Background: The Advanced Trauma Operative Management (ATOM) course which is aimed at improving penetrating trauma management skills is very challenging to conduct. We assessed the feasibility and potential impact of ATOM training in Trinidad and Tobago through the University of Toronto Global surgery initiative and its potential for improving penetrating trauma care in this developing country. Methods: Senior General Surgical trainees were randomly assigned to participate. Other participants consisted of: an experienced international ATOM course Director, one experienced ATOM instructor, an ATOM instructor candidate, an experienced ATOM veterinary medicine technologist, 2 veterinary medicine trainees, 8 senior general surgical trainees who completed the course using the 2 student to one faculty training model. Pre and post course self efficacy scores (a measure of confidence in surgical approach) and scores on multiple choice question exams (MCQ) were compared by paired t tests. The trainees completed 5-point Likert scales to assess different components of the course. Results: The course was successfully completed locally. Mean and SD self efficacy scores improved from 55.4 ± 18.5 to 80.5 ± 9.1 and MCQ improved from 63.0 ± 8.8 to 82.5 ± 9.6 (p Conclusions: Based on trainee course performance and their evaluations, there was significant improvement in trauma skills, knowledge and attitude with enthusiastic support for continuing the program, to improve penetrating trauma care locally and extending this training to other parts of the Caribbean.

# Survivors of traumatic cardiac arrest. {#article-title-2} Traumatic cardiac arrest (TCA) carries high mortality and morbidity. Survival is poor. Recent studies suggest the rate of morbidity and mortality due to TCA is approaching the same as that due to any other cause of cardiac arrest. The

# Outcomes and opportunities for improvement in self-inflicted blunt and penetrating trauma {#article-title-2} Self-inflicted trauma (SIT) is a public health issue ranking 4th as leading cause of death and disability in young adults. Retrospective descriptive analysis of patients admitted to a

BACKGROUND:Student feedback from the old TEAM (Trauma Evaluation and Management) program prompted introduction of simulated trauma patient models in the new program. Performance after the new and old programs was compared to assess the impact of the simulated patient models.METHODS:Final year medical students randomly assigned to control and experimental groups completed a 20-item trauma multiple choice questionnaire examination (MCQE). The experimental groups attended the old or new TEAM program before completing a second MCQE and the control groups completed the same post-test without the TEAM programs. We used paired t tests for within and unpaired t tests for between group comparisons of the control and experimental groups' performances on the MCQ pre- and post-tests. On a 1 to 5 scale, students graded if objectives were met; trauma knowledge improved; trauma skills improved; overall satisfaction; and if TEAM should be mandatory.RESULTS:Post-test scores increased significantly after both the old and new programs but the increase was statistically significantly greater after the new program. In the old TEAM, 51.6% rated improvement in trauma skills at 4 or greater compared with 97.3% in the new program. A large percentage of students in the old program requested more hands-on teaching. Of students, 85% scored honors pass mark after completion of the new TEAM format, and no honors pass marks were achieved after completion of the old TEAM format.CONCLUSION:Simulated trauma patient models were rated highly and improved both trauma skills and knowledge. Wider application of these teaching models is suggested.

BACKGROUND:We previously (1997) demonstrated superior clinical but similar cognitive performance after the new interactive compared to the old ATLS course. The present study is aimed at determining whether this difference was short term or maintained over time (2 years).MATERIALS AND METHODS:Two groups of 13 physicians out of the original 32 physicians were available for the study which compared performance in a 40-item MCQ examination on trauma topics and clinical performance in 4 trauma OSCE stations consisting of simulated trauma patients. Paired and unpaired t tests were used for within- and between-group comparisons, respectively, with P < 0.05 being considered statistically significant. Overall OSCE scores (maximum standard 20), adherence to priority scores (Priority, scale 1 to 7), and overall approach (Approach, scale 1 to 5) scores were analyzed.RESULTS:Values are means +/- SD; (+)-P < 0.05 compared to 1999; *P < 0.05 compared to old group [table in text].CONCLUSIONS:Although knowledge base decreases similarly with time after both courses, the new interactive course participants maintained a consistently higher clinical skill performance level at 2 years.

We tested the effectiveness of a basic prehospital trauma life support (PHTLS) program by assessing cognitive performance and trauma management skills among prehospital trauma personnel. Fourteen subjects who completed a standard PHTLS course (group I) were compared to a matched group not completing a PHTLS program (group II). Cognitive performance was assessed on 50-item multiple choice examinations, and trauma skills management was assessed with four simulated trauma patients. Pre-PHTLS multiple choice questionnaire scores were similar (45.8 ± 9.4% vs. 48.8 ± 8.9% for groups I and II, respectively), but the post-PHTLS scores were higher in group I (80.4 ± 5.9%) than in group II (52.6 ± 4.9%). Pre-PHTLS simulated trauma patient performance scores (standardized to a maximum total of 20 for each station) were similar at all four stations for both groups, ranging from 7.9 to 10.4. The post-PHTLS scores were statistically significantly higher at all four stations for group I (range 16.0–19.0) compared to those for group II (range 8.0–11.1). The overall mean pre-PHTLS score for all four stations was 8.3 ± 2.1 for group I and 8.8 ± 2.0 (NS) for group II; the group I post-PHTLS mean score for the four stations was 17.1 ± 2.7 (p < 0.05) compared to 9.1 ± 2.3 for group II. Pre-PHTLS Adherence to Priority scores on a scale of 1 to 7 were similar (1.1 ± 0.9 for group I and 1.2 ± 1.0 for group II). Post-PHTLS group I Priority scores increased to 5.9 ± 1.1. Group II (1.1 ± 1.0) did not improve their post-PHTLS scores. The pre-PHTLS Organized Approach scores in the simulated trauma patients on a scale of 1 to 5 were 2.1 ± 1.0 for group I and 1.9 ± 1.2 for group II (NS) compared to 4.2 ± 0.9 ( p < 0.05) in group I and 2.0 ± 0.8 in group II after PHTLS. This study demonstrates improved cognitive and trauma management skills performance among prehospital paramedical personnel who complete the basic PHTLS program.

Background: We have previously demonstrated a significant improvement in trauma patient outcome after the Advanced Trauma Life Support (ATLS) program in Trinidad and Tobago. In January of 1992, a Prehospital Trauma Life Support (PHTLS) program was also instituted. This study assessed trauma patient outcome after the PHTLS program.Methods: Morbidity (length of stay and degree of disability), mortality, injury severity score, mechanism of injury, age, and sex among all adult trauma patients transported by ambulance to the major trauma hospital were assessed between July of 1990 to December of 1991 (pre-PHTLS, n = 332) and January of 1994 to June of 1995 (post-PHTLS, n = 350).Results: Age, sex distribution, percentage blunt injury, and injury severity score were similar for both groups. Mortality pre-PHTLS (15.7%) was greater than post-PHTLS (10.6%), Length of stay and disability were statistically significantly decreased post-PHTLS. Age, injury severity score, and mechanism of injury were positively correlated with mortality in both periods. The previously reported post-ATLS mortality was similar to the pre-PHTLS mortality.Conclusions: Post-PHTLS mortality and morbidity were significantly decreased, suggesting a positive impact of the PHTLS program on trauma patient outcome.

BACKGROUND:Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement.METHODS:All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant.RESULTS:The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%).CONCLUSIONS:Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.

Although the Advanced Trauma Life Support (ATLS) course is now taught internationally, its teaching effectiveness still requires confirmation. The Objective Structured Clinical Examination (OSCE) reliably assesses clinical performance by utilizing standardized patients. An OSCE of eight 15 minute trauma patient stations and two 40 item MCQ tests were used to test the teaching effectiveness of the ATLS program in 32 practicing physicians who applied for an ATLS program in Trinidad and Tobago. The physicians were randomly assigned to an ATLS group (n = 16) that completed the ATLS course and a non-ATLS group (n = 16). Before and after the ATLS course, all physicians completed MCQ tests and trauma OSCE. Mean (+/- SD) OSCE scores (standardized to 20) ranged from 9.8 +/- 1.7 to 10.0 +/- 1.7 and 9.5 +/- 1.8 to 10.8 +/- 1.3 in the ATLS and non-ATLS groups, respectively, prior to the ATLS course (NS). Post-ATLS OSCE scores ranged from 15.9 +/- 1.7 to 17.6 +/- 1.7 in the ATLS group (p < 0.05 compared to pre-ATLS) and 9.5 +/- 1.4 to 10.1 +/- 1.3 in the non-ATLS group, which did not improve their OSCE scores. Adherence to priorities was graded 1 to 7 with the pre-ATLS grades of 1.7 +/- 0.6 (ATLS) and 1.8 +/- 0.7 (non-ATLS) and post-ATLS grades of 6.4 +/- 1.1 (ATLS) and 2.1 +/- 0.6 (non-ATLS). Organized approach to trauma was graded 1 to 5 with pre-ATLS grades of 1.6 +/- 0.5 (ATLS) and 1.7 +/- 0.6 (non-ATLS) and post-ATLS grades of 4.5 +/- 0.6 (ATLS) and 1.9 +/- 0.6 (non-ATLS). Pre-ATLS MCQ scores (%) were similar: 53.1 +/- 8.4 (ATLS) and 57.3 +/- 5.4 (non-ATLS), but post-ATLS scores were greater in the ATLS group: 85.8 +/- 7.1 (ATLS) and 64.2 +/- 3.6 (non-ATLS). Our data support the teaching effectiveness of the ATLS program among practicing physicians as measured by improvement in OSCE scores, adherence to trauma priorities, maintenance of an organized approach to trauma care, and cognitive performance in MCQ examinations.