title: The marriage of surgical simulation and telementoring for damage-control surgical training of operational first responders: A pilot study.
abstract: BACKGROUND
  Hemorrhage is the leading cause of preventable posttraumatic death. Many such deaths may be potentially salvageable with remote damage-control surgical interventions. As recent innovations in information technology enable remote specialist support to point-of-care providers, advanced interventions, such as remote damage-control surgery, may be possible in remote settings.
  
  
  METHODS
  An anatomically realistic perfused surgical training mannequin with intrinsic fluid loss measurements (the "Cut Suit") was used to study perihepatic packing with massive liver hemorrhage. The primary outcome was loss of simulated blood (water) during six stages, namely, incision, retraction, direction, identification, packing, and postpacking. Six fully credentialed surgeons performed the same task as 12 military medical technicians who were randomized to remotely telementored (RTM) (n = 7) or unmentored (UTM) (n=5) real-time guidance by a trauma surgeon.
  
  
  RESULTS
  There were no significant differences in fluid loss between the surgeons and the UTM group or between the UTM and RTM groups. However, when comparing the RTM group with the surgeons, there was significantly more total fluid loss (p = 0.001) and greater loss during the identification (p = 0.002), retraction (p = 0.035), direction (p = 0.014), and packing(p = 0.022) stages. There were no significant differences in fluid loss after packing between the groups despite differences in the number of sponges used; RTM group used more sponges than the surgeons and significantly more than the UTM group (p = 0.048). However, mentoring significantly increased self-assessed nonsurgeon procedural confidence (p = 0.004).
  
  
  CONCLUSIONS
  Perihepatic packing of an exsanguinating liver hemorrhage model was readily performed by military medical technicians after a focused briefing. While real-time telementoring did not improve fluid loss, it significantly increased nonsurgeon procedural confidence, which may augment the feasibility of the concept by allowing them to undertake psychologically daunting procedures.
authors.affiliation: From the Canadian Forces Health Services (A.W.K., H.T., J.W., A.B.); Departments of Surgery (A.W.K., D.J.R., C.G.B.), Critical Care Medicine (A.W.K.), and Community Health Sciences (D.J.R.), and Regional Trauma Services (A.W.K., C.G.B.), Foothills Medical Centre; and Innovative Trauma Care (J.L.M.), Edmonton, Calgary, Alberta; Sunnybrook Health Sciences Centre (H.T.), Toronto; and Royal College of Physicians and Surgeons (S.B.); and Flight Research Laboratory (J.K., H.E.W.B.), National Research Council of Canada, Ottawa, Ontario, Canada; Rocky Vista University, Parker, Colorado (A.T.L.); and Strategic Operations (K.L.), San Diego, California.
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
authors.forename: Homer
authors.initials: H
authors.lastname: Tien
authors.forename: Anthony T
authors.initials: AT
authors.lastname: LaPorta
authors.forename: Kit
authors.initials: K
authors.lastname: Lavell
authors.forename: Jocelyn
authors.initials: J
authors.lastname: Keillor
authors.forename: Heather E
authors.initials: HE
authors.lastname: Wright Beatty
authors.forename: Jessica Lynn
authors.initials: JL
authors.lastname: McKee
authors.forename: Susan
authors.initials: S
authors.lastname: Brien
authors.forename: Derek J
authors.initials: DJ
authors.lastname: Roberts
authors.forename: Jonathan
authors.initials: J
authors.lastname: Wong
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
authors.forename: Andrew
authors.initials: A
authors.lastname: Beckett
mesh_terms: D000007:Abdominal Injuries / Q000601:surgery*; D002170:Canada; D002983:Clinical Competence; D004630:Emergencies; D004632:Emergency Medical Services; D004634:Emergency Medical Technicians / Q000193:education*; D005260:Female; D005392:First Aid; D006471:Gastrointestinal Hemorrhage / Q000601:surgery*; D006801:Humans; D007813:Laparotomy / Q000193:education* / Q000379:methods; D008297:Male; D008348:Manikins; D008611:Mentors; D008889:Military Personnel; D010865:Pilot Projects; D017216:Telemedicine / Q000379:methods*