Avoid Blood Draws for Hemoglobin? It’s Reality. News From Mass General
There are too few situations that have a clinical and an administrative upside. The surgeons at Massachusetts General Hospital, however, have found one. Andrew Freiberg, M.D., chief of Hip & Knee Replacement at that institution, tells OTW, “We are utilizing the Masimo Pronto-7, a handheld device that uses pulsoximetry to rapidly calculate hemoglobin. Our team is about to publish a study involving 100 patients where we set out to see if patients could avoid blood draws after surgery by using this device. We found that in 80% of cases, it was indeed possible for patients to use the Pronto-7 and avoid these repeated, often painful needle sticks.”
“This device, which is low cost and results in very high patient satisfaction, is the only device of its kind…and our study was not funded by the company. While it is less accurate than a blood draw, you don’t need it to be that accurate—just plus or minus a gram or two. And if it is low you can check it via blood draw before a transfusion. This is a real win-win for everyone, especially patients. It is more difficult to do a blood draw after surgery; this device means that patients won’t have to endure someone rooting around in their arm and causing pain.”
“On the joint replacement side of things, we have just licensed a new anatomically contoured ceramic head design to CeramTec. Too often, if you use a large diameter femoral head, patients can get psoas tendonitis from impingement. We designed a contoured head that is a little smaller on the inferior half; it is just as stable as a regular head, but on the inferior side there is less material rubbing against the soft tissues.”
“At this point the design is undergoing final testing, which includes pull-off, strength, and burst testing. Prior to that we conducted a significant amount of computer modeling; then we did 3D printing of prototypes, followed by cadaver testing. We expect the product—trademarked as ‘Contoura’—to be FDA approved within 6 to 12 months.”
Tough Loss to Germany, But Brazil Wins Overall as a Host. Here’s the Inside Scoop
Bert Mandelbaum, M.D., an orthopedic surgeon and co-chair of medical affairs at the Institute for Sports Sciences in Los Angeles, was on site at the World Cup. Dr. Mandelbaum, medical director for the FIFA Medical Center of Excellence in Santa Monica, was the FIFA Venue medical officer at the Fortaleza Venue. Dr. Mandelbaum commented to OTW, “I was pleased to see that my concerns about the games were largely unfounded. Prior to opening day, I thought that perhaps we would have issues with communications and connectivity between the 12 soccer venues. Instead, what I found was virtually seamless coordination between venue directors, as well as between the directors and local hospitals that were receiving injured players.”
“Until Brazil lost to Germany, the atmosphere was magical because of all energy in the air. Even Neymar’s injury couldn’t stop the excitement…even more people donned his #10 jersey afterwards. Regarding this incident, his injury turned out to be a transverse process fracture—a serious and rare condition. The Brazilian doctors got him to the hospital quickly, however, and he is expected to recover in roughly three months.”
“There were no security issues except for one occasion when spectators ran onto one of the fields; the protests that I anticipated were almost nonexistent. The only challenge was when we were in Fortaleza and had to implement a new timeout rule put in place for this World Cup—the rule being that we had to stop the game for a ‘cool off’ if the temperature was above 89.6 degrees Fahrenheit. It was very hot and humid that day and we were only three degrees south of the equator. During the Holland/Mexico game we had to stop the game at the 30and 75 minute marks. It was my job to implement this—and do so in a way that got everyone back to play on time. We worked with the referees and training staff to get everyone cooled off and back to play after three minutes.”
“The physicians involved in the World Cup say that we are ‘one world, one medical team’…that there may be different jerseys surrounding us, but we doctors are part of one medical team. As for Brazil, despite what the media wrote about this World Cup, I believe that the country will be well prepared for the Olympics in 2016.”
Largest, Most Comprehensive Surgical Simulation EVER!
Magellan had to circumnavigate the globe in order to find new treasures. Seasoned orthopedic surgeons have found them closer to home, however, using rigorous methods and experience from those in other fields. Richard L. Angelo, M.D., former president of the Arthroscopy Association of North American (AANA) explains, “Five years ago the AANA undertook the ‘Magellan Project’ in an effort to ‘sail the world’ searching across other disciplines, businesses, and organizations to upgrade and optimize our educational activities. We broke into six subcommittees, one of which was ‘Surgical Skills.’ The key question posed by that subcommittee was, ‘Is there a better way to train surgeons on arthroscopic skills?’”
“For centuries, surgeons have trained via an apprenticeship model in which observation, exposure, and graduated practice in the clinical setting were employed. However, in an ideal world, basic procedural skills training would occur before the doctor arrives in the OR and begins to operate on real patients. Like Magellan, we knew there were undiscovered vistas and set out to find opportunities for improvement. Through our research, we discovered an evolving paradigm shift from the apprenticeship model to one of proficiency based progression (PBP) training for surgical and procedural skills. Evidence suggested that a superior and more uniform skill set was the result of this new training strategy.”
Dr. Angelo collaborated with Richard Ryu, M.D. (past president of AANA), Robert Pedowitz, M.D., Ph.D., and consultant Anthony Gallagher, Ph.D., D.Sc. to orchestrate a multicenter study involving orthopedic surgical residents in Post Graduate Years 4 and 5 from 21 ACGME (Accreditation Council for Graduate Medical Education) approved residency training programs. “We selected one procedure—the arthroscopic Bankart repair—and went through task deconstruction, breaking the procedure down into 45 steps and a potential 77 errors (20 of which were critical/sentinel errors). A series of separate, independent validation studies were conducted to evaluate the construct validity of those metrics and determine if one could use them to distinguish between the performance of novice and experienced surgeons. The index research involved three study groups. The first trained using our current AANA Orthopedic Resident Course methods (Group A). The second group used a similar curriculum but with the additional opportunity to work with a dry shoulder model simulator that accurately mimics the human shoulder (Group B). The third group that had the same curriculum but with the addition of directed proximate feedback and the requirement that they demonstrate the ability to meet predefined proficiency benchmarks before being permitted to progress in their training (Group C).”
“The benchmarks were previously established using the mean performance of a group of very experienced shoulder arthroscopists. The assessments included the cognitive knowledge of the steps, errors, and sentinel errors; demonstration of knot tying skill; and performance of an arthroscopic Bankart repair on the shoulder model simulator. All residents were provided access to two orientation videos (lateral decubitus and beach chair) demonstrating or identifying all of the steps and errors. Baseline visuospatial, perceptual, and psychomotor tests were completed on all residents prior to beginning the training and demonstrated no differences between the groups.”
“There were 44 residents in all: 14 in group A, 14 in group B, and 16 in group C. For the final assessment, all residents performed an arthroscopic Bankart repair on a cadaver which was videotaped in its entirety. The tapes were then scored in a blinded fashion by experienced raters.”
“The proficiency benchmark for the final repair was that the trainee could enact no more than three total errors and no more than one sentinel error. In group A, 29% of the residents met the benchmark on the final repair; in group B, 43%; and in group C, 75% of the residents who met all of the intermediary benchmarks through training were also able to achieve the final benchmark. Perhaps the most striking result was that when using logistic regression analysis, the entire group of C residents (whether they met the intermediary benchmarks or not), was over seven times more likely to be able to achieve the final benchmark than those in group A…an extremely powerful statement about the effectiveness of the new paradigm of proficiency based training for surgical skills.”
“This is the largest, most comprehensive assessment of proficiency-based progression simulation training for any surgical procedure. The results show that PBP harnessing simulation provides trainees with a more accurate, superior skill set when compared to the traditional manner of training.”
