured in 10-minute intervals. RESULTS: Average survival time in the FM group (50.0 minutes) was not different from the INT (51.1 minutes) and BVM groups (48.5 minutes) (p = 0.84). Central venous pressure was higher in the FM group as compared with the INT 10 minutes into the shock phase (8.3 mm Hg vs. 5.2 mm Hg, p = 0.04). Drop in cardiac output (p < 0.001) and increase in lactate (p < 0.05) was worse in both PPV groups throughout the shock phase. Creatinine levels were higher in both PPV groups (p = 0.04). The FM group was more hypercarbic and acidotic than the two PPV groups during the shock phase (p < 0.001). CONCLUSION: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

Examining prehospital intubation for penetrating trauma in a swine hemorrhagic shock model.

BACKGROUND: Prehospital intubation does not result in a survival advantage in patients experiencing penetrating trauma, yet resistance to immediate transportation to facilitate access to definitive care remains. An animal model was developed to determine whether intubation provides a survival advantage during severe hemorrhagic shock. We hypothesized that intubation would not provide a survival advantage in potentially lethal hemorrhage. METHODS: After starting a propofol drip, Yorkshire pigs were intubated (n = 6) or given bag-valve mask ventilation (n = 7) using 100% oxygen. The carotid artery was cannulated with a 14-gauge catheter, and a Swan-Ganz catheter was placed under fluoroscopy using a central venous introducer. After obtaining baseline hemodynamic and laboratory data, the animals were exsanguinated through the carotid line until death. The primary end point was time until death, while secondary end points included volume of blood shed, temperature, cardiac index, mean arterial pressure, lactic acid, base excess, and creatinine levels measured in 10-minute intervals. RESULTS: There was no difference in time until death between the two groups (51.1 [2.5] minutes vs. 48.5 [2.4] minutes, p = 0.52). Intubated animals had greater volume of blood shed at 30 minutes (33.6 [4.4] mL/kg vs. 28.5 [4.3] mL/kg, p = 0.03), 40 minutes (41.7 [4.7] mL/kg vs. 34.9 [3.8] mL/kg, p = 0.04), and 50 minutes (49.2 [8.6] mL/kg vs. 40.2 [1.0] mL/kg, p = 0.001). In addition, the intubated animals were more hypothermic at 40 minutes (35.5°C [0.4°C] vs. 36.7°C [0.2°C], p = 0.01) and had higher lactate levels (2.4 [0.1] mmol/L vs. 1.8 [0.4] mmol/L, p = 0.04) at 10 minutes. Cardiac index (p = 0.66), mean arterial pressure (p = 0.69), base excess (p = 0.14), and creatinine levels (p = 0.37) were not different throughout the shock phase. CONCLUSION: Intubation does not convey a survival advantage in this model of severe hemorrhagic shock. Furthermore, intubation in the setting of severe hemorrhagic shock may result in a more profuse hemorrhage, worse hypothermia, and higher lactate when compared with bag-valve mask ventilation.

Still making the case against prehospital intubation: a rat hemorrhagic shock model.

BACKGROUND: Prehospital intubation does not appear to result in a survival advantage for patients experiencing penetrating trauma; yet, there is still resistance to the practice of "scoop and run" to speed access to advanced care. An animal model was used to determine whether intubation provides a survival advantage during potentially lethal hemorrhage. METHODS: The carotid arteries of Sprague-Dawley rats were cannulated, and mean arterial pressure (MAP) was measured. One group of animals (n = 10) was intubated and placed on a ventilator, whereas the other (n = 9) was administered with 100% oxygen via nose cone. Rats were exsanguinated to a MAP of 40 mm Hg and then bled periodically to maintain a MAP between 40 mm Hg and 45 mm Hg. The primary end-point was time until death. Secondary end-points included lactic acid and base excess levels measured in blood collected at 30-minute intervals after inducing shock. RESULTS: There was no significant difference in time until death between the intubated and nose cone groups (85.5 vs. 93.3 minutes, p = 0.60). Intubated animals had higher lactic acid levels at 90 minutes (6.1 vs. 3.5 mmol/L; p = 0.02) and 120 minutes (7.7 vs. 2.6 mmol/L, p = 0.03) after the initiation of shock. In addition, intubated animals had worse base excess at 90 minutes (-13.5 vs. -7.9 mmol/L, p = 0.04). CONCLUSION: Intubation does not result in a survival advantage in this rat model of hemorrhagic shock. Positive pressure ventilation may cause decreased venous return and accentuate end-organ hypoperfusion. Large animal studies are needed to further investigate these findings.

A cost-effective approach to establishing a surgical skills laboratory.

BACKGROUND: Recent studies comparing inexpensive low-fidelity box trainers to expensive computer-based virtual reality systems demonstrate similar acquisition of surgical skills and transferability to the clinical setting. With new mandates emerging that all surgical residency programs have access to a surgical skills laboratory, we describe our cost-effective approach to teaching basic and advanced open and laparoscopic skills utilizing inexpensive bench models, box trainers, and animate models. METHODS: Open models (basic skills, bowel anastomosis, vascular anastomosis, trauma skills) and laparoscopic models (basic skills, cholecystectomy, Nissen fundoplication, suturing and knot tying, advanced in vivo skills) are constructed using a combination of materials found in our surgical research laboratories, retail stores, or donated by industry. Expired surgical materials are obtained from our hospital operating room and animal organs from food-processing plants. In vivo models are performed in an approved research facility. Operation, maintenance, and administration of the surgical skills laboratory are coordinated by a salaried manager, and instruction is the responsibility of all surgical faculty from our institution. RESULTS: Overall, the cost analyses of our initial startup costs and operational expenditures over a 3-year period revealed a progressive decrease in yearly cost per resident (2002-2003, $1,151; 2003-2004, $1,049; and 2004-2005, $982). CONCLUSIONS: Our approach to surgical skills education can serve as a template for any surgery program with limited financial resources.

Successful collaborative model for trauma skills training of surgical and emergency medicine residents in a laboratory setting.

OBJECTIVES: To determine whether interdepartmental educational and technical resources could be combined to successfully train surgery and emergency medicine residents in common diagnostic and therapeutic trauma skills outside the traditional hospital setting. DESIGN: Curriculum improvement survey. SETTING: Surgical Skills Laboratory, Temple University School of Medicine, Philadelphia, Pennsylvania. PARTICIPANTS: A total of 35 surgery residents (PGY 1 to 5) and 26 emergency medicine residents (PGY 1 to 3). METHODS: Emergency medicine attendings used human volunteers to train surgery residents in Focused Assessment with Sonography in Trauma (FAST). Trauma surgery attendings used a porcine model to teach emergency medicine residents tracheostomy, peripheral venous cutdown, diagnostic peritoneal lavage, tube thoracostomy, and bilateral thoracotomy. Upon completion of the courses, all residents were surveyed using a 5-point Likert scale to assess this teaching model. RESULTS: The percentage of residents reporting an improvement in knowledge levels after the course increased significantly (p < 0.003) for all skill modules (FAST, 14% vs 73%; tracheostomy, 20% vs 64%; peripheral venous cutdown, 25% vs 71%; diagnostic peritoneal lavage, 16% vs 60%; tube thoracostomy, 42% vs 92%; thoracotomy, 15% vs 42%). A significant (p < 0.05) increase in comfort levels during performance of the procedures in the clinical setting was also anticipated for all skills modules (FAST, 11% vs 60%; tracheostomy, 12% vs 50%; peripheral venous cutdown, 15% vs 31%; diagnostic peritoneal lavage, 12% vs 58%; tube thoracostomy, 35% vs 73%; thoracotomy, 0% vs 15%). PGY 1 to 4 surgery residents and PGY 1 and 2 emergency medicine residents perceived the greatest benefit (p < 0.05) from their respective courses. The overwhelming majority (89% to 100%) of surgery and emergency medicine residents felt the course was valuable and transferable to the clinical trauma setting. CONCLUSIONS: Interdepartmental collaboration between the Department of Surgery and Department of Emergency Medicine offered a unique training relationship that was a positive educational experience for all residents.