Introduction

The issue of surgical training—whether vascular or general—faces a number of significant current and future challenges. The introduction of work-hour restrictions in the United States, the United Kingdom, and the European Union has led to dramatically decreased opportunities for exposure to patients and clinical material for trainees. The full impact of these work-hour directives has yet to be fully assessed. However, a recent study by the Royal College of Surgeons of England suggests that the quality of patient care has sharply declined because of the lack of continuity of care, and it further suggests that operative exposure is insufficient to ensure competency in an adequate range of procedures for independent practice. The development of ever–increasingly complex procedures, including endovascular techniques, has strained the ability of surgical residency or fellowship programs to endow competence and proficiency in all the required areas of practice. At the same time, there is increasing scrutiny of the quality of health care, brought about by a number of high-profile cases involving medical errors, such as the Bristol Enquiry in the United Kingdom and the “to err is human” report in the United States.

Additionally, there has also been an increasing trend toward conservative management of solid organ injury, which has resulted in significantly less opportunity for trainees to undertake open surgical procedures. The increasing specialization of vascular surgeons and their training has also diluted the available training cases for general surgery residents with the majority of open vascular cases being done by vascular surgeons and vascular residents/fellows. Overall, and in spite of the fact that many still consider vascular surgery to be an integral part of general surgery training, senior trainees are getting less experience in this area. Over the last 10 years, the average number of major vascular repairs for trauma that were reported by graduating chief residents to the American Board of Surgery as being performed over the entire residency program in general surgery decreased from 5.0 in 2001-2002 to 2.1 in 2010-2011 (see Table 24-1 ). It is important to bear in mind that these data reflect average experience, and as such there are significant numbers of trainees who have no experience caring for patients with major vascular trauma. It is also revealing to look at the logbook data reported for numbers of neck explorations for trauma (0.3), for treatment of cardiac injury (0.3), for fasciotomy (1.2), and for trauma splenectomies (2.5) that were undertaken by recent graduates of U.S. training programs. Reported experience concerning exposure of the brachial artery by graduating residents was similarly scant with an average of 0.1 cases per trainee in 2009-2010 and 0.0 in 2010-2011.

Based on the data presented, it is clear that general surgery residents in the U.S. have a suboptimal experience with the surgical management of vascular trauma. In Canada, vascular surgery has been removed from the Canadian general surgery training objectives. In a recent survey of 29 Canadian surgical residents, 90% reported an intention to perform vascular procedures after training despite the same cohort self-reporting of inadequate training in 10 of the 13 procedures surveyed. Unsurprisingly, the authors of this study concluded that current trainees may lack the skills and abilities to deal with vascular emergencies. Furthermore, in spite of the growing prevalence of specialist-trained vascular surgeons, there are still many areas in the world (developed and underdeveloped) where the primary surgeon may not be a vascular surgical specialist and where opportunities to practice a vascular skill set are infrequent. While it may be argued that the solution to this problem is to ensure that a fully trained vascular surgical specialist is available for each and every trauma case, this staffing arrangement is not practical in many hospitals and is certainly unfeasible in the austere domains of military and humanitarian surgical practice. Thus the need to train competent practitioners who can handle vascular trauma is universal.

In the developed world where, in comparison to previous practice, vascular trauma is increasingly funneled toward specialist trauma or vascular surgeons, opportunities to gain experience in vascular trauma are also limited. The numbers of major vascular repairs for trauma that were reported to the American Board of Surgery by vascular surgery fellows—though significantly greater than that reported by graduates of general surgery residencies—are small, with the average number of cases reported as 7.6 in 2001-2002 and 10.8 in 2010-2011 ( Table 24-2 ). Further, 76% of these procedures were peripheral in nature with surgical experience of vascular trauma in the thorax and neck being particularly low, averaging between 0.3 and 0.8 cases per resident, respectively. Additionally, vascular fellows reported an average experience of fasciotomy between 0.8 and 1.4 cases over the last decade, with 0.1 to 0.3 open brachial artery exposures over the last 4 years.

When looking at recertification data emanating from U.S. vascular surgeons, the reported number of trauma cases is also suboptimal. 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 4 procedures.

Though it is difficult to judge proficiency and competence by volume data alone, it is certain that the experience of trainees is anything but uniform. Specialists are expected to graduate with a wide spectrum of abilities; but they, when called on to care for vascular trauma, may or may not have the requisite skill set to ensure the best outcome. Likewise, only a small minority of vascular specialists report that the management of vascular trauma comprises part of their clinical practice.

It is clear that the experiential approach is not sufficient as a means of endowing surgical trainees with the right skills. 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 near-term modalities that are likely to improve the uniformity of training in the management of vascular trauma.

Vascular Training in Evolution

Training in surgery has traditionally followed an apprenticeship model, with the trainee undergoing supervised exposure to decision-making and technical skills under the tutelage of a “craft” master. Historically, the acquisition of vascular techniques—whether by master or apprentice—has followed a model whereby the development of new skills occurs via adaption and remolding of previously learned skill sets. However, the move from open surgery to the endovascular approach represents a paradigm shift in the management of vascular disease, and the opportunity to transfer previously learned skills to these new realms of practice is concordantly lower. New endovascular therapies pose technical challenges, similar to those experienced by practitioners of laparoscopic and minimally invasive surgery (MIS). These include reduced tactile sensation, a two-dimensional (2-D) (rather than a three-dimensional [3-D]) perspective, and the need to overcome proprioceptive and visual issues. New decision-making algorithms and treatment opportunities often require new training models and educational curricula—applicable to both established specialists and surgical trainees—while paying heed to new restrictions in duty hours. The relentless and inevitable drive to subspecialize has required practitioners to master new techniques at the cost of narrowing clinical focus and constraining the surgical armamentarium required for injury stabilization and vessel repair. With these issues in mind, it is timely to consider new and emerging ways of delivering training to surgeons expected to manage patients with vascular trauma.

Vascular Trauma Training Considerations

As previous chapters demonstrate, effective trauma management presents specific 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 flexibly deployed to deal with the individual situation at hand.

Training must be set at two distinct levels: (1) the decision-making and technical skills 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 complications, and longer-term management. Training may be delivered via a vascular or trauma surgery curriculum (i.e., as part of a generic surgical training rotation or as part of a dedicated vascular program/fellowship for the specialist) through supervised and controlled exposure to patients and their management. Such training must be part of a properly planned curriculum, tailored to meet the learning outputs required of the target audience.

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 information and to a 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. Didactic lectures, textual material and, more recently, case-based 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, 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. Effective and systematic training is a byproduct of the quality of the curriculum that is developed to enhance that training.

Within the United Kingdom, the vascular curriculum is set by the Intercollegiate Surgical Curriculum Programme (ISCP). The ISCP benefits from the input of specialty advisory committees (SACs) representing each of the ten surgical specialties. It is also informed by and collaborates with the Surgical Royal Colleges of Great Britain and Ireland and other professional bodies, including the Local Education and Training Boards (established in 2013) a and the General Medical Council (GMC). In 2012 , vascular surgery became established as a fully-fledged surgical specialty and left the aegis of the General Surgery SAC, with a dedicated training pathway leading to specialist certification, separate from that of general surgery.

In the United States, vascular surgery has been (and is still considered by many to be) an integral part of general surgery training and practice. Before 1960, no specific training programs existed in vascular surgery, and vascular surgery was practiced by general and cardiothoracic surgeons. The first vascular surgery–specific training programs were, in essence, apprenticeships directed by some of the pioneers of vascular surgery. Training opportunities were advanced considerably when the membership of the Society for Vascular Surgery (SVS) voted in 1979 to develop accredited vascular training programs. Initially, 17 programs were approved, rising to 52 programs by 1982. In 1982, the first 14 American Board of Surgery (ABS) Certificates of Special Qualifications in General Vascular Surgery were issued, each earned after successful completion of a written examination. In the 1990s, leading vascular surgeons pushed for recognition of vascular surgery as a specialty distinct from general surgery, based on the underlying premise that patient outcomes were improved when care was provided by a specialist in vascular surgery rather than a general surgeon who occasionally performed vascular operations. Subsequently, vascular surgery became a distinct specialty of surgery on March 17, 2005, when (with approval of the American Board of Medical Specialties) the ABS agreed to offer a Primary Certificate in Vascular Surgery. In October 2005, training program requirements for this certificate were approved; and the traditional requirement for 5 years of training and certification in general surgery was eliminated. Effective July 1, 2006, the ABS converted its certificate in vascular surgery from a subspecialty certificate to a specialty (primary) certificate. These landmark changes heralded the development of several new training paradigms. Multiple flexible training pathways—leading to either dual certification ( Traditional: 5 years general plus 2 years vascular training; Early Specialization Program : 4 years general plus 2 years vascular training) or vascular surgery certification alone ( Integrated: 1 plus 5; Independent: 3 plus 3)—are now available.

The current trend in surgical training within the U.S. is toward a structured, competency-based curriculum with objective and ongoing documentation of proficiency within residency training and then going into independent practice. Toward this end, national organizations including the American College of Surgeons (ACS), the ABS, the Residency Review Committee—Surgery, the American Surgical Association, the Association for Program Directors in Surgery, and the Association for Surgical Education have established a national consortium called the Surgical Council on Resident Education (SCORE) to reform general surgical residency education. The thrust of SCORE’s endeavors is to develop a national curriculum that will include a spectrum of educational offerings delivered in a modular system. The curriculum includes didactic content; simulated experiences; clinical and surgical experiences; and valid, reliable performance assessments. The Association for Program Directors in Vascular Surgery has begun to adopt some of the same principles in the development of vascular curricula. The aim is to ensure alignment of the core content of the training program, the core competencies expected as learning outcomes, and the assessment practices. This will confirm that—no matter what program or tract a resident completes—measurable and acceptable levels of competence are achieved in all required areas.

As yet, the ideal curriculum for training in vascular trauma has not been delineated and will likely be specific 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 proficient 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

As previously emphasized, effective training begins and ends with effective curricula. The tools currently available to teach the management of vascular trauma include the following:

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  Clinical case material—care of patients

  
  
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  Didactic lectures

  
  
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  Textbook and digital media

  
  
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  Case-based discussion

  
  
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  Team-based training

  
  
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  Animal-model–based training

  
  
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  Human-cadaver–based training

  
  
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  Simulation-based training

  
  
  
  
  • a.
    

    Synthetic models—Low and high fidelity

    
    
  • b.
    

    Virtual reality

  
  

Ideally, curricular offerings with regard to the management of vascular trauma will incorporate several of these tools, each selected according to the goals and objectives of the educational program. Clinical case material has long been the mainstay of vascular trauma training but can no longer be counted on to provide sufficiently high volume. Didactic lectures, textbook and digital media, and case-based discussion represent the bulk of traditional curricular efforts but have limited applicability if not focused and incorporated within a meaningful curriculum. Likewise, animal models and human cadavers have proved important 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.

The use of animals for training has several advantages and a number of distinct limitations. Animals provide excellent representations 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. However, maintenance of an animal lab is expensive and logistically intensive, requiring the means for veterinary support, animal care facilities, sterile operating room (OR) facilities, and proper disposal of the animals. Animal laboratories are rightly subject to stringent care standards in order to ensure animal welfare is respected. The use of animals is a highly visible and emotionally charged issue decried by very active and vocal animal rights groups. The other key disadvantage of animal models concerns differences in anatomy: animals 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 U.S., multiple and repeated efforts to outlaw the use of live animals for trauma training continue unabated. A recent bill put before Congress seeks to require the Secretary of Defense to use only human-based methods for the training of Armed Forces in the management of severe combat injuries—thereby effectively outlawing the use of animals by 2016. Though this particular initiative is likely to be defeated, many similar endeavors will threaten the place of such training within surgical curricula. 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. 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 ASSET course) is highly variable, ranging up to $8000, depending on the U.S. state concerned. Even in areas where it is possible to obtain cadaveric, material the number of adequate specimens may not be sufficient 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 same.

Though cadavers give an excellent representation of human anatomy, the anatomy is specific to that particular cadaver. As there is great variability in human anatomy, this represents a potential limitation. Additionally, most cadavers are elderly and deconditioned; and, as such, translating the lessons learned on an 80-year-old woman with diminished muscle mass to a 20-year-old combat soldier may be difficult. The way in which a cadaver is preserved also affects the utility of the cadaver model. Cadaver tissue preserved in formalin has very different characteristics than tissue found in a fresh or fresh-frozen cadaver. Cadavers have no vessel flow and do not bleed. Attempts have been made to improve the fidelity of cadaveric specimens by cannulating the vessels of very fresh cadavers and perfusing them with artificial blood in a pulsatile fashion. Initially developed for neurosurgical training, such perfused cadaver models have been modified as potential tools for training on trauma surgical procedures. Pulsatile flow can be obtained using a modified intraaortic balloon pump system and injuries created in the heart, lung, liver, and inferior vena cava, allowing for repair in a “bleeding human model.” Though this technique improves the fidelity of the cadaveric model, it requires significant preprocessing and equipment, as well as very fresh cadaveric material, making it impractical for widespread use and adoption.

New ways of surgical training have been developed in order to respond to the limitations of more traditional methods, and the remainder of this chapter will focus on team-based training and simulation.

Team-Based Training for Vascular Trauma

The last decade has seen an explosion of interest in training hospital teams using methods similar to those utilized by the aviation industry. Nontechnical 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 significantly influence the quality of care afforded to the injured patient, especially with regard to nonoperative management strategy. 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 in order to secure the best possible outcome. No amount of technical virtuosity on the part of the surgeon will prevent such errors, which can only be addressed through effective training in teamwork, decision making, and communication. As such, CRM is now high on the clinical agenda with the UK House of Commons Health Committee recently acknowledging the critical influence of human factors on patient safety. Examples of a CRM skills include the following:

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  Teamwork/team coordination

  
  
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  Communication

  
  
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  Leadership/followership

  
  
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  Decision making

  
  
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  Conflict resolution

  
  
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  Assertiveness

  
  
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  Management of stress and fatigue

  
  
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  Workload management

  
  
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  Prioritization of tasks

  
  
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  Situational awareness

There is increasing evidence that CRM skills-training significantly improves patient outcomes. A Veteran’s Administration study reported a 50% reduction in surgical mortality between CRM-trained surgical teams versus non–CRM-trained surgical teams. 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. The U.S. Department of Defense (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. 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. In general, CRM within both military and civilian trauma systems is underresearched, although a set of related studies from the aviation, the organizational sciences, and the social psychology domains illustrate 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. While 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 is a core feature of the UK Defence Medical Services predeployment Military Operational Surgical Training (MOST). This course, which has a significant vascular trauma component, will be discussed in greater detail later in this chapter.