- Email: [email protected]
Training Physicians for Combat Casualty Care on the Modern Battlefield
ORIGINAL REPORTS
Training Physicians for Combat Casualty Care on the Modern Battlefield Vance Y. Sohn, MD,* Lloyd A. Runser, MD,† Robert A. Puntel, MD,‡ James A. Sebesta, MD,* Alec C. Beekley, MD,* Jennifer L. Theis, CVT,§ Nancy L. Merrill, DVM,§ Bernard J. Roth, MD,储 and Robert M. Rush, Jr., MD* *Department of Surgery, †Department of Family Medicine, ‡Department of Pediatrics, §Department of Clinical Investigation, and 储Department of Graduate Medical Education, Madigan Army Medical Center, Tacoma, Washington INTRODUCTION: Trauma training among nonsurgical physicians in the military is highly variable in amount and quality. However, all deployed military physicians, regardless of specialty, are expected to provide combat casualty care. The goal was to assess the effectiveness of an intense modular trauma refresher course for nonsurgical physicians deploying to a combat zone. METHODS: All graduating nonsurgical residents participated in
this 2.5-day course, consisting of 4 modules: (1) didactic session; (2) simulation with interactive human surgical simulators; (3) case presentations and triage scenarios from Iraq/Afghanistan with associated skill stations; and (4) live tissue surgical procedure laboratory. Competency tests, surveys, and after action comments were reviewed and compared before and after course completion. RESULTS: Between May 2005 and April 2007, 60 physicians
participated in the course. By specialties, there were 32 internists, 16 pediatricians, 7 general practitioners, 4 obstetricians/ gynecologists, and 1 “other” nonsurgical physician represented. Precourse and postcourse tests were administered to 31 of 60 participants. The mean test scores improved from 76% to 96% upon completion of the course (p ⬍ 0.01). Additionally, selfperceived confidence levels in handling battlefield casualties from questionnaires based on Likert scale responses (1 ⫽ not confident, 5 ⫽ confident) improved from an average of 2.3 before the course to 3.9 upon completion of the course (p ⬍ 0.01). CONCLUSION: All military physicians must be prepared to
manage combat casualties. This hybrid training model may be an effective method to prepare nonsurgeons to deal with battle injuries. This course significantly improved the knowledge and
Correspondence: Inquiries to Robert M. Rush, Jr., MD, Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431; e-mail: [email protected] The opinions expressed herein are the private views of the authors and are not to be construed as official or reflecting of the views of the Department of Defense or the Department of Army.
confidence among primary care physicians. (J Surg 64: 199-203. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery.) KEY WORDS: training, trauma, education, simulation, animal model, combat care COMPETENCY: Patient Care, Medical Knowledge, Practice Based Learning and Improvement
INTRODUCTION The United States is currently involved in a military endeavor of larger scale and consequence than any in recent history. Over 150,000 US troops are deployed in diverse combat situations requiring comprehensive logistical and medical support. An essential part of this endeavor is to provide high-quality trauma care for soldiers. Primary care and other nonsurgical physicians represent a diverse group of health-care providers disseminated throughout the multiple levels, or echelons, of care within the Army medical support doctrine in time of war. The care provided may range from routine illnesses to the stabilization and evacuation of an acutely injured patient. Uniformly, these different roles require the nonsurgical physician to respond to trauma situations; however, trauma training in this group of physicians is highly variable in amount and quality. For physicians, the introduction to military medicine begins with the Army Medical Department’s Officer Basic Course and the Combat Casualty Care Course (C4) where residents gain knowledge of basic tenets of combat medicine. This training is supplemented by Advanced Trauma Life Support (ATLS), which all military physicians are required to complete during their internship. From these baseline training requirements, knowledge and experience varies greatly. Primary-care residency programs require a variable number, if any, of trauma/ critical care, emergency medicine, and surgery rotations. Although ATLS provides pertinent training, there is growing concern that this training should not be considered “stand
Journal of Surgical Education • Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
1931-7204/07/$30.00 doi:10.1016/j.jsurg.2007.05.007
199
alone” and may not adequately encompass the combat casualty or scenario.1 Hence, there is the recognition within the military medical community that further combat medical training is necessary. To meet this identified training need, a modified version of the previously reported Tactical Combat Casualty Course (TCCC) was designed and implemented at Madigan Army Medical Center (Tacoma, Washington).2 This course is mandatory training for all nonsurgical residents before completion of their residency. The goal of this training is to augment previous training during residency and to provide preparation for future combat medicine. Several combat trauma training courses have been implemented in other military organizations and have been shown to be efficacious.3-5 The experience of the authors in preparing Army physicians for combat casualty care is described.
METHODS Nonsurgery, graduating resident physicians were required to participate in this course and were assumed to be deploying to either Iraq or Afghanistan within 1 year of graduation. No exclusion criteria existed. This study was approved by the Institutional Animal Care and Use Committee (IACUC) and Graduate Medical Education Committee (GMEC). The 2.5-day course consisted of 4 phases: (1) one day didactic session; (2) half-day patient simulation with interactive human surgical/trauma simulators; (3) half-day of real-life case presentations and triage scenarios from Iraq/Afghanistan with associated skills stations; and (4) half-day live tissue laboratory where procedures were performed on anesthetized swine (Sus scrufa) in a controlled environment. Volunteer instructors participated in all stages of the course and included surgeons, medics, and pediatricians, all with previous combat experience. The didactic lectures (Table 1) incorporated basic trauma principles with an emphasis on commonly encountered mechanisms of injury, such as blast, gunshot, and burn injuries. Additionally, military unique topics, such as tactical stages of care, mass casualty situations, and military medical air evacuation were covered. In phase 2, procedural tasks, treatment team exercises, and scenario training were performed on medical simulation mannequins (SimMan: Laerdal Inc., Wappingers Falls, NY) (Table 2). Procedural proficiency at this phase, subjectively TABLE 1. Core Lecture Program Tactical stages of care Airway management Rapid sequence intubation CNS: head and spinal injuries Chest injuries Abdominal trauma Burn injuries Shock/fluid therapy/lessons learned Detainee medicine Pharmaceuticals 200
TABLE 2. Medical Simulation Mannequin Procedures Trauma assessment Endotracheal intubation and airway management Surgical airway Venous access (including interosseous line placement) Tube thoracostomy Tourniquet application Team triage
determined by each instructor, was required before proceeding to the live tissue laboratory. Phase 3 consisted of small group discussions of case-based scenarios from recent war theater experiences. The final phase of the curriculum exposed students to live tissue familiarity by performing procedures on swine taught by combat-experienced surgeons (Table 3). Student-to-animal and student-to-instructor ratios were 4:1. Maneuvers most commonly performed in theater, such as external/extremity hemorrhage control with tourniquets and hemostatic dressing application, chest tube insertion, splinting of fractures, and airway management, were emphasized. Veterinary personnel ensured each pig was properly anesthetized throughout the procedure laboratory. General anesthesia was used, and all animals were euthanized while under anesthesia at the conclusion of the laboratory. Induction and maintenance of anesthesia was performed using ketamine, xylazine, and isoflurane. A 1-page questionnaire was administered upon completion of the training. This questionnaire was used to gain background demographics, for course improvement and feedback, as well as to measure changes in confidence levels before and after the course. In addition, a 50-question examination was given before start of the course to test baseline knowledge on trauma management. Another written examination was then given after the course, and the difference was recorded as a metric of knowledge improvement/decrement. These examinations were not administered during the inception of the course and were added during the study period. Wilcoxon signed ranks tests and a Student t-test were used for statistical analysis.
RESULTS Between May 2005 and April 2007, 60 physicians participated in the course. By specialty, there were 32 internists, 16 pediatricians, 7 general practitioners, 4 obstetricians/gynecologists, and 1 “other” nonsurgical physicians represented. Precourse TABLE 3. Live Tissue Procedures Fracture/amputation management Tourniquet application Direct pressure hemostasis Hemostatic dressing application Management of evisceration Tube thoracostomy Surgical airway
Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
and postcourse tests were administered to 31 of 60 participants during the latter half of the study period. This multiple choice test was created from a pool of 200 questions and included multiple versions, each balanced in complexity and covered topics. The mean test scores improved from 76% to 96% upon completion of the course (p ⬍ 0.01). All participants completed the postcourse questionnaire. Improved trauma readiness and confidence were measured by questions that specifically addressed whether students felt an improvement in their confidence in taking care of injured soldiers on the battlefield. Based on Likert scale responses, 17% of respondents either strongly agreed or agreed that they were prepared to go into battle and care for casualties before taking the course. In contrast, 75% of attendees either strongly agreed or agreed that the course improved their confidence in taking care of injured trauma victims. In total, 21% were unsure, 5% respondents disagreed, and no one strongly agreed that this course was not helpful. The difference in participant confidence before and after the course was found to be statistically significant (p ⬍ 0.01). Furthermore, when asked, “I would take this course again if offered,” 90% strongly agreed or agreed that they would repeat the course. When asked, “I would recommend this course to other health care providers ready to deploy,” 100% agreed or strongly agreed. At the end of the questionnaire, students commented, “SimMan and live tissue are ideal models to use before doing procedures on live patients,” “Awesome course, most useful Army training I’ve had,” and “having instructors that have deployed made talks/lectures valuable.” The remaining survey questions and answers are listed in Table 4.
DISCUSSION Since the attacks of September 11, 2001, the US military has been called to engage in warfare to support the global war on terror. Traditionally, surgeons have been called on to treat battlefield casualties; however, all military physicians, regardless of specialty, must be ready to appropriately triage, treat, and evacuate severely injured battlefield casualties. Because of the paucity of this type of training during a primary care residency, this course was developed to better prepare these physicians for the perils of combat trauma care. Advanced Trauma Life Support remains the mainstay of trauma training experience in most primary care residencies. At
Madigan Army Medical Center, all physicians are required to successfully complete ATLS during their internship and most are required to recertify before deploying to the combat theater. Although this course has successfully standardized trauma management on a global level, loss of knowledge has been well documented in providers who do not see trauma on a regular basis. Ali et al6 found that trauma patient volume, regardless of gender, practice specialty, and age, was the most significant factor in the rate of attrition of ATLS acquired skills. Similarly, Blumenfeld et al7 determined that most physicians lose a significant portion of their acquired cognitive knowledge after 3.5 years, roughly equivalent to a pediatric, family medicine, and internal medicine residency. It is because of these factors, coupled with the high likelihood that primary care physicians would be expected to provide combat casualty care within 6-12 months after graduation, that this refresher course was initiated. Loosely modeled after the proven successful methods of ATLS, this course also employed didactic lectures, case-based scenarios, small groups, in addition to skills stations. This hybrid modular training combined cognitive processing with the performance of demonstrative psychomotor skills, both of which have been found to be far more effective and validated than the traditional training modalities.8,9 Of course, key aspects were modified with the target audience in mind. For instance, the case-based scenarios highlighted mass casualty situations encountered in the war. Also, to simulate the “fog of war” and “care under fire,” camouflage netting, artillery simulators, and other pyrotechnics were strategically employed during the patient simulation portion of the course. Furthermore, in much the same way that ATLS has continued to evolve since its inception in 1978, a series of improvements has also been done based on student feedback and results of casualty treatment.10 In this format, significant improvements in knowledge and confidence were obtained from nonsurgical resident physicians completing this course. Perhaps the current situation of deployed military physicians is most similar to the experience of Israeli military physicians. Irregardless of specialty, Israeli physicians are also expected to provide trauma care. Therefore, since 1989, all Israeli military physicians have been mandated to participate in combat trauma life support (CTLS), which in essence, is ATLS with an additional 2-day military-specific curriculum. Topics not covered during ATLS, such as mass casualty scenarios, crush injury syn-
TABLE 4. Questionnaire and Corresponding Average Likert Score Question 1. 2. 3. 4. 5. 6. 7.
The didactic portion of the course contained topics not previously covered. The SimMan portion of the course taught me procedures not previously covered. The animal lab taught me procedures not covered in previous training. Before I took the course, I was prepared to go into battle and take care of casualties. Now that I have taken the course, I am prepared to go into battle and care for casualties. I would take this course again if offered. I would recommend this course to other health care providers ready to deploy.
Score (1: strongly disagree, 5: strongly agree) 3.98 4.25 4.35 2.15* 3.93* 4.23 4.71
*p ⬍ 0.05. Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
201
dromes, penetrating neck wounds, and ophthalmologic trauma are emphasized. Additionally, the course offers more extensive and comprehensive skill stations. In a postcourse questionnaire study of nonsurgical physicians who completed CTLS, Ben Abraham et al11 found that nearly half of the respondents had applied the skills learned during CTLS training. Attributed procedures performed included intubations, tube thoracotomies, cricothyroidotomies, and venous cutdowns, with half of these interventions performed while in the civilian sector. Understandably, 65% of these family physicians, psychiatrists, and geriatricians responded that the course had a high impact on improving their manual skills.12 While we do not have as robust a data set or physician cohort as the Israelis undergoing CTLS, we are confident that our experience will correlate with the same long-term benefits of the described implementation of a similar trauma refresher course. This type of learning model, despite being resource intensive, is generalizable and would benefit health-care providers who do not care frequently care for traumatically injured patients. In addition to military physicians, this may include surgeons who do not routinely cover trauma and physicians who practice in rural locations where an established trauma system is not readily available. Furthermore, from the educational perspective, surgical residents can gain experience managing trauma patients before caring for a human victim. Correspondingly, the quest to improve trauma readiness through novel learning modalities has been aided by technologic advances in the field of computer simulation. For instance, the benefits of using patient simulators, which comprises only a single aspect of this course, include increased confidence of the student in managing trauma scenarios, improved trauma team dynamics, and most importantly, improved management skills.13,14 Even simulators for diagnostic testings, such as ultrasonography in trauma, has been beneficial and compares favorably with experience gained with traditional hands-on patient models.15 When these simulators are combined with live tissue training, there is even more benefit. The greatest limitation to this study is the lack of follow-up data of the graduates of this course. Although immediate benefits in knowledge and confidence were realized, it is unknown whether these measures were sustained and, more importantly, if it equated to positive clinical outcomes. Attempts at obtaining postdeployment feedback have been largely unsuccessful, although initial reports are encouraging. For the most part, these graduates currently remain engaged in taking care of wounded soldiers in the war theater. Therefore, it is difficult to objectively validate the clinical significance of these findings. Future studies, aimed at obtaining such an analysis, as well as other measures to improve the overall training process are actively being pursued. Finally, as only 50% of this cohort took the written examination, it is important to continue to ensure that all participants take these tests as a further objective metric of knowledge increment. The principle finding in this study is that military primary care resident physicians can and should be expected to provide 202
competent trauma care upon completion of their training program. By providing a course that integrates lectures, medical simulators, and live tissue training, these physicians can rapidly be retaught the tenets of trauma management with improvements in aptitude and confidence. Although they cannot be expected to provide the same level of care as surgeons, they can relieve the burden of battlefield trauma management by aiding surgeons to readily identify patients in need for urgent surgical procedures and by performing immediate action life-saving procedures at the bedside. Ultimately, these types of modular trauma training may even benefit surgeons who only occasionally handle trauma patients.
REFERENCES 1. Baker MS. Advanced trauma life support: is it adequate
stand-alone training for military medicine? Mil Med. 1994;159:587-590. 2. Sohn VY, Miller JP, Koeller CA, et al. From the combat
medic to the forward surgical team: the Madigan model for improving trauma readiness of brigade combat teams fighting the Global War on Terror. J Surg Res. 2007;138: 25-31. 3. Blumenfeld A, Kluger Y, Ben AR, et al. Combat trauma
life support training versus the original advanced trauma life support course: the impact of enhanced curriculum on final student scores. Mil Med. 1997;162:463-467. 4. Kluger Y, Rivkind A, Donchin Y, et al. A novel approach
to military combat trauma education. J Trauma. 1991;31: 564-569. 5. Scope A, Lynn M, Farkash U, et al. Military trauma life
support: a comprehensive training program for military physicians. Mil Med. 2001;166:385-388. 6. Ali J, Howard M, Williams JI. Do factors other than
trauma volume affect attrition of ATLS-acquired skills? J Trauma. 2003;54:835-841. 7. Blumenfeld A, Ben AR, Stein M, et al. Cognitive knowl-
edge decline after Advanced Trauma Life Support courses. J Trauma. 1998;44:513-516. 8. Carmont MR. The Advanced Trauma Life Support
course: a history of its development and review of related literature. Postgrad Med J. 2005;81:87-91. 9. Hill D, Stalley P, Pennington D, et al. Competency-based
learning in traumatology. Am J Surg. 1997;173:136-140. 10. Carley S, Driscoll P. Trauma education. Resuscitation.
2001;48:47-56. 11. Ben-Abraham R, Stein M, Kluger Y, et al. The impact of
advanced trauma life support course on graduates with a
Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
non-surgical medical background. Eur J Emerg Med. 1997;4:11-14.
tient simulator for resuscitation training. J Trauma. 2002;52:1078-1085.
12. Ben-Abraham R, Stein M, Shemer J, et al. Advanced
14. Marshall RL, Smith JS, Gorman PJ, et al. Use of a human
trauma life support (ATLS) courses: should training be refocused towards rural physicians? Eur J Emerg Med. 1999;6:111-114.
patient simulator in the development of resident trauma management skills. J Trauma. 2001;51:17-21. 15. Knudson MM, Sisley AC. Training residents using simu-
13. Holcomb JB, Dumire RD, Crommett JW, et al. Evaluation
of trauma team performance using an advanced human pa-
Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
lation technology: experience with ultrasound for trauma. J Trauma. 2000;48:659-665.
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Training Physicians for Combat Casualty Care on the Modern Battlefield Vance Y. Sohn, MD,* Lloyd A. Runser, MD,† Robert A. Puntel, MD,‡ James A. Sebesta, MD,* Alec C. Beekley, MD,* Jennifer L. Theis, CVT,§ Nancy L. Merrill, DVM,§ Bernard J. Roth, MD,储 and Robert M. Rush, Jr., MD* *Department of Surgery, †Department of Family Medicine, ‡Department of Pediatrics, §Department of Clinical Investigation, and 储Department of Graduate Medical Education, Madigan Army Medical Center, Tacoma, Washington INTRODUCTION: Trauma training among nonsurgical physicians in the military is highly variable in amount and quality. However, all deployed military physicians, regardless of specialty, are expected to provide combat casualty care. The goal was to assess the effectiveness of an intense modular trauma refresher course for nonsurgical physicians deploying to a combat zone. METHODS: All graduating nonsurgical residents participated in
this 2.5-day course, consisting of 4 modules: (1) didactic session; (2) simulation with interactive human surgical simulators; (3) case presentations and triage scenarios from Iraq/Afghanistan with associated skill stations; and (4) live tissue surgical procedure laboratory. Competency tests, surveys, and after action comments were reviewed and compared before and after course completion. RESULTS: Between May 2005 and April 2007, 60 physicians
participated in the course. By specialties, there were 32 internists, 16 pediatricians, 7 general practitioners, 4 obstetricians/ gynecologists, and 1 “other” nonsurgical physician represented. Precourse and postcourse tests were administered to 31 of 60 participants. The mean test scores improved from 76% to 96% upon completion of the course (p ⬍ 0.01). Additionally, selfperceived confidence levels in handling battlefield casualties from questionnaires based on Likert scale responses (1 ⫽ not confident, 5 ⫽ confident) improved from an average of 2.3 before the course to 3.9 upon completion of the course (p ⬍ 0.01). CONCLUSION: All military physicians must be prepared to
manage combat casualties. This hybrid training model may be an effective method to prepare nonsurgeons to deal with battle injuries. This course significantly improved the knowledge and
Correspondence: Inquiries to Robert M. Rush, Jr., MD, Department of Surgery, Madigan Army Medical Center, Tacoma, WA 98431; e-mail: [email protected] The opinions expressed herein are the private views of the authors and are not to be construed as official or reflecting of the views of the Department of Defense or the Department of Army.
confidence among primary care physicians. (J Surg 64: 199-203. Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery.) KEY WORDS: training, trauma, education, simulation, animal model, combat care COMPETENCY: Patient Care, Medical Knowledge, Practice Based Learning and Improvement
INTRODUCTION The United States is currently involved in a military endeavor of larger scale and consequence than any in recent history. Over 150,000 US troops are deployed in diverse combat situations requiring comprehensive logistical and medical support. An essential part of this endeavor is to provide high-quality trauma care for soldiers. Primary care and other nonsurgical physicians represent a diverse group of health-care providers disseminated throughout the multiple levels, or echelons, of care within the Army medical support doctrine in time of war. The care provided may range from routine illnesses to the stabilization and evacuation of an acutely injured patient. Uniformly, these different roles require the nonsurgical physician to respond to trauma situations; however, trauma training in this group of physicians is highly variable in amount and quality. For physicians, the introduction to military medicine begins with the Army Medical Department’s Officer Basic Course and the Combat Casualty Care Course (C4) where residents gain knowledge of basic tenets of combat medicine. This training is supplemented by Advanced Trauma Life Support (ATLS), which all military physicians are required to complete during their internship. From these baseline training requirements, knowledge and experience varies greatly. Primary-care residency programs require a variable number, if any, of trauma/ critical care, emergency medicine, and surgery rotations. Although ATLS provides pertinent training, there is growing concern that this training should not be considered “stand
Journal of Surgical Education • Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery
1931-7204/07/$30.00 doi:10.1016/j.jsurg.2007.05.007
199
alone” and may not adequately encompass the combat casualty or scenario.1 Hence, there is the recognition within the military medical community that further combat medical training is necessary. To meet this identified training need, a modified version of the previously reported Tactical Combat Casualty Course (TCCC) was designed and implemented at Madigan Army Medical Center (Tacoma, Washington).2 This course is mandatory training for all nonsurgical residents before completion of their residency. The goal of this training is to augment previous training during residency and to provide preparation for future combat medicine. Several combat trauma training courses have been implemented in other military organizations and have been shown to be efficacious.3-5 The experience of the authors in preparing Army physicians for combat casualty care is described.
METHODS Nonsurgery, graduating resident physicians were required to participate in this course and were assumed to be deploying to either Iraq or Afghanistan within 1 year of graduation. No exclusion criteria existed. This study was approved by the Institutional Animal Care and Use Committee (IACUC) and Graduate Medical Education Committee (GMEC). The 2.5-day course consisted of 4 phases: (1) one day didactic session; (2) half-day patient simulation with interactive human surgical/trauma simulators; (3) half-day of real-life case presentations and triage scenarios from Iraq/Afghanistan with associated skills stations; and (4) half-day live tissue laboratory where procedures were performed on anesthetized swine (Sus scrufa) in a controlled environment. Volunteer instructors participated in all stages of the course and included surgeons, medics, and pediatricians, all with previous combat experience. The didactic lectures (Table 1) incorporated basic trauma principles with an emphasis on commonly encountered mechanisms of injury, such as blast, gunshot, and burn injuries. Additionally, military unique topics, such as tactical stages of care, mass casualty situations, and military medical air evacuation were covered. In phase 2, procedural tasks, treatment team exercises, and scenario training were performed on medical simulation mannequins (SimMan: Laerdal Inc., Wappingers Falls, NY) (Table 2). Procedural proficiency at this phase, subjectively TABLE 1. Core Lecture Program Tactical stages of care Airway management Rapid sequence intubation CNS: head and spinal injuries Chest injuries Abdominal trauma Burn injuries Shock/fluid therapy/lessons learned Detainee medicine Pharmaceuticals 200
TABLE 2. Medical Simulation Mannequin Procedures Trauma assessment Endotracheal intubation and airway management Surgical airway Venous access (including interosseous line placement) Tube thoracostomy Tourniquet application Team triage
determined by each instructor, was required before proceeding to the live tissue laboratory. Phase 3 consisted of small group discussions of case-based scenarios from recent war theater experiences. The final phase of the curriculum exposed students to live tissue familiarity by performing procedures on swine taught by combat-experienced surgeons (Table 3). Student-to-animal and student-to-instructor ratios were 4:1. Maneuvers most commonly performed in theater, such as external/extremity hemorrhage control with tourniquets and hemostatic dressing application, chest tube insertion, splinting of fractures, and airway management, were emphasized. Veterinary personnel ensured each pig was properly anesthetized throughout the procedure laboratory. General anesthesia was used, and all animals were euthanized while under anesthesia at the conclusion of the laboratory. Induction and maintenance of anesthesia was performed using ketamine, xylazine, and isoflurane. A 1-page questionnaire was administered upon completion of the training. This questionnaire was used to gain background demographics, for course improvement and feedback, as well as to measure changes in confidence levels before and after the course. In addition, a 50-question examination was given before start of the course to test baseline knowledge on trauma management. Another written examination was then given after the course, and the difference was recorded as a metric of knowledge improvement/decrement. These examinations were not administered during the inception of the course and were added during the study period. Wilcoxon signed ranks tests and a Student t-test were used for statistical analysis.
RESULTS Between May 2005 and April 2007, 60 physicians participated in the course. By specialty, there were 32 internists, 16 pediatricians, 7 general practitioners, 4 obstetricians/gynecologists, and 1 “other” nonsurgical physicians represented. Precourse TABLE 3. Live Tissue Procedures Fracture/amputation management Tourniquet application Direct pressure hemostasis Hemostatic dressing application Management of evisceration Tube thoracostomy Surgical airway
Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
and postcourse tests were administered to 31 of 60 participants during the latter half of the study period. This multiple choice test was created from a pool of 200 questions and included multiple versions, each balanced in complexity and covered topics. The mean test scores improved from 76% to 96% upon completion of the course (p ⬍ 0.01). All participants completed the postcourse questionnaire. Improved trauma readiness and confidence were measured by questions that specifically addressed whether students felt an improvement in their confidence in taking care of injured soldiers on the battlefield. Based on Likert scale responses, 17% of respondents either strongly agreed or agreed that they were prepared to go into battle and care for casualties before taking the course. In contrast, 75% of attendees either strongly agreed or agreed that the course improved their confidence in taking care of injured trauma victims. In total, 21% were unsure, 5% respondents disagreed, and no one strongly agreed that this course was not helpful. The difference in participant confidence before and after the course was found to be statistically significant (p ⬍ 0.01). Furthermore, when asked, “I would take this course again if offered,” 90% strongly agreed or agreed that they would repeat the course. When asked, “I would recommend this course to other health care providers ready to deploy,” 100% agreed or strongly agreed. At the end of the questionnaire, students commented, “SimMan and live tissue are ideal models to use before doing procedures on live patients,” “Awesome course, most useful Army training I’ve had,” and “having instructors that have deployed made talks/lectures valuable.” The remaining survey questions and answers are listed in Table 4.
DISCUSSION Since the attacks of September 11, 2001, the US military has been called to engage in warfare to support the global war on terror. Traditionally, surgeons have been called on to treat battlefield casualties; however, all military physicians, regardless of specialty, must be ready to appropriately triage, treat, and evacuate severely injured battlefield casualties. Because of the paucity of this type of training during a primary care residency, this course was developed to better prepare these physicians for the perils of combat trauma care. Advanced Trauma Life Support remains the mainstay of trauma training experience in most primary care residencies. At
Madigan Army Medical Center, all physicians are required to successfully complete ATLS during their internship and most are required to recertify before deploying to the combat theater. Although this course has successfully standardized trauma management on a global level, loss of knowledge has been well documented in providers who do not see trauma on a regular basis. Ali et al6 found that trauma patient volume, regardless of gender, practice specialty, and age, was the most significant factor in the rate of attrition of ATLS acquired skills. Similarly, Blumenfeld et al7 determined that most physicians lose a significant portion of their acquired cognitive knowledge after 3.5 years, roughly equivalent to a pediatric, family medicine, and internal medicine residency. It is because of these factors, coupled with the high likelihood that primary care physicians would be expected to provide combat casualty care within 6-12 months after graduation, that this refresher course was initiated. Loosely modeled after the proven successful methods of ATLS, this course also employed didactic lectures, case-based scenarios, small groups, in addition to skills stations. This hybrid modular training combined cognitive processing with the performance of demonstrative psychomotor skills, both of which have been found to be far more effective and validated than the traditional training modalities.8,9 Of course, key aspects were modified with the target audience in mind. For instance, the case-based scenarios highlighted mass casualty situations encountered in the war. Also, to simulate the “fog of war” and “care under fire,” camouflage netting, artillery simulators, and other pyrotechnics were strategically employed during the patient simulation portion of the course. Furthermore, in much the same way that ATLS has continued to evolve since its inception in 1978, a series of improvements has also been done based on student feedback and results of casualty treatment.10 In this format, significant improvements in knowledge and confidence were obtained from nonsurgical resident physicians completing this course. Perhaps the current situation of deployed military physicians is most similar to the experience of Israeli military physicians. Irregardless of specialty, Israeli physicians are also expected to provide trauma care. Therefore, since 1989, all Israeli military physicians have been mandated to participate in combat trauma life support (CTLS), which in essence, is ATLS with an additional 2-day military-specific curriculum. Topics not covered during ATLS, such as mass casualty scenarios, crush injury syn-
TABLE 4. Questionnaire and Corresponding Average Likert Score Question 1. 2. 3. 4. 5. 6. 7.
The didactic portion of the course contained topics not previously covered. The SimMan portion of the course taught me procedures not previously covered. The animal lab taught me procedures not covered in previous training. Before I took the course, I was prepared to go into battle and take care of casualties. Now that I have taken the course, I am prepared to go into battle and care for casualties. I would take this course again if offered. I would recommend this course to other health care providers ready to deploy.
Score (1: strongly disagree, 5: strongly agree) 3.98 4.25 4.35 2.15* 3.93* 4.23 4.71
*p ⬍ 0.05. Journal of Surgical Education • Volume 64/Number 4 • July/August 2007
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dromes, penetrating neck wounds, and ophthalmologic trauma are emphasized. Additionally, the course offers more extensive and comprehensive skill stations. In a postcourse questionnaire study of nonsurgical physicians who completed CTLS, Ben Abraham et al11 found that nearly half of the respondents had applied the skills learned during CTLS training. Attributed procedures performed included intubations, tube thoracotomies, cricothyroidotomies, and venous cutdowns, with half of these interventions performed while in the civilian sector. Understandably, 65% of these family physicians, psychiatrists, and geriatricians responded that the course had a high impact on improving their manual skills.12 While we do not have as robust a data set or physician cohort as the Israelis undergoing CTLS, we are confident that our experience will correlate with the same long-term benefits of the described implementation of a similar trauma refresher course. This type of learning model, despite being resource intensive, is generalizable and would benefit health-care providers who do not care frequently care for traumatically injured patients. In addition to military physicians, this may include surgeons who do not routinely cover trauma and physicians who practice in rural locations where an established trauma system is not readily available. Furthermore, from the educational perspective, surgical residents can gain experience managing trauma patients before caring for a human victim. Correspondingly, the quest to improve trauma readiness through novel learning modalities has been aided by technologic advances in the field of computer simulation. For instance, the benefits of using patient simulators, which comprises only a single aspect of this course, include increased confidence of the student in managing trauma scenarios, improved trauma team dynamics, and most importantly, improved management skills.13,14 Even simulators for diagnostic testings, such as ultrasonography in trauma, has been beneficial and compares favorably with experience gained with traditional hands-on patient models.15 When these simulators are combined with live tissue training, there is even more benefit. The greatest limitation to this study is the lack of follow-up data of the graduates of this course. Although immediate benefits in knowledge and confidence were realized, it is unknown whether these measures were sustained and, more importantly, if it equated to positive clinical outcomes. Attempts at obtaining postdeployment feedback have been largely unsuccessful, although initial reports are encouraging. For the most part, these graduates currently remain engaged in taking care of wounded soldiers in the war theater. Therefore, it is difficult to objectively validate the clinical significance of these findings. Future studies, aimed at obtaining such an analysis, as well as other measures to improve the overall training process are actively being pursued. Finally, as only 50% of this cohort took the written examination, it is important to continue to ensure that all participants take these tests as a further objective metric of knowledge increment. The principle finding in this study is that military primary care resident physicians can and should be expected to provide 202
competent trauma care upon completion of their training program. By providing a course that integrates lectures, medical simulators, and live tissue training, these physicians can rapidly be retaught the tenets of trauma management with improvements in aptitude and confidence. Although they cannot be expected to provide the same level of care as surgeons, they can relieve the burden of battlefield trauma management by aiding surgeons to readily identify patients in need for urgent surgical procedures and by performing immediate action life-saving procedures at the bedside. Ultimately, these types of modular trauma training may even benefit surgeons who only occasionally handle trauma patients.
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