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4 • Training Paradigms for Vascular Trauma 45
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Endovascular surgery has had a mixed effect on case volume in vascular training programs. Open peripheral case
volume has remained stable, whereas endovascular case
volume has exploded.56 Open aortic case volume, however,
has decreased dramatically. Of the approximately 45,000
abdominal aortic aneurysms (AAA) repaired in the United
States each year, only 15% are repaired with open techniques.57 The effect of this on vascular surgical trainees’
ability to care for vascular trauma is unknown.
After training, experience with vascular trauma remains
limited for many surgeons. US vascular surgeons seeking
recertication have reported the following data: in 2003,
only 46% of surgeons reported having undertaken any
trauma cases in the previous 12 months; in 2009, this
proportion had diminished to 23%. In both cohorts, the
accumulated annual experience amounted to an average of
four procedures.58 Though it is difcult to judge prociency
and competence by volume data alone, it is certain that the
experience of trainees is anything but uniform, and the limited experience raises the question whether these specialists
have the requisite skill set to ensure the best outcomes when
called to care for patients with vascular injuries. Likewise,
only a small minority of vascular specialists report that
management of vascular trauma comprises part of their
clinical practice.
It is clear that the experiential approach cannot be relied
on as a means of endowing surgical trainees with the
required KSAs to expertly manage vascular injuries. As
such, there is a critical need to improve the way training is
conducted in order to secure the best care for patients with
vascular trauma. The remainder of this chapter explores
the evolving challenges faced by those tasked with training
the surgeon of the future and discusses current and nearterm modalities that are likely to improve the uniformity of
training in the management of vascular trauma.
information and to construct a strategy that enables the
best use of the relevant skill. In other words, cognitive orientation is needed in order to make appropriate decisions.59
Didactic lectures, textual material, and, more recently, casebased training have been used for transfer of information
and cognitive skills. Technical and cognitive components
of clinical training are inseparable; they inform each other.
Since Dewey’s 1938 pioneering work,60 experiential learning has been recognized as an important part of how adults
acquire new knowledge and skills (i.e., “learning by doing”
is a particularly effective method for advancing cognitive
and technical skills). Modern theory emphasizes the problem-centered approach and the need to understand the
contextual orientation of the adult learner.61 Effective and
systematic training is a byproduct of the quality of the curriculum that is developed to enhance that training.
As yet, the ideal curriculum for training in vascular
trauma has not been delineated and will likely be specic
to national situations as well as the needs of and learning
styles of individual learners. However, the ideal curricula
will clarify goals and objectives in unambiguous terms,
driven by consensus of expert opinion. The obvious goal is
to produce competent and procient practitioners who can
appropriately diagnose and apply cognitive, technical, and
teamwork skills to the management of patients presenting
with vascular trauma, aided by a thorough understanding of anatomy and current open-surgical and endovascular techniques. The remainder of this chapter will focus
on the wide variety of tools that are currently employed to
train in vascular surgery in general and vascular trauma in
particular.
VASCULAR TRAUMA TRAINING TOOLS
The tools currently available to teach the management of
vascular trauma include the following:
Ways Forward for Vascular Trauma
Training
As previous chapters demonstrate, effective trauma management presents specic challenges, with the requirement
for rapid, systematic assessment and decision making to
prevent patient deterioration. However, every injury pattern is unique with some factors coming to light only in the
operative phase of management, and it is not always possible to rehearse and preplan all aspects of surgical management. This mandates that any training algorithm must
include core principles that can be adapted and can be exibly deployed to deal with the individual situation at hand.
Training must be set at two distinct levels: (1) the KSAs
required by nonvascular specialists to prevent deterioration,
to surgically stabilize the patient, and to set the conditions
for further specialist intervention and (2) the advanced
specialist skills necessary to deal with complex injuries,
postoperative issues, complications, and guide long-term
management. Clinical educators generally consider surgical
training to have the following two separate components: (1)
a “hands-on” practical learning of technical skills and (2)
the acquisition of knowledge and cognitive skills. Cognitive
orientation centers around the ability to organize relevant
1. Clinical case material—care of patients
2. Didactic lectures
3. Textbook and digital media
4. Case-based discussion
5. Team-based training
6. Animal-model–based training
7. Human-cadaver–based training
8. Simulation-based training
a. Synthetic models—low and high delity
b. Virtual reality
The ideal vascular trauma curricula will incorporate several of these tools ordered to the goals and objectives of the
educational program. Clinical case material has long been
the mainstay of vascular trauma training, but, as discussed
previously, can no longer be counted on to provide sufcient
experience. Didactic lectures, textbook and digital media,
and case-based discussion represent the bulk of traditional
methods to convey information, but have limited effectiveness if not focused by and incorporated within a meaningful curriculum. Likewise, simulation training using animal
models and human cadavers have proved extremely useful
in the training of surgeons, but their use must be based on
a thorough needs assessment and on a good understanding
of their inherent limitations.
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The use of animals for training has several advantages
and a number of distinct limitations. Animals provide excellent approximations of human physiology, necessitating
careful and appropriate choices and executions of surgical
maneuvers in order to avoid excess hemorrhage and death.
Animal tissues require standard operating equipment and
supplies; they bleed when cut; and they exhibit damage if
not handled, dissected, and sutured carefully.
62,63
However,
maintenance of an animal laboratory is expensive and
logistically intensive, requiring veterinary support, animal
care facilities, sterile operating rooms (OR), and humane
and sanitary disposal of the animals. Animal laboratories
are rightly subject to stringent care standards in order to
ensure animal welfare. The use of animals is a highly visible
and emotionally charged issue decried by very active and
vocal animal rights groups.64 Another key disadvantage of
animal models concerns differences in anatomy such that
they are usually inadequate for teaching anatomic vascular
exposures. The availability of live animal models for training purposes is highly variable across the world and is prohibited in many areas. Though still available in the United
States, the US Department of Defense (DoD) has directed
that medical simulation and other alternative methods of
training are to be utilized to the maximum extent practicable before the use of animals for the training of physicians
and combat medics.65 The surgical community must therefore be proactive in searching for replacements to live-tissue
training as this model is unlikely to be universally available
in the future.
Cadaver-based training is particularly useful for teaching vascular exposures in humans, a skill essential to the
effective treatment of vascular injuries.
64,66
The availability
and cost of cadavers is highly variable, as is the cultural
acceptability of using cadaveric material around the world.
For instance, the cost of obtaining cadavers for one such
trauma course (the Advanced Surgical Skills for Exposure
in Trauma [ASSET] course) is highly variable, ranging up to
$8000, depending on the US state concerned. Even in areas
where it is possible to obtain cadaveric material, the number of adequate specimens may not be sufcient to meet the
need. Of interest is the low willingness of medical professionals to donate their own bodies for medical education. In
a recent survey of medical professionals in India, only 22%
of physicians stated that they were willing to donate their
bodies for medical education (though only 7% had already
registered to do so), but 68% expected the public to do the
67
same.
Though cadavers give an excellent representation of
human anatomy, they have some limitations. Most cadavers are elderly and deconditioned—translating the lessons
learned on an 80-year-old woman with diminished muscle mass to a muscular 20-year-old male may be difcult.
Cadaver tissue preserved in formalin has very different
characteristics than tissue found in a fresh or fresh-frozen
cadaver. Cadavers have no blood ow and do not bleed.
Attempts have been made to improve the delity of cadaveric
specimens by cannulating the vessels of very fresh cadavers
and perfusing them with articial blood in a pulsatile fash-
68–70
ion.
Initially developed for neurosurgical training, such
perfused cadaver models have been modied as potential
tools for training on trauma surgical procedures. Pulsatile
ow can be obtained using a modied intraaortic balloon
pump system and injuries created in the heart, lung, liver,
and inferior vena cava, allowing for repair in a “bleeding
human model.”70 Though this technique improves the delity of the cadaveric model, it requires signicant preprocessing and equipment, as well as very fresh cadaveric material,
making it impractical for widespread use and adoption.
TEAM-BASED TRAINING FOR VASCULAR TRAUMA
Since the turn of the century, there has been an explosion
of interest in training hospital teams using methods similar
to those utilized by the aviation industry.
skills are the cognitive and social skills that enable people
working in safety-critical industries to function effectively
and safely. Decision-making and nontechnical skills signicantly inuence the quality of care afforded to the injured
patient. It is abundantly clear that the surgeon is just one
part of the health-care team and that the team as a whole
that must function optimally to secure the best possible
outcome. No amount of technical virtuosity on the part
of the surgeon will overcome such errors, which can only
be addressed through effective training in teamwork, decision making, and communication. As such, crew resource
management (CRM) is now high on the clinical agenda
with the UK House of Commons Health Committee recently
acknowledging the critical inuence of human factors on
patient safety.77 Examples of CRM skills include the following:
n Teamwork/team coordination
n Communication
n Leadership/followership
n Decision making
n Conict resolution
n Assertiveness
n Management of stress and fatigue
n Workload management
n Prioritization of tasks
n Situational awareness
CRM skills-training signicantly improves teamwork and
communications skills and there is increasing evidence
that it improves patient outcomes.
(VA) study reported a 50% reduction in surgical mortality
between CRM-trained surgical teams versus non–CRMtrained surgical teams.72 Further studies in the VA system
showed a reduction of 18% in mortality rates in 74 facilities that received training compared to a 7% reduction in 34
control facilities.80 The US DoD has implemented a program
called TeamSTEPPS to address CRM issues in DoD facilities,
and it is currently used widely both in civilian and military
settings.76 US military units have undergone and implemented CRM training in deployed environments.81 This
approach has also been used in Norway, using a live porcine
model, to develop team skills in damage control surgery in
a rural setting.82 In general, CRM within both military and
civilian trauma systems is under-researched, although a
set of related studies from the aviation, the organizational
sciences, and the social psychology domains illustrates the
potential for future study in this area.
Clinical CRM training should involve the whole team so
that all members share a common purpose and develop a
full understanding of individual and team roles. Although
71–76
Nontechnical
74,78,79
A Veterans Affairs
83
4 • Training Paradigms for Vascular Trauma 47
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likely to be important in civilian settings, there is no doubt
that exceptional nontechnical skills are essential for the
military trauma team practicing in austere circumstances.
As such, CRM training was a core feature of the UK Defence
Medical Services predeployment Military Opera tional Surgical Training (MOST).
SIMULATION-BASED TRAINING FOR VASCULAR
TRAUMA
Simulation-based training is becoming widely established
within surgical education, and simulation centers dedicated to teaching the technical aspects of surgical skill have
become increasingly popular.
ous benets to novice surgeons who are learning invasive
procedural skills and to practicing surgeons who need skill
refreshment. Simulation-based training provides a safe,
structured environment for motor skills acquisition, with
the aim of preparing trainees for real-life OR experience.
Trainees may improve their performance, may overcome
learning curves, and may manage simulated procedural
complications without risk to patients.
of simulation in training has been recognized by the Residency Review Committee for Surgery, with the most recent
ACGME Program Requirements for General Surgery stating
that resources should include “simulation and skills laboratories.” The Agency for Healthcare Research and Quality
supports the effectiveness of simulation training “especially
for psychomotor and communication skills,” although it
is recognized that supportive data is limited.89 However,
the available evidence suggests that technical skills gained
in the simulation laboratory do transfer to the OR
benet also demonstrated for endovascular simulators in
animal91 and human92 studies. Practice of open surgical
skills on low-delity models (e.g., synthetic models) has
also been shown to improve technical skill acquisition and
retention.
93–95
Current trends in medical and surgical skills training
conrm movement away from the traditional apprenticeship model of graded responsibility to a more structured
approach, with stepwise progress toward the attainment of
technical competence.
novice” used by educational psychologists refers to a
learner who has automated the required suite of basic psychomotor skills and spatial judgments.98 Enabling a trainee
to reach this position via simulation is attractive because
subsequent OR training is likely to be a higher-yield experience for the learner and is likely to be safer for the patient.
Simulation-based training should commence with initial
cognitive training,99 should include predened prociency
levels that trainees must reach before moving to the next
100,101
level,
and should offer distributed practice sessions
to reinforce acquired skills.
avoids the random presentation of cases typical of experiential Halstedian learning. Cases should include complicated
and crisis scenarios, so that correct management of potential problems is therefore practiced. Simulation programs
methods of assessment, and should have protected time for
feedback and error analysis88 because this has been shown
to improve performance. Although the optimal type of
feedback has not been established, the facility to undertake
64,84
This training offers obvi-
85–88
The importance
96,97
The concept of the “pretrained
102,103
This structured approach
43,90
—a
near-instant feedback that is informed by objective assessment data, which has been captured during the simulated
procedure, would seem desirable.
104,105
In contrast to the
traditional “learning by doing” model (where assessment is
often subjective and biased toward individual supervisors),
performance data obtained from simulators allow mentors
to objectively evaluate problems and to address these systematically before moving on to the next stage. Appropriate
mentorship within the curriculum is crucial.
Simulation is a tool within a curriculum and is not its
98,107
end
; the curriculum developers set the context with
regard to subject matter and schedule of learning.
106
108
However, in order to make the best use of simulated training,
it is best that educators and simulation experts align their
efforts from the outset and work in tandem.
109
Certainly the
potential for use of simulation for technical skills is signicant for vascular trauma training. Simulations may include
both open and endovascular skills and may cover the following learning outputs:
n Assessment, planning, and prioritization
n Surgical approaches and anatomy
n Control of hemorrhage
n Repair of vascular structures
Simulators applicable to vascular surgery range from
partial-task trainers to high-delity mock operating rooms.
The key to successful simulation is “willing suspension
of disbelief” on the part of the learner—in that he or she
nds it difcult to distinguish between the simulator and
a live patient or scenario. Simulators designed to mimic
endovascular or laparoscopic procedures are better able to
accomplish this, whereas those designed to represent open
vascular surgical procedures are generally of lower delity
and may suffer from inadequate face and content validity—
which can directly affect applicability of simulator-acquired
skills to real world scenarios.
Sidhu et al. studied a group of surgical residents learning vascular anastomoses skills and found that skill transfer was better when they were trained on a higher-delity
model (human cadaver brachial arteries) when compared
with those training on a lower-delity (plastic models) variant.93 This lesson must not be overlooked by those responsible for developing simulation models—it is not enough
to incorporate a simulator into a curriculum without rst
ensuring that it has the appropriate level of delity to meet
the goals and objectives required.
Like endoscopy and laparoscopy, practitioners of endovascular surgical techniques use screen-based technologies,
enabling more opportunity for faithful simulation as compared with open surgery. Several endovascular simulators
are currently commercially available, providing a variety
of training options, such as angioplasty and stenting of the
carotid, renal, iliac, and supercial femoral arteries; caval
lter deployment; and aortic aneurysm stent repair. These
are classied as high-delity simulators as haptic (touch),
aural, and visual interfaces are simulated, providing nearrealistic representations.
110,111
Chaer et al. conducted the rst randomized study examining the transfer of simulator-trained endovascular skills
to the clinical environment.92 Twenty general surgery
residents without prior endovascular experience were
48 SECTION 1 • Setting the Stage
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randomized to a 2-hour period of simulator training versus
no training. Participants were then supervised through two
endovascular interventions in patients with lower extremity occlusive disease. Using a global performance rating
scale, the residents who received simulation training scored
higher by their supervisors than the control group in the
rst endovascular case, and this nding persisted with
second case performance. A separate review performed
by the Best Evidence Medical Education (BEME) collaboration found that “the weight of the best available evidence
suggests that high-delity medical simulations facilitate
learning under the right conditions.”
112
It also found that
the quality of the supportive literature was generally poor
and was based around narrative and qualitative analyses.
Further studies are required to determine how degree of
exposure to simulation relates to benet, to investigate the
optimal strategy for incorporation into training curricula,
and to better understand for which interventional procedures endovascular simulation is best suited.
The European Board of Vascular Surgery (EBVS) has
been the vanguard of using simulation as an assessment
tool (probably out of necessity due to the wide spectrum
of differences in training among the countries of the European Union). Qualication as a vascular surgeon by the
EBVS requires a demonstration of knowledge and cognitive ability coupled with a technical and endovascular skills
assessment.
113
Validation studies of the EBVS skills assessment have been conducted, which have promoted acceptance and continued use of simulation in the evaluation of
vascular surgical candidates.
114,115
However, in spite of advances in simulation for training
in endovascular therapy, it is important to note that the
vast majority of vascular trauma is (and will likely continue
to be in the near future) treated using open surgical techniques. As such, there is an unmet need to develop open
skills simulation and assessment for the management of
vascular trauma. Sidhu and colleagues
116
have developed a
comprehensive vascular skills assessment (CVSA) for surgical trainees. Candidates undergo a series of four 20-minute
vascular skills stations where control and repair of inferior
vena cava injury, a femoral embolectomy, a graft-to-artery
anastomosis, and an ultrasound-guided line insertion are
assessed by a vascular surgeon using a previously validated
global rating scale.
117
The CVSA has excellent construct
validity and correlates well with postgraduate-year level,
although the actual performance scores obtained by the
residents were low (with a mean score of 50%), reinforcing
the need for improved and targeted training.
Several barriers to widespread integration of endovascular simulators into training programs exist. The devices are
expensive (in excess of $100,000) and require regular calibration, maintenance, and updating as reliability remains
problematic. Current training on the simulator is also limited by realism with regard to tactile feedback and graphical
interfaces. Transferability of endovascular and open skills
from the virtual reality realm to the OR remains to be denitively proven. However, there is little doubt that the concept
of simulation is here to stay. As technology continues to
advance, more sophisticated simulators will become available to help surgeons achieve clinical competence, thereby
reducing the number of errors and ultimately improving
patient safety.
VASCULAR TRAUMA SURGERY SHORT COURSES
A number of courses and curricula have been developed to
teach basic and advanced vascular trauma skills. The following section highlights a selection of such courses that
are embraced by leading surgical organizations designed to
meet this challenge.
The Definitive Surgical Trauma Care Course
The Denitive Surgical Trauma Care (DSTC) course traces
its origins to a meeting of ve internationally known trauma
surgeons from the United States, Canada, France, and
Australia. These ve members of the Societé International
de Chirugie (SIC) and the International Association for the
Surgery of Trauma and Surgical Intensive Care (IATSIC)
determined that there was a worldwide need to enhance
surgical training in the technical aspects of trauma care.
118
DSTC is designed to teach qualied surgeons and advanced
surgical trainees strategic thinking and decision making in
the management of severely injured patients, and provide
them with the surgical skills required to manage major
organ injury. Taught by experienced trauma-trained surgeons, it is an intensive 2-day course comprising lectures,
interactive case discussions, and laboratory-based surgical skills training. The surgical skills laboratory is variably
comprised of cadaver, animal (pig or goat), or both animal
and cadaver models, depending on local availability and
cultural sensitivities regarding the use of such models. In
2014, DSTC courses were taught in 41 centers around the
world at sites including Spain, Israel, Canada, Denmark,
the Netherlands, Australia, New Zealand, South Africa,
Austria, Portugal, Norway, Sweden, Germany, France,
Greece, Singapore, and Argentina. This truly international
course provides a broad overview of techniques applicable
to the patient who requires surgery and intensive care for
major trauma. The exibility of the course ensures that it
can be adapted to local conditions although some degree
of standardization is lost. The course includes vascular
exposures and hemorrhage control but does not set out to
teach repair or advanced management of vascular trauma
injuries.
Definitive Surgical Trauma Skills
Denitive Surgical Trauma Skills (DSTS) is a 2-day (originally 3-day) hands-on practical cadaveric workshop course
for civilian surgeons who are required to perform lifepreserving surgery on severely injured patients, as part
of their on-call duties, and for military and humanitarian
surgeons who may deploy to conict zones.
119
This course
was a collaborative effort between the Royal College of Surgeons of England, the UK Defence Medical Services, and the
Uniformed Services University of the Health Sciences in the
United States. Though there is signicant content overlap
with the DSTC course, DSTS was developed specically to
meet local needs and to include an emphasis on cardiothoracic injuries and vascular surgical techniques. In the
words of the original conveners:
To manage trauma competently there is a need to master operative skills that cover the whole of the abdominal cavity, including the pelvis and the retroperitoneum. General surgeons should
be competent and condent to carry out trauma thoracotomies
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and able to cope with central and peripheral vascular trauma.
Further skills and knowledge are also required … encompassing
trauma epidemiology, critical decision making and, not least, a
detailed knowledge of surgical anatomy.
118
Taught by an experienced international faculty of civilian and military surgeons, the course emphasizes the concepts of damage control resuscitation and surgery using
limited didactic material, multiple case discussions, and
extensive “bedside” exposure in the human cadaver lab.
These scenario-driven sessions are supported by surgical
anatomy tutorials using the extensive prosected specimen
preparations of the Royal College of Surgeons of England,
under the supervision of a senior clinical anatomist.
DSTS covers all of the techniques required for vascular
exposure of the vessels in the torso, as well as the junctional
and proximal extremities. Techniques such as shunting,
primary repair, and vessel patching are taught, although
the course emphasizes damage control over denitive vascular repair. As such, DSTS in its current form provides
familiarization with the essence of vascular repair, but it is
not designed to formally teach vascular surgery. The use of
fresh frozen cadavers, combined with excellent anatomic
prosections and the real-time input of a senior anatomist,
provides a level of anatomic accuracy and tactile realism
unique to this course.
Advanced Trauma Operative Management
The Advanced Trauma Operative Management (ATOM)
course uses standardized porcine models to teach the repair
of penetrating trauma. It is offered in over 26 sites in the
United States, Canada, Africa, the Middle East, and Japan.
The ATOM course was developed at Hartford Hospital
(Hartford, CT, USA) and uses a standardized simulation
in which proper methods of repairing severe penetrating
trauma are taught and evaluated.
120
ATOM employs a 1:1
faculty-to-student ratio and a rigidly standardized curriculum to teach the surgical management of injuries to the
bladder, small intestine, kidney, ureter, spleen, pancreas,
stomach, diaphragm, duodenum, liver, lung, inferior vena
cava, and heart. Though it is an excellent primer in the
management of penetrating trauma, the vascular-specic
component of the course is limited to the inferior vena cava
(IVC) and the heart, where injuries bleed profusely and
must be managed correctly if the pig is to survive. A survey
of perceptions among ATOM participants was reported in
2005 and documented post-course improvement in participant self-condence with regard to repairing penetrating
injuries.
121
A worldwide follow-up survey of 1001 ATOM
course participants conducted in 2008 found that participants perceived the course allowed them to identify injuries
more rapidly, to have a more organized operative approach,
and to control bleeding more quickly.
122
The ATOM course is now managed by the surgical skills
subcommittee of the ACS Committee on Trauma (ACSCOT).
Limitations of the course include the associated costs,
the lack of exposure to human anatomy, and the lack of
emphasis regarding exposure and repair of vascular trauma
(other than the IVC and heart). Additionally, the use of live
animals limits utility in certain areas of the world, and it
should be anticipated that such use will be further restricted
in the future.
Advanced Surgical Skills for Exposures in Trauma
(ASSET)
ACSCOT established a Surgical Skills Committee in 2005
that was tasked to develop a standardized, skills-based
course targeted at surgical exposure of those vital structures most likely to be involved following potentially or
immediately life- or limb-threatening injuries. This resulted
in the establishment of a new educational course known
as ASSET. The committee established the following three
educational objectives for the course participants: to
gain knowledge in the proper surgical exposure of lifethreatening injuries, to improve self-condence in operative exposure, and to promote technical competence in
accessing vital structures. The intended audience include
senior surgical residents (postgraduate years [PGY]-4
and PGY-5), trauma and acute care surgery fellows, and
practicing general surgeons involved with trauma care.
To develop the curriculum, the committee developed a
comprehensive list of life- and limb-threatening injuries
for potential inclusion. Using a modied-Delphi process,
the committee members ranked each item for priority and
relevance in the practice of trauma surgery; a specic surgical exposure had to be endorsed by at least 90% of the
committee membership for inclusion. The various injuries
were then grouped by anatomic region as follows: (1) head
and neck, (2) thorax, (3) abdomen and pelvis, (4) retroperitoneum, and (5) extremities. Course materials were generated
for each of these areas and vetted by members of the committee to achieve a consensus view of the materials taught. The
ASSET course was piloted in March 2008 at the Uniformed
Services University in Bethesda, MD, USA. Four beta courses
were then conducted to further codify and rene ASSET,
which began to be formally offered by the ACS in March
2010. This course rapidly gained a foothold with a total of
19 course sites established in the United States and Canada
by the end of 2011, with 54 courses offered and over 500
students and 100 instructors trained.
The ASSET course in its nal form is conducted over a
6- to 7-hour time period using fresh or fresh-frozen cadavers with a student-to-faculty ratio of four to one. The entire
course is conducted in the cadaver dissection lab at the
table side with minimal didactics. The course is designed
specically to teach vascular exposure for management
of trauma. The dissections are guided by a case-based
approach, wherein a few PowerPoint slides are used to present a case (e.g., a patient shot in the upper arm with loss of
pulses and a presumed brachial artery injury), followed by
a few slides of relevant anatomy and a brief narrated video
showing step by step how to do the procedure. The students
are then urged to rapidly perform the exposure with the
help of the faculty who seek to instill a sense of urgency as
if this were an actively bleeding patient. Faculty are guided
by a manual with the specic goals and objectives for each
dissection, but they are also encouraged to engage the students in additional dialog reinforcing the dissections with
their personal clinical pearls and tips. A richly illustrated
laboratory manual and a DVD containing all the vascular
exposures are also provided to the students. Both the manual and the DVD can be purchased outside the course.
123
In an analysis of the rst four beta courses, it was noted
that the general level of trauma experience was low, even
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Table 4.2 Comparison of Mean Pre-ASSET and Post-ASSET
Surgical Self-Assessed Confidence (SSAC) and Mean
Instructor-Assessed Participant Evaluation
Region/Level Pre-SSAC Post-SSAC Difference*
Neck 2.76 3.69 0.93 4.12
Chest 2.49 3.71 1.22 4.03
Abdomen 3.28 4.00 0.72 4.00
Pelvis 2.97 3.97 1.00 4.02
Lower extremity 2.88 3.97 1.09 4.07
Upper extremity 2.63 3.96 1.33 3.93
Note: A five-point Likert scale is used for these scores.
* = P < .05.
Instructor
Evaluation
A
among senior course participants.
124
Participants were
asked to assess comfort level in performing the vascular
exposures both before and after attending ASSET. As seen
in Table 4.2, there was a signicant improvement in con-
dence; additionally, when asked to rate the course using a
ve-point Likert scale, participants had an average response
of 4.8 to the statement “I learned new knowledge”; 4.8 to
“I am better prepared to obtain exposure of injured structures”; and 4.91 to “I would recommend this course to a
colleague.”
The ASSET course was developed to teach vascular exposure and specically does not teach vascular repair. This
factor, course expense, variability in cadaveric availability,
and the fact that the cadaveric model does not bleed comprise the major limitations of ASSET. Nonetheless, it would
appear that the course is tailored to meet the needs of surgeons wishing to learn how to perform the vascular exposures key to the management of vascular injury.
The US military is considering ASSET+ as an assessment
of the readiness of general surgeons before deployment to
a combat zone. ASSET+ will utilize a reduced student-tofaculty ratio, and it will incorporate a second session of dissection in which the students’ abilities to perform the vascular exposures taught in the rst session will be assessed.
In addition, material covering emergent cesarean section,
craniotomy for head trauma, and lateral canthotomy for
retrobulbar hematoma is included. The rst pilot was held
at the University of Maryland in April 2019 (Fig. 4.1).
B
European Vascular Masterclass
In response to work-hour restrictions imposed by the
European Working Time Directive and in an attempt to
standardize vascular training in the European Union, leading European vascular centers developed a European Vascular Masterclass (EVM) course with the specic aim to
train vascular surgeons on realistic open and endovascular
simulators using a standardized teaching approach.
This approach uses stepwise teaching of a consensusformulated approach to performing open vascular procedures. Task-specic learning processes are understood to
be acquired in the following two phases: fast-phase learning and slow-phase learning. Fast-phase learning is set
within individual skill sessions, with complementary slowphase learning occurring between sessions during times of
126
rest.
The EVM provides hands-on experience with pulsa-
tile realistic models (open simple and complex aortic repair,
94,125
C
Fig. 4.1 The ASSET+ Course. (A) Students and faculty review a brief
video of an exposure before performing the procedure on a fresh
cadaver. (B) The reduced student-faculty and student-cadaver ratios
ensure students can perform each exposure and give faculty the
opportunity to closely observe and assess each student. (C) Students
perform an exposure under the observation and instruction of experienced faculty.
endovascular aortic reconstruction, carotid endarterectomy, and distal bypass surgery) and virtual simulators (for
carotid, iliac, and renal interventions). The physical models
have been developed by Synbone (www.synbone.ch), but
they are not currently widely available, nor have they been
4 • Training Paradigms for Vascular Trauma 51
https://t.me/medicina_free
validated as effective teaching tools. The EVM is meeting a
perceived educational need to train basic and advanced vascular surgical techniques, but once again it was not developed to address vascular injuries from trauma.
Basic Endovascular Skills for Trauma (BEST)
With the development of endovascular techniques such as
resuscitative endovascular balloon occlusion of the aorta
(REBOA) and most general and trauma surgeons’ lack
of training in endovascular skills and techniques, multiple courses have arisen to equip these surgeons with the
needed basic endovascular skills necessary to safely employ
new technologies. The BEST course uses a cadaveric model
to teach REBOA, percutaneous and open femoral access,
and common femoral artery repair. The course is primarily offered to fully trained trauma and acute care general
surgeons. Developed by surgeons at the University of
Maryland, the one-day course is now offered under the
auspices of the ACSCOT.
127,128
Endovascular Skills for Trauma and Resuscitative
Surgery (ESTARS)
The ESTARS course is a more extensive course designed to
teach more advanced endovascular skills. Specic learning objectives include REBOA, basic angiography, selective
angiographic vessel catheterization, coil embolization, percutaneous femoral access, upsizing sheaths, and management of large sheath arteriotomies. In addition to didactics,
ESTARS utilizes hands-on instruction with both simulation and an animal model. Simulations are performed on
the Mentice Vascular Intervention System Trainer (VIST,
Evanston, IL). Yorkshire swine of 70 to 90 kg are used as an
animal model.
129
Endovascular Resuscitation and Trauma
Management (EVTM) Workshop
The EVTM society is registered in Sweden, and it has held
a workshop in Orebro, Sweden, since 2014. Workshops
have also been held in several European cities and internationally. The objectives are similar to the ESTARS course.
EVTM also uses both live tissue training and simulation
to teach REBOA, embolization, percutaneous access, and
other endovascular skills useful in managing trauma. Resident physicians and physicians from other specialties are
included in the target audience.
130
Summary
As outlined in this chapter, there are numerous challenges
in educating the surgeon caring for vascular trauma.
Work-hour restrictions are here to stay, a trend that will
increasingly intrude on the time allotted to train the next
generation. We must be more efcient in the way that we
teach and maximize the time available through employment of high-impact, validated curricula designed to meet
the goal of producing competent and procient practitioners. Furthermore, designers of curricula must take advantage of the numerous educational tools discussed in this
chapter, with simulation taking on an ever-increasing role
in the training of vascular trauma specialists. The delity
of endovascular simulators is excellent, but simulators that
allow for the training of open surgical procedures are in
their infancy. Several excellent physical models that approximate human tissue characteristics are currently in development, and they will no doubt make a big impact on future
training. Comprehensive curricula must teach the management of vascular trauma incorporating surgical exposure
of blood vessels (as is done with the DSTS, ASSET, MOST,
and some DSTC courses), control of bleeding (as is taught
in limited fashion in the ATOM and some DSTC courses),
and basic vascular techniques (both open and endovascular). Such a comprehensive vascular trauma curriculum
does not currently exist, and it is incumbent on the community of surgeons caring for patients with vascular trauma
to address this decit in the near future in order to ensure a
legacy of highly skilled surgeons who are able to manage all
aspects of vascular trauma.
References
1. Pickersgill T. The European working time directive for doctors in train-
ing. BMJ. 2001;323:1266.
2. Lamont PM, Scott DJ. The impact of shortened training times on
the discipline of vascular surgery in the United Kingdom. Am J Surg.
2005;190:269–272.
3. Pellegrini CA, Warshaw AL, Debas HT. Residency training in surgery
in the 21st century: a new paradigm. Surgery. 2004;136:953–965.
4. Bell Jr RH, Banker MB, Rhodes RS, Biester TW, Lewis FR. Graduate
medical education in surgery in the United States. Surg Clin North Am.
2007;87:811–823.
5. Barden CB, Specht MC, McCarter MD, Daly JM, Fahey 3rd TJ.
Effects of limited work hours on surgical training. J Am Coll Surg.
2002;195(4):531–538.
6. Benes V. The European Working Time Directive and the effects on
training of surgical specialists (doctors in training): a position paper
of the surgical disciplines of the countries of the EU. Acta Neurochir
(Wien). 2006;148(11):1227–1233.
7. Ferguson C, Kellogg K, Hutter M, Warshaw AL. Effect of work-hour
reforms on operative case volume of surgical residents. Curr Surg.
2005;62:535–538.
8. Thomas RL, Karanja N. Comparison of SHO surgical log books a
generation apart. Ann R Coll Surg Eng. 2009;9(Suppl):356–359.
9. Lewis FR, Klingensmith ME. Issues in general surgery residency
training—2012. Ann Surg. 2012;256(4):553–559.
10. Smith R. Regulation of doctors and the Bristol inquiry. Both need
to be credible to both the public and doctors. BMJ. 1998;317(7172):
1539–1540.
11. Walshe K, Offen N. A very public failure: lessons for quality improve-
ment in healthcare organisations from the Bristol Royal Inrmary.
Qual Health Care. 2001;10(4):250–256.
12. Institute of Medicine (US) Committee on Quality of Health Care in
America. In: Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is
Human: Building a Safer Health System. Washington, DC: National
Academies Press (US); 2000. Available from http://www.nation-
alacademies.org/hmd/Reports/1999/To-Err-is-Human-Building-ASafer-Health-System.aspx.
13. Leape LL, Berwick DM. Five years after To Er r Is Human: what have we
learned? JAMA. 2005;293(19):2384–2390.
14. Dutta S, Dunnington G, Blanchard MC, etal. And doctor, no residents
please! J Am Coll Surg. 2003;197:1012–1017.
15. Gallagher AG, McClure N, McGuigan J, Ritchie K, Sheehy NP. An ergo-
nomic analysis of the fulcrum effect in the acquisition of endoscopic
skills. Endoscopy. 1998;30(7):617–620.
16. Gallagher AG, Cates CU. Approval of virtual reality training for carotid
stenting: what this means for procedural-based medicine. JAMA.
2004;292(24):3024–3026.
17. Bell RH. Surgical council on resident education: a new organiza-
tion devoted to graduate surgical education. J Am Coll Surg. 2007;
204(3):341–346.
18. The SCORE Portal. https://www.surgicalcore.org/public/about. Acces-
sed 26 May 2019.
52 SECTION 1 • Setting the Stage
https://t.me/medicina_free
19. Association of Program Directors in Vascular Surgery. 2019 APDVS
Spring Meeting. Available at: https://vascular.org/apdvs/meetings/
past-events/2019-apdvs-spring-meeting. Accessed 22 August 2019.
20. Joels CS, Langan 3rd EM, Cull DL, et al. Effects of increased vascu-
lar surgical specialization on general surgery trainees, practicing
surgeons, and the provision of vascular surgical care. J Am Coll Surg.
2009;208(5):692–697.
21. Grabo DJ, DiMuzio PJ, Kairys JC, et al. Have endovascular proce-
dures negatively impacted general surgery training? Ann Surg.
2007;246:472–477.
22. Lin PH, Bush RL, Milas M, etal. Impact of an endovascular program
on the operative experience of abdominal aortic aneurysm in vascular
fellowship and general surgery residency. Am J Surg. 2003;186:189–193.
23. Cronenwett JL. Vascular surgery training: is there enough case mate-
rial? Semin Vasc Surg. 2006;19:187–190.
24. Shannon AH, Robinson WP, Hanks JB, Potts III JR. Impact of new
vascular fellowship programs on vascular surgery operative volume
of residents in associated general surgery programs. J Am Coll Surg.
2019;228:525–535.
25. Carrol MI, Downes K, Miladinovic B, etal. A single-institution experi-
ence: the integrated vascular surgery residency’s effect on Fellowship
and general surgery resident case volume and diversity. Ann Vasc Surg.
2014;28:253–259.
26. Cortez AR, Dhar VK, Sussman JJ, Pritts TA, Edwards MJ, Quillin III RC.
Not all operative experiences are created equal: a 19-year analysis of
a single center’s case logs. J Surg Res. 2018;229:127–133.
27. Drake FT, Horvath KD, Goldin AB, Gow KW. The general surgery chief
resident operative experience: 23 years of National ACGME case logs.
JAMA Surg. 2013;148:841–847.
28. Potts III JR, Valentine RJ. Declining resident experience in open
vascular operations threatens the status of vascular surgery as an
essential content area of general surgery training. Ann Surg. 2018;
268:665–673.
29. Accreditation Council for Graduate Medical Education. Case log
graduate statistics. Available from: https://www.acgme.org/Data-
Collection-Systems/Case-Logs-Statistical-Reports. Accessed 25 May
2019.
30. Yan H, Maximus S, Koopmann M, etal. Vascular trauma operative
experience if inadequate in general surgery programs. Ann Vasc Surg.
2016;3:94–97.
31. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH,
Rasmussen TE. The epidemiology of vascular injury in the wars in
Iraq and Afghanistan. Ann Surg. 2011;253:1184–1189.
32. Patel JA, White JM, White PW, Rich NM, Rasmussen TE. A contempo-
rary, 7-year analysis of vascular injury from the war in Afghanistan.
J Vasc Surg. 2018;68(6):1872–1879.
33. Bulinski P, Bachulis B, Naylor Jr DF, etal. The changing face of trauma
management and its impact on surgical resident training. J Trauma.
2003;54(1):161–163.
34. Brigham RA, Salander JM. Lack of a signicant exposure to trauma
by residents. Mil Med. 1989;154(11):581.
35. Gaarder C, Skaga NO, Eken T, Pillgram-Larsen J, Buanes T, Naess PA.
The impact of patient volume on surgical trauma training in a Scandinavian trauma centre. Injury. 2005;36:1288–1292.
36. Drake FT, Aarabi S, Garland BT, et al. Accreditation Council for
Graduate Medical Education (ACGME) surgery resident operative
logs: the last quarter century. Ann Surg. 2017;265:923–929.
37. Quillin III RC, Cortez AR, Pritts TA, Hanseman DJ, Edwards MJ,
Davis BR. Operative variability among residents has increased since
implementation of the 80-hour workweek. J Am Coll Surg. 2016;
222:1201–1210.
38. Strumwasser A, Grabo D, Inaba K, etal. Is your graduating general
surgery resident qualied to take trauma call? A 15-year appraisal of
the changes in general surgery education for trauma. J Trauma Acute
Care Surg. 2017;82:470–480.
39. Boutros J, Sekhon M, Webber E, Sidhu RS. Vascular surgery training,
exposure, and knowledge during general surgery residency: implications for the future. Am J Surg. 2007;193:561–566.
40. van Bockel JH, Bergqvist D, Cairols M, et al. European Section and
Board of Vascular Surgery of the European Union of Medical Specialists: Education in vascular surgery: critical issues around the globetraining and qualication in vascular surgery in Europe. J Vasc Surg.
2008;48(6 Suppl):69S–75S.
41. Veller MG. Education in vascular surgery-critical issues: a Southern
African perspective. J Vasc Surg. 2008;48(6 Suppl):84S–86S.
42. Burkhardt GE, Rasmussen TE, Propper BW, Lopez PL, Gifford SM,
Clouse WD. A national survey of evolving management patterns for
vascular injury. J Surg Educ. 2009;66(5):239–247.
43. Eckert M, Cuadrado D, Steele S, Brown T, Beekley A, Martin M. The
changing face of the general surgeon: national and local trends in
resident operative experience. Am J Surg. 2010;199(5):652–656.
44. Rasmussen TE, Stockinger Z, Antevil J, etal. Wartime vascular injury.
Mil Med. 2018;183(Suppl_2):101–104.
45. Intercollegiate Surgical Curriculum Programme. Available at: https://
www.iscp.ac.uk/curriculum/surgical/surgical_syllabus_list.aspx.
Accessed 22 August 2019.
46. Mills Sr. JL. Vascular surgery training in the United States: a half-
century of evolution. J Vasc Surg. 2008;48(Suppl 6):90S–97S.
47. Goldstone J. New training paradigms and program requirements.
Semin Vasc Surg. 2006;19:168–171.
48. DeWeese JA. Accreditation of vascular training programs and certi-�
cation of vascular surgeons. J Vasc Surg. 1996;23:1043–1053.
49. DeWeese JA. Should vascular surgery become an independent spe-
cialty. J Vasc Surg. 1990;12:605–606.
50. Barnes RW, Ernst CB. Vascular surgical training of general and vascu-
lar surgery residents. J Vasc Surg. 1996;24:1057–1063.
51. Stanley JC, Barnes RW, Ernst CB, etal. Vascular surgery in the United
States: workforce issues. Report of the Society for Vascular Surgery
and the International Society for Cardiovascular Surgery, North
American Chapter, Committee on Workforce Issues. J Vasc Surg.
1996;23:172–181.
52. Tanious A, Wooster M, Jung A, Nelson PR, Armstrong PA, Shames
ML. Comparison of the integrated vascular surgery resident operative experience and the traditional vascular surgery fellowship. J Vasc
Surg. 2017;66:307–310.
53. Phair J, Car nevale ML, Teveris VG, Koleilat I, Indes JE. Peripheral arterial
occlusive disease operative case volume in the nal years of 5+2 and
0+5 vascular training paradigms. Surgery. 2019;166(2):198–202.
54. Tanious A, Wooster M, Jung A, Nelson PR, Armstrong PA, Shames
ML. Open abdominal surgical training differences experienced
by integrated vascular and general surgery residents. J Vasc Surg.
2017;66:1280–1284.
55. Smith BK, Kang C, McAninch C, Leverson G, Sullivan S, Mitchell EL.
0+5 Vascular surgery residents’ operative experience in general surgery: an analysis of operative logs from 12 integrated programs. J Surg
Educ. 2016;73:536–541.
56. Nandivada P, Lagisetty KH, Giles K, etal. The impact of endovascular
procedures on fellowship training in lower extremity revascularization. J Vasc Surg. 2012;55:1814–1820.
57. Dua A, Koprowski S, Upchurch G, Lee CJ, Desai SS. Progressive short-
fall in open aneurysm experience for vascular surgery trainees with
the impact of fenestrated and branched endovascular technology.
J Vasc Surg. 2017;66:257–261.
58. Eidt JF, Mills J, Rhodes RS, et al. Comparison of surgical operative
experience of trainees and practicing vascular surgeons: a report from
the Vascular Surgery Board of the American Board of Surgery. J Vasc
Surg. 2011;53(4):1130–1139.
59. Saltzman PD. In: Saltzman PD, ed. Best Practices in Surgical Education:
Innovations in Skills Training. Cincinnati, OH: Ethicon Endo-Surgery,
Inc; 2010.
60. Dewey J. Experience and Education. New York: Simon & Schuster; 1938.
61. Knowles MS, Holton EF, Swanson RA. The Adult Learner. 5th ed.
Woburn, MA: Butterworth-Heinemann; 1998.
62. Reeds MG. Trauma training using the live tissue model. J Trauma.
2010;69:999–1000.
63. Sohn VY, Miller JP, Koeller CA, etal. From the combat medic to the
forward surgical team: the Madigan model for improving trauma
readiness of brigade combat teams ghting the Global War on
Terror. J Surg Res. 2007;138:25–31.
64. Ritter EM, Bowyer MW. Simulation for trauma and combat casualty
care. Minim Invasive Ther Allied Technol. 2005;14(224–234)
65. DOD Instruction 3216.01. Use of animals in DoD conducted and
supported research and training. https://www.esd.whs.mil/Portals/
54/Documents/DD/issuances/dodi/321601p.pdf Accessed 22 August
2019.
66. Gambhir RPS, Agrawal A. Training in trauma management. Med J
Armed Forces India. 2010;66:354–356.
67. Ballala K, Shetty A, Malpe SB. Knowledge, attitude, and practices
regarding whole body donation among medical professionals in a
hospital in India. Anat Sci Educ. 2011;4:142–150.
4 • Training Paradigms for Vascular Trauma 53
https://t.me/medicina_free
68. Aboud E, Al-Mefty O, Yasargil MG. New laboratory model for
neurosurgical training that simulates live surgery. J Neurosurg.
2002;97:1367–1372.
69. Aboud E. Live Surgery Practice using Perfused Human Cadavers.
Paper presented at: Alternatives in the Mainstream: Innovations
in Life Science Education and Training. 2nd InterNICHE Conference, Oslo Norway, 2005 May 12–15. http://new.interniche.org.
Accessed 17 December 2011.
70. Aboud ET, Krisht AF, O’Keefe T, etal. Novel simulation training for
trauma surgeons. J Trauma. 2011;71:1484–1490.
71. Sundar E, Sundar S, Pawlowski J, Blum R, Feinstein D, Pratt S.
Crew resource management and team training. Anesthesiol Clin.
2007;25:283–300.
72. Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian
JP. Medical team training: applying crew resource management
in the Veterans Health Administration. Jt Comm J Qual Patient Saf.
2007;33:317–325.
73. France DJ, Leming-Lee S, Jackson T, Feistritzer NR, Higgins MS. An
observational analysis of surgical team compliance with perioperative safety practices after crew resource management training. Am
J Surg. 2008;195:546–553.
74. Armour Forse R, Bramble JD, McQuillan R. Team training can
improve operating room performance. Surgery. 2011;150:771–
778.
75. Sanfey H, McDowell C, Meier AH, Dunnington GL. Team training
for surgical trainees. Surgeon. 2011;9(Suppl 1):S32–S34.
76. King HB, Battles J, Baker DP, et al. TeamSTEPPS: team strategies
and tools to enhance performance and patient safety. In: Henrickson K, Battles JB, Keyes MA, et al., eds. Advances in Patient Safety:
New Directions and Alternative Approaches, vol 3, Performance and
Tools. Rockville, MD: Agency for Healthcare Research and Quality
(US); 2008.
77. House of Commons Health Committee. Patient Safety. Sixth Report
of Session 2008–2009. London: The Stationery Ofce Limited;
2009.
78. O’Dea A, O’Connor P, Keogh I. A meta-analysis of the effectiveness
of crew resource management training in acute care domains.
Postgrad Med J. 2014;90:699–708.
79. Hughes AM, Gregory ME, Joseph DL, etal. Saving lives: A meta-anal-
ysis of team training in healthcare. J Appl Psychol. 2016;101(9):
1266–1304.
80. Neily J, Mills PD, Young-Xu Y, etal. Association between implemen-
tation of a medical team training program and surgical mortality.
JAMA. 2010;304:1693–1700.
81. Kellicut DC, Kuncir EJ, Williamson HM, Masella PC, Nielsen PE.
Surgical team assessment training: improving surgical teams
during deployment. Am J Surg. 2014;208(2):275–283.
82. Hansen KS, Uggen PE, Brattebø G, Wisborg T. Team-oriented train-
ing for damage control surgery in rural trauma: a new paradigm.
J Trauma. 2008;64(4):949–953.
83. Midwinter M, Mercer S, Lambert AW, de Rond M. Making difcult
decisions in major military trauma: a crew resource management
perspective. J R Army Med Corps. 2011;157(3 suppl):299–304.
84. Bowyer MW. Educational Case Study: The National Capital Area
Medical Simulation Center of the Uniformed Services University
of the Health Sciences. In: Saltzman PD, ed. Best Practices in Surgi-
cal Education: Innovations in Skills Training. Cincinnati, OH: Ethicon
Endo-Surgery, Inc; 2010.
85. Ziv A, Wolpe PR, Small SD, Glick S. Simulation-based medical edu-
cation: an ethical imperative. Acad Med. 2003;78:783–788.
86. Reznick RK, Macrae H. Teaching surgical skills–changes in the
wind. N Engl J Med. 2006;355:2664–2669.
87. Satava RM. Virtual reality surgical simulator. The rst steps. Surg
Endosc. 1993;7:203–205.
88. Tsuda S, Scott D, Doyle J, Jones DB. Surgical skills training and sim-
ulation. Curr Probl Surg. 2009;46:271–370.
89. Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness
of continuing medical education: evidence report/technology
assessment No. 149 (prepared by the Johns Hopkins EvidenceBased Practice Center, under contract No. 290-02-0018) (Agency
for Healthcare Research and Quality, Rockville, MD) AHRQ Publication No. 07-E006, 2007.
90. Seymour N. VR to OR: a review of the evidence that virtual real-
ity simulation improves operating room performance. World J Surg.
2008;32:182–188.
91. Berry M, Lystig T, Beard J, Klingestierna H, Reznick R, Lönn L. Por-
cine transfer study: virtual reality simulator training compared
with porcine training in endovascular novices. Cardiovasc Intervent
Radiol. 2007;30:455–461.
92. Chaer RA, DeRubertis BG, Lin SC, etal. Simulation improves resi-
dent performance in catheter-based intervention: results of a randomized, controlled study. Ann Surg. 2006;244:343–352.
93. Sidhu RS, Park J, Brydges R, MacRae HM, Dubrowski A. Laboratory
based vascular anastomosis training: a randomized controlled trial
evaluating the effects of bench model delity and level of training
on skill acquisition. J Vasc Surg. 2007;45:343–349.
94. Pandey V, Wolfe JH, Moorthy K, Munz Y, Jackson MJ, Darzi AW.
Technical skills continue to improve beyond surgical training. J Vasc
Surg. 2006;43:539–545.
95. Black SA, Harrison RH, Horrocks EJ, Pandey VA, Wolfe JH. Compe-
tence assessment of senior vascular trainees using a carotid endarterectomy bench model. Br J Surg. 2007;94:1226–1231.
96. Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg. 2000;87:
28–37.
97. Neequaye SK, Aggarwal R, Van Herzeele I, Darzi A, Cheshire NJ.
Endovascular skills training and assessment. J Vasc Surg. 2007;46(5):
1055–1064.
98. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality
simulation for the operating room: prociency based training as
a paradigm shift in surgical skills training. Ann Surg. 2005;24:
364–372.
99. Van Herzeele I, Aggarwal R, Neequaye S, Darzi A, Vermassen F,
Cheshire NJ. Cognitive training improves clinically relevant outcomes during simulated endovascular procedures. J Vasc Surg.
2008;48:1223–1230.
100. Ahlberg G, Enochsson L, Gallagher AG, etal. Prociency-based vir-
tual reality training signicantly reduces the error rate for residents
during their rst 10 laparoscopic cholecystectomies. Am J Surg.
2007;193:797–804.
101. Seymour N, Gallagher A, Sanziana R, etal. Virtual reality train-
ing improves operating room performance: results of a randomized,
double-blinded study. Ann Surg. 2002;236:458–464.
102. Verdaasdonk EG, Stassen LP, van Wijk RP, Dankelman J. The inu-
ence of different training schedules on the learning of psychomotor
skills for endoscopic surgery. Surg Endosc. 2007;21:214–219.
103. Moulton CA, Dubrowski A, Macrae H, Graham B, Grober E, Reznick
R. Teaching surgical skills: what kind of practice makes perfect? A
randomized, controlled trial. Ann Surg. 2006;244:400–409.
104. Darzi A, Mackay S. Assessment of surgical competence. Qual Health
Care. 2001;10:64–69.
105. Smith SG, Torkington J, Darzi A. Objective assessment of surgical
dexterity using simulators. Hosp Med. 1999;60:672–675.
106. Gould DA, Reekers JA, Kessel DO, et al. Simulation devices in
interventional radiology: validation pending. J Vasc Interv Radiol.
2006;17:215–216.
107. McClusky 3rd DA, Smith CD. Design and development of a surgical
skills simulation curriculum. World J Surg. 2008;32:171–181.
108. Satava RM. Identication and reduction of surgical error using
simulation. Minim Invasive Ther Allied Technol. 2005;14:257–261.
109. Arora S, Lamb B, Undre S, etal. Framework for incorporating simu-
lation into urology training. BJU Int. 2011;107:806–810.
110. Aggarwal R, Cheshire N, Darzi A. Endovascular simulation-based
training. Surgeon. 2008;6:196–197.
111. Tsang JS, Naughton PA, Leong S, Wong KC, Chan YC. Virtual
reality simulation in endovascular surgical training. Surgeon.
2008;6(4):214–220.
112. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese
RJ. Features and uses of high-delity medical simulations that
lead to effective learning: a BEME systematic review. Med Teach.
2005;27:10–28.
113. Bismuth J, Donovan MA, O’Malley MK, etal. Incorporating simu-
lation in vascular surgery education. J Vasc Surg. 2010;52:1072–
1080.
114. Pandey VA, Wolfe JHN, Lindahl AK, etal. on behalf of the Euro-
pean Board of Vascular Surgery. Validity of an exam assessment
in surgical skill: EBSQ-VASC pilot study. Eur J Vasc Endovasc Surg.
2004;27:341–348.
115. Pandey VA, Wolfe JH, Liapis CD, Bergqvist D. European Board of
Vascular Surgery. The examination assessment of technical competence in vascular surgery. Br J Surg. 2006;93:1132–1138.
54 SECTION 1 • Setting the Stage
https://t.me/medicina_free
116. Sidhu RS, Chen J, Baxter K, Wu H. Development of a comprehen-
sive vascular skills assessment for surgical trainees. Am J Surg.
2009;197:591–594.
117. Reznick R, Regehr G, MacRae H, Martin J, McCulloch W. Testing
technical skill via an innovative “bench station” examination. Am J
Surg. 1997;173:226–230.
118. Ryan JM, Roberts P. Denitive surgical trauma skills: a new skills
course for specialist registrars and consultants in general surgery
in the United Kingdom. Trauma. 2002;4:184–188.
119. Royal College of Surgeons of England. https://www.rcseng.ac.uk/
education-and-exams/courses/search/denitive-surgical-traumaskills-dsts/. Accessed 23 October 2019.
120. Jacobs LM, Burns KJ, Kaban JM, etal. Development and evaluation
of the Advanced Trauma Operative Management course. J Trauma.
2003;55:471–479.
121. Jacobs LM, Burns KJ, Luk SS, Marshall 3rd WT. Follow-up survey
of participants attending the Advanced Trauma Operative Management (ATOM) course. J Trauma. 2005;58:1140–1143.
122. Jacobs L, Burns K, Hull S. Advanced Trauma Operative Manage-
ment course: participant survey. World J Surg. 2010;34:164–168.
123. American College of Surgeons. Advanced Surgical Skills for Exposure in Trauma. https://www.facs.org/quality-programs/trauma/
education/asset. Accessed 23 October 2019.
124. Kuhls DA, Risucci DA, Bowyer MW, etal. Advanced Surgical Skills
for Exposure in Trauma (ASSET): a new surgical skills cadaver
course for surgery residents and fellows. JACS. 2013;74(2):664–
670. 2012 submitted unpublished data.
125. European Vascular Course. http://www.vascular-course.com/.
Accessed 25 October 2019.
126. Walker MP, Brakeeld T, Hobson J, Stickgold R. Dissociable stages
of human memory consolidation and reconsolidation. Nature.
2003;425:616–620.
127. Brenner M, Hoehn M, Pasley J, Dubose J, Stein D, Scalea T. Basic
endovascular skills for trauma course: bridging the gap between
endovascular techniques and the acute care surgeon. J Trauma
Acute Care Surg. 2014;77(2):286–291.
128. American College of Surgeons. Basic Endovascular Skills for
Trauma. Available at: https://www.facs.org/quality-programs/
trauma/education/best.
129. Villamaria CY, Eliason JL, Napolitano LM, Stanseld RB, Spencer
JR, Rasmussen TE. Endovascular Skills for Trauma and Resuscitative Surgery (ESTARS) course: curriculum development, content
validation, and program assessment. J Trauma Acute Care Surg.
2014;76(4):929–935, discussion 935-936.
130. Endovascular Resuscitation and Trauma Management. Available
at: http://www.jevtm.com/workshop/.
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