Simulation-Based Training in Cardiac Surgery.

BACKGROUND: Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons. METHODS: Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals. RESULTS: The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean ± two SEs): cardiopulmonary bypass, 4.80 ± 0.12; coronary artery bypass grafting, 4.41 ± 0.19; aortic valve replacement, 4.51 ± 0.20; massive air embolism, 0.68 ± 0.14; acute intraoperative aortic dissection, 4.52 ± 0.17; and sudden deterioration in cardiac function, 4.76 ± 0.16. The transient detrimental effect of time away from training was also evident. CONCLUSIONS: Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons.

Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey.

BACKGROUND: The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience. METHODS: Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated. RESULTS: Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%). CONCLUSIONS: The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management.

Cardiopulmonary bypass simulation at the Boot Camp.

OBJECTIVE: At Boot Camp, we evaluated a modular approach to skills mastery related to cardiopulmonary bypass and crisis scenarios. METHODS: With 32 first-year cardiothoracic surgery residents divided into 4 groups, 4 consecutive hours were devoted to cardiopulmonary bypass skills by using a perfused nonbeating heart model, computer-controlled CPB simulator, and perfused beating heart simulator. Based on the cardiopulmonary bypass simulator, each resident was assessed by using a checklist rating score on cardiopulmonary bypass management and 1 crisis scenario. An overall cardiopulmonary bypass score was determined. Economy of time and thought was assessed (1 = unnecessary/disorganized to 5 = maximum economy). At the end of the session, residents completed a written examination. Residents rated the sessions on cannulation skills, cardiopulmonary bypass knowledge, and cardiopulmonary bypass emergency and crisis scenarios on a 5-point scale (5 = very helpful to 1 = not helpful). RESULTS: Thirty residents completed cardiopulmonary bypass simulator exercises. For initiation and termination of cardiopulmonary bypass, most residents performed the tasks and sequence correctly. Some elements were not performed correctly. For instance, 3 residents did not verify the activated clotting time before cardiopulmonary bypass initiation. Four residents demonstrated inadequate communication with the perfusionist, including lack of assertiveness and unclear commands. In crisis scenarios management of massive air embolism (n = 8) was challenging and resulted in the most errors; poor venous drainage and high arterial line pressure scenarios were managed with fewer errors. For the protamine reaction scenario, all residents (n = 7) identified the problem, but in 3 cases heparin was not redosed before resuming cardiopulmonary bypass for right ventricular failure. The score for economy of time and thought was 3.83 ± 0.6 (range, 3-5). The score of the written examination was 90.0 ± 11.3 (range, 60-100), which did not correlate with the overall cardiopulmonary bypass score of 91.4 ± 7.1 (range, 80-100; r = 0.07). The session on acquiring aortic cannulation skills was rated 4.92, that for cardiopulmonary bypass knowledge was rated 4.96, and that for cardiopulmonary bypass crisis scenarios was rated 4.96. CONCLUSIONS: This Boot Camp session introduced residents early in their training to aortic cannulation, principles and management of cardiopulmonary bypass, and crisis management. Based on a modular approach, technical skills and knowledge of cardiopulmonary bypass can be acquired and assessed by using simulations, but further work with more comprehensive educational modules and practice will accelerate the path to mastery of these critical skills.

Pancreaticopleural fistula: a rare thoracic complication of pancreatic duct disruption.

Pancreaticopleural fistula resulting in a chronic pleural effusion is a rare complication of pancreatic duct disruption. We describe the presentation and management of 2 children with pancreaticopleural fistulas. Pleural fluid amylase concentration and contrast computed tomography were sufficient to establish the diagnosis in both cases. The initial management of these fistulas should be conservative, by tube thoracostomy and suppression of pancreatic secretion. Operative treatment is necessary for those who fail to resolve. Complete diversion of the pancreatic juice into the gastrointestinal tract by longitudinal pancreaticojejunostomy has been an effective surgical option leading to fistula closure.

A high fidelity tissue-based cardiac surgical simulator.

OBJECTIVE: Issues concerning the training and certification of surgical specialists have taken on great significance in the last decade. A realistic computer-assisted, tissue-based simulator developed for use in the training of cardiac surgical residents in the conduct of a variety of cardiac surgical procedures in a low-volume cardiothoracic surgery unit of a typical developing country is described. The simulator can also be used to demonstrate the function of technology specific to cardiac surgical procedures in a way that previously has only been possible via the conduct of a procedure on a live animal or human being. METHODS: A porcine heart in a novel simulated operating theatre environment with real-time simulated haemodynamic monitoring and coronary blood flow, in arrested and beating-heart modes, is used as a training tool for surgical residents. RESULTS: Standard and beating-heart coronary arterial bypass, aortic valve replacement, aortic homograft replacement and pulmonary autograft procedures can be simulated with high degrees of realism and with the superimposition of adverse clinical scenarios requiring valid decision making and clinical judgments to be made by the trainees. CONCLUSIONS: The cardiac surgical simulation preparation described here would appear to be able to contribute positively to the training of residents in low-volume centres, as well as having the potential for application in other settings as a training tool or clinical skills assessment or accreditation device. Collaboration with larger centres is recommended in order to accurately assess the utility of this preparation as an adjunctive cardiothoracic surgical training aid.

Struma cordis in a Jamaican woman.

A case of ectopic thyroid within the right ventricle (struma cordis) occurring in a middle-aged Jamaican woman is described. This rare and fascinating condition is curable utilizing standard open-heart surgical techniques. Investigations to rule out primary thyroid or ovarian malignancy, as well as the presence of remaining normal thyroid tissue or other ectopic thyroid rests are important in the management of these patients.

Thoracic endometriosis syndrome in Jamaica.

Thoracic endometriosis syndrome (TES) is a rare presentation of systemic endometriosis. An unusual cluster of patients from the Caribbean who were treated at a single hospital during the year 2001 is presented. All patients were managed surgically in the acute phase, with satisfactory results. The etiology and management of TES has been controversial. A therapeutic approach that includes aggressive surgery to obliterate the pleural space combined with a course of hormonal suppression offers the best chance of cure for these patients.

Surgery for patent ductus arteriosus

The surgical treatment of Patent Ductus Arteriosus (PDA) at the University Hospital of the West Indies, Kingston, Jamaica was examined over an eight-year period. The results of standard surgical modalities were comparable to large published series. A review of the literature regarding the treatment options for PDA does not support a change in management strategy in favour of non-surgical methods. The treatment of PDA at this centre has shown excellent long-term results, with miminal mortality and morbidity.(Au)

Penetrating Injury to the great vessels: case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.

Penetrating Injury to the Great Vessels: Case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.(AU)

Emergency bypass without bypass

We present 2 cases of failed coronary angioplasty, with hemodynamic compromise, where emergengy coronary artery bypass. The hypodynamic nature of the stunned myocardium in this circumstance allow this technique to be applied with relative ease to accessible vessels. As a consequence, reduced morbidity and hospital stay can be anticipated.{AU}

Childhood portal hypertension in Jamaica

Portal hypertension and bleeding from oesophageal varices in children remain a difficult medical problem. The clinical course and management of children with portal hypertension seen over a 14-year period was reviewed. There were 5 females and 2 males with a mean age of 3.6 years at presentation. Five patients presented with severe upper gastrointestinal bleeding and two with severe hypersplenism. All patients had extra-hepatic portal hypertension. Five patients were treated with endoscopic sclerotherapy, including one who had bleeding five years post-splenectomy. A mean of 9 sclerotherapy sessions was performed in each patient. Complete obliteration of varices was not achived in any patient and a single rebleeding episode occurred in four. Three children underwent operative management consisting of splenectomy in two and splenectomy and central spleno-renal shunt in one. There was no mortality in either group after a mean follow-up of 4.3 years. Sclerotherapy may not be totally successful in long-term management of childhood portal hypertension. Surgical therapy or a combination of sclerotherapy and surgery may be the best approach

Childhood portal hypertension in Jamaica

Portal hypertension and bleeding from oesophageal varices in children remain a difficult medical problem. The clinical course and management of children with portal hypertension seen over a 14-year period was reviewed. There were 5 females and 2 males with a mean age of 3.6 years at presentation. Five patients presented with severe upper gastrointestinal bleeding and two with severe hypersplenism. All patients had extra-hepatic portal hypertension. Five patients were treated with endoscopic sclerotherapy, including one who had bleeding five years post-splenectomy. A mean of 9 sclerotherapy sessions was performed in each patient. Complete obliteration of varices was not achived in any patient and a single rebleeding episode occurred in four. Three children underwent operative management consisting of splenectomy in two and splenectomy and central spleno-renal shunt in one. There was no mortality in either group after a mean follow-up of 4.3 years. Sclerotherapy may not be totally successful in long-term management of childhood portal hypertension. Surgical therapy or a combination of sclerotherapy and surgery may be the best approach (AU)

The nature of interpersonal violence in Jamaica and its strain on the national health system

A random prospective study of 640 victims (76.6 percent) in the 15-39-year-old age group) of interpersonal violence (IPV) at the Kingston Public Hospital was conducted over three months. About 87.5 percent of the aggression on males and 74.5 percent on females was committed by males. However, there was more female/female than female/male violence. Weapons used ranged from guns to a variety of cooking wares, though knives were used most frequently (34.8 percent) for stabbing 48 percent of the victims. Head, neck and upper limb were the main sites of injury; only 13.4 percent of all the injured had complications, and 63 percent of these required hospitalization. Family members and acquaintances contributed to about 84 percent of the violence. Instinctive spontaneous aggression aimed at maiming the victim characterizes IPV in Jamaica. The Jamaican taxpayer bears 90-94 percent of the cost of managing trauma injuries. These costs should be recovered from the assailants, even in the form of blood donations and community service. (AU)