Damage-control vascular surgery in Canada: supporting surgeons and teams.

SummaryIn Canada, trauma patients often present initially to non-trauma hospitals without vascular surgeons on site. Local surgeons need skills and support for damage-control vascular surgery. Canadian training programs in general surgery should equip trainees with skills in this area, including resuscitation, identification of vascular injury, hemorrhage control, and temporizing measures (e.g., shunts, ligation). Caring for trauma patients is a multidisciplinary endeavour; understanding local/regional skill sets and from whom to seek help is vital. Opportunities for skills maintenance should also be encouraged for surgeons practising at sites where acutely injured patients present.

Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Paramedic to trauma team verbal handover optimization - a complex interaction.

BACKGROUND: Handover to the trauma team is crucial to trauma care. The emergency medical services (EMS) report must be concise, contain key details, and be time-limited. Effective handover is difficult, often occurring between unfamiliar teams, in chaotic environments, and without standardization. We aimed to evaluate handover formats in comparison to ad-lib communication during trauma handover. METHODS: We conducted a single-blind randomized simulation trial evaluating 2 structured handover formats. Paramedics randomly assigned to ad-lib, ISOBAR (identify, situation, observations, background, agreed plan, and readback) or IMIST (identification, mechanism/medical complaint, injuries/ information about complaint, signs, treatments) handover formats underwent scenarios in an ambulance, then transfer to the trauma team. Assessment of handovers was completed by the trauma team and by experts using audiovisual recordings. RESULTS: Twenty-seven simulations were conducted, 9 for each handover format. Participant ratings of the usefulness of the IMIST and ISOBAR formats were 9/10 and 7.5/10, respectively (p = 0.097). Quality of the handover was deemed higher by team members when a statement of objective vital signs and a logical format was used. Handovers delivered with confidence, directed and summarized by a trauma team leader, before physical patient transfer, and without interruption were identified as having the highest quality. The type of format was not a significant contributor to handover; however, we identified a matrix of factors affecting the quality of trauma handover. CONCLUSION: Our study shows agreement by prehospital and hospital personnel that a standardized handover tool is preferred. A brief confirmation of physiologic stability, including vital signs, limiting distractions, and team summarization improves handover effectiveness.

Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review.

OBJECTIVE: This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA: Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS: A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS: There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS: This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.

Innovative curriculum is needed to address residents' attitudes toward older adults: the case of geriatric trauma.

BACKGROUND: Medical trainees' negative perceptions towards older adult care have been widely reported, catalyzing targeted curricula in geriatric medicine. Little is known about surgical residents' attitudes toward and perceptions of the educational value of caring for injured older adults. This information is needed to ensure the surgical workforce is adequately trained to care for this growing patient population. In this study, we assessed surgical trainees' attitudes towards geriatric trauma care to inform a curriculum in geriatric trauma. METHODS: We surveyed North American general surgery trainees' beliefs and attitudes toward caring for older trauma patients, and the educational value they ascribed to learning about older trauma patient care. Descriptive statistics were used to report participant characteristics and responses. RESULTS: Three hundred general surgery trainees from 94 post-graduate programs responded. Respondents reported too much time co-ordinating care (56%), managing non-operative patients (56%), and discharge planning (65%), all activities important to the care of older trauma patients. They recognized the importance of geriatric trauma care for their future careers (52%) but were least interested in reading about managing geriatric trauma patients (28%). When asked to rank clinical vignettes by educational value, respondents ranked the case of an older adult as least interesting (74%). As respondents progressed through their training, they reported less interest in geriatric trauma care. CONCLUSIONS: Our survey results demonstrate the generally negative attitudes and beliefs held by postgraduate surgical trainees towards the care of older adult trauma patients. Future work should focus on identifying specific changes to the postgraduate surgical curriculum which can effectively alter these attitudes and beliefs and improve the care for injured older adults.

Timing of cholecystectomy following endoscopic sphincterotomy: a population-based study.

BACKGROUND: Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regard to early cholecystectomy on a provincial level. METHODS: Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada, from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Regression analysis was performed for length of stay (LOS) and additional procedures. Outcome data were risk adjusted for age, gender, comorbidities, socioeconomic status, and year of procedure. Variability of early cholecystectomy crude rates across census areas was determined using a funnel plot. RESULTS: There were 4287 eligible patients. Of these, 1905 (44.4%) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Median interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p < 0.05). Patients initially admitted to a surgical service were more likely to undergo early cholecystectomy (60 vs. 36%, p < 0.001). There was no difference between groups in terms of bile duct injury or mortality. There was wide variability in rates of early cholecystectomy among census areas (range 0-96%) and health regions (range 20-66%) which was not explained by population density or geography. CONCLUSION: Early cholecystectomy is the ideal approach to gallstone disease post-sphincterotomy. Despite this, a large amount of clinical variance exists in regard to timing of cholecystectomy which seems to be primarily institution dependent.

Early versus delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis.

BACKGROUND: The recommended treatment for patients presenting with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data are less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity. METHODS: A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 to 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications, and conversion rate. Student t test was used to compare continuous data and Fischer's exact test was used for categorical data. RESULTS: 80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5-10) in the early group and 141.6 (range 18-757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60%) in the delayed group experienced biliary complications compared with 1 of 45 (2%) in the early group (p < 0.001). 14 patients in the delayed group required re-admission (40%) and 5 (14%) required additional procedures. Secondary outcomes were not statistically significant. CONCLUSIONS: The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.

Redefining Trauma Training in Canada: A National Delphi Study on Curriculum, Educational Resources, and Training Initiatives.

OBJECTIVE: This study aims to develop a set of curriculum recommendations to support trauma training in Canadian general surgery residency programs. DESIGN: A modified Delphi study was conducted with a panel of trauma and surgical education experts. Proposed curriculum components were developed from Canadian trauma surgery exposure and educational needs assessment data. Panelists were asked to rate each potential curriculum component for inclusion (mandatory or exemplary) or exclusion in the ideal and feasible trauma training curriculum. SETTING: This national Delphi study was conducted in the Canadian trauma education context. PARTICIPANTS: A panel of trauma experts and surgeons holding leadership positions in training programs and professional societies across Canada were invited to participate. RESULTS: Nineteen panelists representing all geographic regions of Canada achieved consensus on a set of curriculum components. The panel was largely in agreement with the RCPSC trauma competencies. At the end of the study, 71 items were considered mandatory for all programs (such as dedicated trauma rotations, trauma resuscitation and operative skills courses, structured trauma teaching within academic half day, and simulation experiences), and 21 items were considered exemplary (such as program funding for trauma courses, and opportunities to participate in trauma research and quality improvement projects). CONCLUSIONS: This study suggests a framework of education components for curricular reform for trauma training in Canadian general surgery residency programs. Such recommendations include rotations, formal courses and certifications, education resources, and simulation experiences to supplement limited clinical exposure.

Validity Evidence for Procedure-specific Competence Assessment Tools in Orthopaedic Surgery: A Scoping Review.

INTRODUCTION: Competency-based training requires frequent assessment of residents' skills to determine clinical competence. This study reviews existing literature on procedure-specific competence assessment tools in orthopaedic surgery. METHODS: A systematic search of eight databases up to May 2023 was conducted. Two reviewers independently assessed validity evidence and educational utility of each assessment tool and evaluated studies' methodological quality. RESULTS: Database searching identified 2,556 unique studies for title and abstract screening. Full texts of 290 studies were reviewed; 17 studies met the inclusion criteria. Bibliography review identified another five studies, totaling 22 studies examining 24 assessment tools included in the analysis. These tools assessed various orthopaedic surgery procedures within trauma, sports medicine, spine, and upper extremity. Overall validity evidence was low across all studies, and was lowest for consequences and highest for content. Methodological quality of studies was moderate. Educational utility assessment was not explicitly done for most tools. DISCUSSION: The paucity of current procedure-specific assessment tools in orthopaedic surgery lacks the validity evidence required to be used reliably in high-stake summative assessments. Study strengths include robust methodology and use of an evidence-based validity evidence framework. Poor-quality existing evidence is a limitation and highlights the need for evidence-based tools across more subspecialties.

Attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers: a multicentre survey.

Background: Medical student interest in surgical specialties continues to decline. This study aims to characterize attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers. Methods: An anonymous survey was custom designed and distributed to medical students at the University of Alberta and University of Calgary. Survey questions characterized student interest in surgical specialties, barriers to pursuing surgery, and influence of surgical education opportunities on career interest. Results: Survey engagement was 26.7% in 2015 and 24.2% in 2021. General surgery had the highest rate of interest in both survey years (2015: 38.3%, 2021: 39.2%). The most frequently reported barrier was worry about the stress that surgical careers can put on personal relationships (2015: 70.9%, 2021: 73.8%, p= 0.50). Female respondents were significantly more likely to cite gender discrimination as a deterrent to surgical careers (F: 52.0%, M: 5.8%, p < 0.001). Conclusions: Despite substantial interest, perception of work-life imbalance was the primary reported barrier to surgical careers. Further, female medical students' awareness of gender discrimination in surgery highlights the need for continued efforts to promote gender inclusivity within surgical disciplines to support early career women interested in surgery.

Contexte: L'intérêt des étudiants en médecine canadiens pour les spécialités chirurgicales est en diminution constante. Cette étude vise à caractériser leurs attitudes à l'égard de la formation en chirurgie et les obstacles qu'ils perçoivent à la poursuite d'une carrière dans cette discipline. Méthodes: Un sondage anonyme conçu sur mesure a été distribué aux étudiants en médecine de l'Université de l'Alberta et de l'Université de Calgary. Les questions de l'enquête portaient sur leur intérêt pour les spécialités chirurgicales, sur ce qui les empêche de les choisir comme voie de carrière et sur l'influence des possibilités de formation en chirurgie sur leur intérêt à suivre une carrière dans ces spécialités. Résultats: Le taux de participation à l'enquête était de 26,7 % en 2015 et de 24,2 % en 2021. La spécialité qui a recueilli le taux d'intérêt le plus élevé était la chirurgie générale, et ce pour les deux années d'enquête (2015 : 38,3 %, 2021 : 39,2 %). L'obstacle le plus fréquemment cité était la difficile conciliation entre la vie personnelle et les exigences des carrières chirurgicales (2015 : 70,9 %, 2021 : 73,8 %, p = 0,50). Les femmes interrogées étaient significativement plus susceptibles de citer la discrimination fondée sur le sexe comme frein au choix d'une carrière chirurgicale (F : 52,0 %, M : 5,8 %, p < 0,001). Conclusions: Malgré un intérêt considérable, la perception d'un déséquilibre entre la vie professionnelle et la vie personnelle est le principal obstacle déclaré au choix d'une carrière dans le domaine de la chirurgie. De plus, la discrimination sexuelle perçue par les étudiantes dans la discipline souligne le besoin d'efforts soutenus pour promouvoir l'inclusivité des sexes dans les spécialités chirurgicales afin de soutenir les femmes en début de carrière qui s'intéressent à la chirurgie.

Remote Instruction in Focused Assessment With Sonography in Trauma (FAST) Exams for Surgery Residents: A Pilot Study.

BACKGROUND: The Focused Assessment with Sonography in Trauma (FAST) exam is an important component to the evaluation of trauma patients. With advances in technology and meeting limitations due to COVID-19, remote instruction and learning have gained popularity. We sought to determine whether remote instruction of FAST exams was feasible as sustainable surgical education and a possible alternative to traditional in-person teaching. METHODS: General surgery residents completed a baseline survey and skills assessment on FAST exams and were then randomized to remote or in-person instruction. The remote group participated in an instructional session with a content expert through video conference and then practiced on a simulated mannequin while the expert remotely provided feedback. The in-person group received the experience with the content expert in the room. Both groups completed a post-course survey immediately after the session and a follow-up survey and objective assessment at six-months. Results were compared with two-way analysis of variance (ANOVA). RESULTS: 14 residents underwent the curriculum, seven in each group. There was a significant increase in self-reported confidence when comparing pre- and immediate post-course results for both the remote and in-person groups. At six months, confidence scores remained elevated and skill assessment scores improved, although the latter did not reach significance. There was no significant difference in post-course results between the groups. CONCLUSIONS: Remote instruction of FAST exams was feasible. Pilot data demonstrated an increase in confidence and suggest outcomes that are similar to in-person instruction, which has positive implications for future remote educational and potentially clinical initiatives.

Validity Evidence for Procedure-Specific Competency Assessment Tools in Cardiovascular and Thoracic Surgery: A Scoping Review.

OBJECTIVE: Surgical education has shifted from a time-based approach to the achievement and demonstration of procedural competency. High quality, objective assessment instruments are required to support this new approach. This study comprehensively reviewed the literature to identify and evaluate available procedure-specific assessment instruments in cardiothoracic and vascular surgery. DESIGN: A systematic search of 8 databases identified studies containing procedure-specific operative assessment instruments in cardiothoracic and vascular surgery. Generic global rating scales were excluded, unless modified to be procedure-specific. Two reviewers independently evaluated the validity evidence, methodological rigour and educational utility of each instrument using objective scoring criteria. Validity evidence was evaluated with a scoring tool aligned with the contemporary framework of validity. Methodological rigour was evaluated using the Medical Education Research Study Quality Instrument. Educational utility was evaluated according to the Accreditation Council for Graduate Medical Education (ACGME) framework. RESULTS: There were 2130 unique studies describing procedure-specific assessment in surgery. Of these, 9 studies evaluating 8 procedure-specific assessment instruments met inclusion criteria for cardiothoracic and vascular surgery. Four instruments were identified in thoracic surgery, 2 in cardiac surgery, and 2 in vascular surgery. Only 1 instrument was designed to evaluate surgeon performance, with the remainder designed to evaluate residents. No single instrument scored the maximum score of 15 for validity evidence. The highest score was 11, with 62.5% (n = 5) of instruments scoring greater than 10. All tools attained high scores in content validity, with minimal evidence generally presented regarding the consequences of assessment using a particular instrument. All but 1 instrument scored greater than 11 out of a maximum 16.5 points for methodological rigour. Very few studies reported on the ACGME domains of educational utility. CONCLUSIONS: In an era where surgical education is shifting towards the demonstration of procedural competency, objective procedure-specific assessment is critical. This review identified that few procedure-specific assessment instruments in cardiothoracic and vascular surgery exist, emphasizing the need for such instruments to ensure the success of competency-based education models.

Diagnosis and management of bile leaks after severe liver injury: A Trauma Association of Canada multicenter study.

BACKGROUND: Optimal management of bile leaks (BLs) after severe liver injury is unknown. Study objectives were to define current practices in diagnosis and management of BL to determine which patients may benefit from endoscopic retrograde cholangiopancreatography (ERCP). METHODS: American Association for the Surgery of Trauma grade ≥III liver injuries from 10 North American trauma centers were included in this retrospective study (February 2011 to January 2021). Groups were defined as patients who developed BL versus those who did not. Subgroup analysis of BL patients was performed by management strategy. Bivariate analysis compared demographics, clinical/injury data, and outcomes. Receiver operating characteristic curves were performed to investigate the relationship between bilious drain output and ERCP. RESULTS: A total of 2,225 patients with severe liver injury met the study criteria, with 108 BLs (5%). Bile leak patients had higher American Association for the Surgery of Trauma grade of liver injury ( p < 0.001) and were more likely to have been managed operatively from the outset (69% vs. 25%, p < 0.001). Bile leak was typically diagnosed on hospital day 6 [4-10] via surgical drain output (n = 37 [39%]) and computed tomography scan (n = 34 [36%]). On the BL diagnosis day, drain output was 270 [125-555] mL. Endoscopic retrograde cholangiopancreatography was the most frequent management strategy (n = 59 [55%]), although 32 patients (30%) were managed with external drains alone. Bile leak patients who underwent ERCP, surgery, or percutaneous transhepatic biliary drain had higher drain output than BL patients who were managed with external drains alone (320 [180-720] vs. 138 [85-330] mL, p = 0.010). Receiver operating characteristic curve analysis of BL demonstrated moderate accuracy (area under the receiver operating characteristic curve, 0.636) for ERCP at a cutoff point of 390 mL of bilious output on the day of diagnosis. CONCLUSION: Patients with BL >300 to 400 mL were most likely to undergo ERCP, percutaneous transhepatic biliary drain, or surgical management. Once external drainage of BL has been established, we recommend ERCP be reserved for patients with BL >300 mL of daily output. Prospective multicenter examination will be required to validate these retrospective data. LEVEL OF EVIDENCE: Therapeutic and Care Management; Level IV.

A needs assessment of Canadian general surgery postgraduate trauma training.

BACKGROUND: Clinical exposure to operative trauma cases for general surgery residents has decreased over recent decades. However, trainees are still expected to demonstrate competency in trauma care and injury management. METHODS: A prospective survey based on preliminary qualitative analysis and a trauma education conceptual framework was distributed to general surgery educators, trauma surgeons, and general surgery residents across the country. Participants were asked to describe their trauma training experience, the educational resources available at their training programs, and their level of support for potential curriculum components. RESULTS: 45% (31/69) of educators and 14% (58/405) of trainees responded to the survey. Perceived deficiencies were identified in the operative management of thoracic (educators 13%, trainees 28%), mediastinal (3%, 14%), neck (16%, 33%), and vascular (26%, 47%) injuries. Additional educational deficiencies were also identified in the domains of trauma systems and epidemiology, research and quality improvement, and injury prevention. Educators identified more inadequacies in training than trainees. Both groups supported participation in radiology (77%, 85%) and guideline (74%, 90%) reviews, journal clubs (84%, 81%), education rounds (90%, 88%), leading trauma resuscitations (94%, 98%), and trauma resuscitation simulations (90%, 95%) as valuable educational initiatives. CONCLUSIONS: Trauma training in Canada is currently perceived to be inadequate to support resident education. The development and implementation of competency-based curricular components will be essential to address the identified deficiencies. This data will be used to inform the development of a national trauma training curriculum and initiatives to enhance resident education.

Learner Phenotypes in Competency-Based Medical Education.

With the launch of competency-based medical education internationally, the practical realities of implementation have failed to live up to many of the proposed theoretical benefits. Specifically, as educators we have observed a number of assessment challenges that seem directly related to identified learner phenotypes. This commentary seeks to describe these specific learner phenotypes, along with actionable recommendations for programs and their competence committees in order to overcome the associated obstacles in assessment. We describe strategies related to both the individual and program level, which can be utilized for both short-term adjustments and long-term programmatic transformation.

Toward competency based continuing professional development for practicing surgeons.

BACKGROUND: There has been a recent call for formal competency assessments of practicing physicians and surgeons to form a framework of competency based continuing professional development (CBCPD). METHODS: An email questionnaire was conducted regarding CBCPD. Responses were further used to inform development of semi-structured interviews. RESULTS: There were 58 questionnaire respondents (42%). There was moderate support for assessment of surgeons' technical skills (50.9%) or decision making (56.6%). Support was highest for a mechanism to flag surgeons in need of a focused competence assessment (83.0%). Eight surgeons participated in interviews. Interviews identified a range of benefits of CBCPD but also several challenges to implementation, including the need for fair, data-driven assessments, taking into account patient outcomes. CONCLUSIONS: Through listening to surgeon concerns and recommendations for implementation strategies, this study's findings may support development of an effective CBCPD strategy with the potential to be embraced by surgeons and foster an environment of improved safety and performance.

Development of a novel conceptual framework for curriculum design in Canadian postgraduate trauma training.

BACKGROUND: Recent changes in practice patterns and training paradigms in trauma care have resulted in a critical review of postgraduate curricula. Specifically, a shift towards non-operative management of traumatic injuries, and reduced resident work-hours, has led to a significant decrease in trainees' surgical exposure to trauma. The purpose of our study is to perform an exploratory review and needs assessment of trauma curricula for general surgery residents in Canada. METHODS: Our study design includes semi-structured interviews with trauma education experts across Canada and focus groups with various stakeholder groups. We performed qualitative analysis of comments, with two independent reviewers, using inductive thematic analysis to identify themes and sub-themes. RESULTS: We interviewed four trauma education experts and conducted four focus groups. We formulated two main themes: institutional context and transferability of curricular components. We further broke down institutional context into sub-themes of culture, resources, trauma system, and trauma volume. We developed a new conceptual framework to guide ongoing curricular reform for trauma care within the context of general surgery training. CONCLUSIONS: The proposed framework, developed through qualitative analysis, can be utilized in a collaborative fashion in the curricular reform process of trauma care training in Canada.

CONTEXTE: Les changements récents liés aux modes de pratique et aux paradigmes de formation en matière de soins en traumatologie ont donné lieu à un examen critique des programmesde formation médicale postdoctorae. Précisément, la transition vers la gestion non chirurgicaledes blessurestraumatiques, et la réduction des heures de travail des résidents a diminué considérablement l'exposition chirurgicale des stagiaires aux situations de traumatologie. Le but de notre étude consiste à mener une revueexploratoire et une évaluation des besoins des programmes de traumatologie pour les résidentsen chirurgie générale au Canada. MÉTHODES: Notre devis comprend des entrevues semi-structurées auprès d'experts de formation en traumatologie de partout au Canada ainsi que des groupes de discussion avec différentes parties prenantes. Nous avons effectué une analyse qualitative des commentaires, avec deux examinateurs indépendants, au moyen d'une analyse thématique inductive pour définir des thèmes et sous-thèmes. RÉSULTATS: Nous avons interviewé quatre experts de formation en traumatologie et mené quatre groupes de discussion. Nous avons formulé deux thèmes principaux : le contexte institutionnel et la transférabilité des composantes du cursus. Nous avons également décomposé le contexte institutionnel en sous-thèmes de culture, de ressources, de systèmes de traumatologie, et de volume de traumatologie. Nous avons développéun nouveau cadre conceptuel pour guider les réformes en coursdes cursusde formation en traumatologie pour la formation en chirurgie générale. CONCLUSIONS: Le cadre proposé, et créé d'après une analyse qualitative, peut être utilisé de façon collaborative dans le processus de réforme du des cursus de formation en traumatologie au Canada.

Bowel obstruction following appendectomy: what is the true incidence?

INTRODUCTION: Appendicitis is a common problem that is typically treated with an appendectomy. Following abdominal surgery, adhesions may form and may cause a subsequent small bowel obstruction (SBO). The purpose of our study was to determine the rate of post-appendectomy SBO in an adult population, and to observe any difference in SBO rates between open versus laparoscopic appendectomies. METHODS: All patients who underwent an appendectomy at an adult hospital in the Calgary Health Region between 1999 and 2002 were identified by using the administrative discharge database. Pathology and operative technique (laparoscopic, McBurney incision, midline laparotomy) were reviewed. Using those regional health numbers, any further admissions with a diagnostic code for bowel obstruction were identified. Medical charts (n = 1777) were reviewed to confirm the rate of post-appendectomy SBO. A logistic regression was performed to identify risk factors of post-appendectomy SBO and expressed as odds ratios (95% confidence interval). RESULTS: The overall SBO rate was 2.8% over an average 4.1-year follow-up period. The risk factors for developing SBO following appendectomy for appendicitis included, perforated appendicitis (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 1.5-6.6), and midline incisions (OR = 5.4, 95% CI: 2.8-10.4). Those with pathology of cancer or chronic appendicitis conferred the greatest overall risk of SBO (OR = 7.4, 95% CI: 2.7-20.3). CONCLUSIONS: The rate of SBO following appendectomy in adults was 2.8%, or 0.0069 cases per person-year. The greatest risk factors for developing SBO were midline incision and nonappendicitis pathology. There is no statistically significant difference in SBO rates following laparoscopic appendectomy compared with open approaches.

Blood transfusion and coagulopathy in geriatric trauma patients.

BACKGROUND: Trauma resuscitation has undergone a paradigm shift with new emphasis on the early use of blood products and increased proportions of plasma and platelets. However, it is unclear how this strategy is applied or how effective it is in the elderly population. The study aim is to identify differences in transfusion practices and the coagulopathy of trauma in the elderly. METHODS: Data was prospectively collected on all consecutive patients that met trauma activation criteria at a Level I trauma centre. Data fields included patient demographics, co-morbidities, injury and resuscitation data, laboratory values, thromboelastography (TEG) results, and outcome measures. Elderly patients were defined as those 55 and older. Propensity-score matched analysis was completed for patients receiving blood product transfusion. Patients were matched by gender, mechanism, injury severity score (ISS), head injury, and time from injury. RESULTS: Total of 628 patients were included, of which 142 (23%) were elderly. Elderly patients were more likely to be female (41% vs. 24%), suffer blunt mechanism of trauma (96% vs. 80%), have higher ISS scores (mean 25.4 vs. 21.6) and mortality (19% vs. 8%). Elderly patients were significantly more likely to receive a blood transfusion (42% vs. 30%), specifically for red cells and plasma. Propensity-matched analysis resulted in no difference in red cell transfusion or mortality. Despite the broad similarities between the matched cohorts, trauma coagulopathy as measured by TEG was less commonly observed in the elderly. DISCUSSION: Our results suggest that elderly trauma patients are more likely to receive blood products when admitted to a trauma centre, though this may be attributed to under-triage. The results also suggest an altered coagulopathic response to traumatic injury which is partially influenced by increased anticoagulant and antiplatelet medication use in the geriatric population. CONCLUSION: It is not clear whether the acute coagulopathy of trauma is equivalent in geriatric patients, and further study is therefore warranted.