Walter B Kucera, MD, Matthew D Nealeigh, DO, Brenton Franklin, MD, Mark Bowyer, MD, W. Brian Sweeney, MD, E. Matthew Ritter, MD. Uniformed Services University / Walter Reed National Military Medical Center
Objectives: Many injuries from the wars in Iraq and Afghanistan involve extremity trauma secondary to blasts. The wounding patterns from these blasts predispose patients to developing extremity compartment syndrome during intercontinental evacuation. Based on data from 2006, 17% of fasciotomies performed in-theater required revision on arrival to a Role 4 hospital (definitive medical/surgical care outside the combat zone), and 41% had missed compartments. A training program was implemented in 2007, resulting in improvement with 8% requiring revision, but given the increased mortality associated with missed injuries, this number is still too high. We conducted a focused needs assessment to guide the development of simulation-based lower extremity fasciotomy training based on the current performance of military surgeons preparing for deployment.
Methods: As part of a routine pre-deployment assessment, 42 military surgeons were instructed to perform a 2-incision, 4-compartment, lower-extremity fasciotomy on simulated lower leg models (Operative Experience, North East, MD). Models were each assessed twice for standardized and objectively-assessed major (inadequate skin incisions, inadequate fascial incisions, missed compartments) and minor (failure to make an H-shaped incision over the lateral compartments, division of the greater saphenous vein) errors based on current Joint Trauma System clinical practice guidelines and approved training curricula.
Results: Only 4 of 42 (9.5%) models contained no errors. Models had, on average, 4.3 +/-2.6 major errors and 0.3 +/-0.5 minor errors. 11 models (26.2%) had at least one missed compartment. The most commonly missed compartments were the deep posterior (17%) and anterior (14%). 29 models (69%) had inadequate or poorly-placed skin incisions, with the most common errors being inadequate distal extension of the medial (10, 24%) and lateral (14, 33%) incisions, inadequate proximal extension of the lateral incision (6, 14%), medial incision too close to the tibia (7, 17%), and lateral incision over or behind the fibula (12, 29%). 36 models (86%) had inadequate fascial incisions. Inadequate fasciotomies were seen in the anterior (57%), lateral (55%), superficial (52%) and deep (34%) posterior compartments
Conclusion: Military surgeons continue to struggle to maintain currency in the infrequently-performed, but mission-critical, lower extremity fasciotomy. Performance on the simulation models approximates what has been seen during the recent wars in Iraq, Afghanistan, and beyond. We will use this needs assessment to develop a simulation curriculum based on error management and mastery learning theory to reduce the morbidity associated with lower extremity compartment syndrome.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87089
Program Number: MSS13
Presentation Session: Full-Day Military Surgical Symposium – Trauma/Critical Care Presentations
Presentation Type: MSSPodium