Jameel Ali - Academia.edu (original) (raw)

Papers by Jameel Ali

Research paper thumbnail of Superior Performance of Atls Trained Senior Medical Students on Examinations Involving Simulated Trauma Patients

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

Research paper thumbnail of Demonstration of acquisition of trauma management skills by senior medical students completing the ATLS Program

The Journal of trauma, 1995

To assess the teaching effectiveness of the Advanced Trauma Life Support (ATLS) Program among sen... more To assess the teaching effectiveness of the Advanced Trauma Life Support (ATLS) Program among senior medical students. We used objective structured clinical examination (OSCE) and multiple choice question (MCQ) testing to assess 40 senior medical students (20 ATLS and 20 non-ATLS) at the University of Toronto. Pre- and post-ATLS, all students had four 15-minute OSCE stations and a 40-item MCQ test. The pre- and post-ATLS performance for the ATLS and non-ATLS group were compared. Cronbach's reliability coefficients were 0.81 and 0.93 for the pre- and post-ATLS OSCEs. The mean (+/- SD) OSCE scores at the four pre-ATLS OSCE stations were 7.6 +/- 2.8, 7.4 +/- 2.3, 8.3 +/- 2.7, and 10.5 +/- 3.4 for the ATLS group and 6.5 +/- 2.1, 7.0 +/- 2.2, 7.6 +/- 2.5, and 9.6 +/- 3.1 for the non-ATLS group (p = NS). Post-ATLS scores for the four OSCE stations were: 15.5 +/- 1.6, 14.1 +/- 3.2, 12.3 +/- 2.9, and 18.3 +/- 1.0 (ATLS group) and 7.9 +/- 3.5, 6.3 +/- 2.8, 7.6 +/- 2.3, and 10.9 +/- 3.3 (...

Research paper thumbnail of Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures

Canadian journal of surgery. Journal canadien de chirurgie, 2009

BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing ... more BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. METHODS: We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] >/= 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and chi(2) tests, followed by logistic regression analysis. RESULTS: Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12...

Research paper thumbnail of Is attrition of advanced trauma life support acquired skills affected by trauma patient volume?

American journal of surgery, 2002

We assessed the effect of trauma volume on skills attrition among physicians completing the advan... more We assessed the effect of trauma volume on skills attrition among physicians completing the advance trauma life support (ATLS) course. Cognitive (40 item multiple choice question [MCQ] examination) and clinical (4 objective structured clinical examinations [OSCE] trauma stations) performances were compared among physicians who completed the ATLS course, subdividing them into groups treating more than 50 and fewer than 50 trauma patients per year. Both groups had 12 physicians from six periods (n = 144) related to time of course completion: immediate (0), 6 months, 2 years, 4 years, 6 years, and 8 years after ATLS. OSCE scores (maximum standardized: 20), the degree of adherence to priorities (priority score: range 1 to 7), the degree of organized approach (approach score: range from 1 to 5) were compared. The mean precourse MCQ scores (59.4% to 62.4%) were similar for both groups. Immediate and progressive cognitive skill attrition and detailed clinical skill attrition were worse in ...

Research paper thumbnail of Effect of the Prehospital Trauma Life Support Program (PHTLS) on Prehospital Trauma Care

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

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

Research paper thumbnail of Effect of the Advanced Trauma Life Support Program on Medical Students' Performance in Simulated Trauma Patient Management

The Journal of Trauma: Injury, Infection, and Critical Care, 1998

Part of the senior medical students' examination at the University of Toronto inv... more Part of the senior medical students' examination at the University of Toronto involves testing with simulated patient management. We compared the performance in these simulations of senior medical students who received Advanced Trauma Life Support (ATLS) training with those who did not receive ATLS training. Thirty-two students (group I) completed a standard ATLS course, 12 students (group II) audited the ATLS course, and their performance in the trauma simulations was compared with 44 matched control students (group III) from the same class. Performance in the nontrauma patient simulation stations was also analyzed. The score on each station was standardized to a maximum of 20. The students were also graded on overall Approach (scale of 1 to 5) and pass status. The mean scores (+/-SD, *p < 0.05 compared with other groups) were as follows: Trauma Station, 17.5 +/- 1.02* for group I, 11.76 +/- 0.72* for group II, and 14.67 +/- 0.54* for group III; Nontrauma Station, 13.05 +/- 0.95 for group I, 12.25 +/- 0.72 for group II, and 11.88 +/- 0.80 for group III; Approach, 4.45 +/- 0.50* for group I, 2.09 +/- 0.60* for group II, 3.50 +/- 0.67* for group III. The ATLS-trained and ATLS-audit students had higher scores in the trauma stations than the control group, with the highest scores being in the ATLS-trained group. All ATLS-trained students passed with 62.5% honors and 37.5% passing grades. The ATLS-audit group had 33.3% honors and 66.6% passing grades, compared with the control group who had 84.09% pass, 9.09% borderline, and 6.82% failure in the trauma stations. The ATLS course, both complete and audit status, prepares students more appropriately for managing trauma patients as judged by trauma simulation scenarios. Consideration should be given for including ATLS as an integral part of the senior medical student curriculum.

Research paper thumbnail of Predictors of Fetal Mortality in Pregnant Trauma Patients

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

Fetal mortality after trauma is significant. This study was aimed at identifying factors responsi... more Fetal mortality after trauma is significant. This study was aimed at identifying factors responsible for this high fetal mortality. All pregnant trauma patients admitted to the two major Toronto trauma institutions during the period of November of 1991 to February of 1996 with an Injury Severity Score (ISS) > or = 12 were assessed. Data on age, gestation, hypotension, ISS, hemoglobin, blood transfusion, length of stay, disseminated intravascular coagulation (DIC), and specific maternal injury were analyzed retrospectively to determine predictors of fetal mortality by comparison of patients with and without fetal survival. Twenty of a total of 68 pregnant trauma patients qualified for entry into the trauma registry by having an ISS > or = 12. Overall fetal mortality was 65% (13 of 20) for ISS > or = 12, and there was one maternal death (age, 29 years; ISS, 66). There were no statistically significant differences between the fetal death and fetal survival groups in age (29.2 +/- 6.2 vs. 30.4 +/- 3.9 years), gestation (25.3 +/- 10.5 vs. 24.1 +/- 9.2 weeks), lowest systolic blood pressure (98.3 +/- 33.8 vs. 112 +/- 18.0 mm Hg), head injury rate (3 of 13 vs. 1 of 7), extremity injury rate (8 of 13 vs. 2 of 7), abdominal injury rate (4 of 13 vs. 0 of 7), pelvic fracture rate (6 of 13 vs. 1 of 7), and chest injury rate (5 of 13 vs. 3 of 7). However, ISS (27.7 +/- 3.5 vs. 14.2 +/- 11.4), lowest hemoglobin level (78.8 +/- 17.0 vs. 101.9 +/- 17.1), blood transfusions (10.8 +/- 6.3 vs. 0.9 +/- 1.6 units), length of stay (20.9 +/- 16.7 vs. 8.2 +/- 4.9 days), and the incidence of DIC (8 of 13 vs. 0 of 7) were statistically significantly different between the two groups (p < 0.05). All eight patients with abruptio placentae had associated fetal mortality. Apart from ISS, blood loss, and abruptio placentae; the presence of DIC was the most significant predictor of fetal mortality. This finding may represent stimulation of DIC by placental products entering the maternal circulation after significant intrauterine injury.

Research paper thumbnail of Trauma Patient Outcome after the Prehospital Trauma Life Support Program

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

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

Research paper thumbnail of Comparison of Performance of Interns Completing the Old (1993) and New Interactive (1997) Advanced Trauma Life Support Courses

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as it... more The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as its major change. The impact of this change is assessed in this study. We compared two matched groups of 16 interns completing either the old (group I) or new (group II) ATLS course. Cognitive skills (40 standard ATLS questions plus 10 additional questions on airway and shock) and clinical trauma management skills (four trauma objective structured clinical examinations [OSCEs] on simulated trauma patients) were tested. OSCE station scores (standardized to a maximum of 20), priority scores (graded 1-7), organized approach global passing grades (graded 1-5), and initial assessment test station scores (graded 1-5) were compared. Using ATLS criteria, three interns failed in each group. Post-ATLS examination question scores were similar (84.5+/-6.9 for group I, 85.9+/-7.1 for group II); scores for the airway and shock questions were higher but not different between the two groups. The four OSCE station mean scores varied between 13.9+/-2.0 and 15.4+/-2.1 for group I and were higher (p < 0.05) for group II (17.9+/-1.6 to 19.1+/-1.0). Priority scores were similar (group I, 6.3+/-1.1; group II, 6.4+/-1.2), but approach scores (3.9+/-0.1 for group I and 4.9+/-0.8 for group II) were lower in group I, as were the initial assessment test scores (2.9+/-0.2 for group I and 4.9+/-0.8 for group II). There were 8 honors grades in group I and 40 (p < 0.05) in group II. Interactive teaching, adult education principles, opportunities for discussion, provision of feedback, and stimulation of self-learning were rated more highly in the new course. Using standard ATLS pass criteria, performance after the new and old ATLS courses was similar. Superior performances were measured using OSCE methodology for clinical trauma management skills after the new compared with the old ATLS course in this population of interns.

Research paper thumbnail of Acute Calculous Cholecystitis

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Acute Abdominal Pain: General Approach

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Acquired Aneurysm

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Acid Fast Bacilli (AFB)

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Abscess

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Abdominal Pain

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of ABCDEs

Encyclopedia of Intensive Care Medicine, 2012

Research paper thumbnail of Teaching Effectiveness of the Advanced Trauma Life Support Program as Demonstrated by an Objective Structured Clinical Examination for Practicing Physicians

World Journal of Surgery, 1996

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

Research paper thumbnail of Effect of Basic Prehospital Trauma Life Support Program on Cognitive and Trauma Management Skills

World Journal of Surgery, 1998

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

Research paper thumbnail of The effects of positive airway pressure and intra-abdominal pressure in diaphragmatic rupture

World Journal of Surgery, 1992

Arterial blood gases (80% oxygen), intraperitoneal pressure (IP), stomach position relative to th... more Arterial blood gases (80% oxygen), intraperitoneal pressure (IP), stomach position relative to the diaphragm (S/D by fluoroscopy), blood pressure, and cardiac output were monitored in 16 anaesthetized New Hampshire piglets with a 12 cm laceration of the left hemidiaphragm. Group I (8 animals) were spontaneously breathing. Group II (8 animals) had a pneumatic antishock garment (PASG) inflated to an IP of 40 torr for 15 mins followed by positive pressure ventilation (PPV) of 20 cm H2O for 15 min and PPV of 40 cm H2O (PPV-40) for 30 more minutes. All Group I animals survived. Three Group II animals died by 15 min after PASG inflation. Seven Group I animals showed no displacement of the stomach above the diaphragm. Blood pressure, cardiac output, and blood gases remained unchanged in Group I compared to baseline with pO2 varying from 436 +/- 44 torr to 417 +/- 31 torr, pCO2 from 38 +/- 1 torr to 39 +/- 1 torr, and pH 7.4 +/- 0.02. Blood pressure in Group I was 109 +/- 3 torr at baseline to 110 +/- 2 torr at 60 mins, and baseline cardiac output was 3.9 +/- 0.2 L/min and 3.8 +/- 0.2 L/min at 60 min. Group II animals had a baseline arterial pO2 of 423 +/- 15 torr and 100 +/- 15 torr at 15 min after PASG. With PPV-20 arterial pO2 increased to 178 +/- 13 torr and further increased to 230 +/- 9 torr at PPV-40.(ABSTRACT TRUNCATED AT 250 WORDS)

Research paper thumbnail of Is attrition of advanced trauma life support acquired skills affected by trauma patient volume?

The American Journal of Surgery, 2002

We assessed the effect of trauma volume on skills attrition among physicians completing the advan... more We assessed the effect of trauma volume on skills attrition among physicians completing the advance trauma life support (ATLS) course. Cognitive (40 item multiple choice question [MCQ] examination) and clinical (4 objective structured clinical examinations [OSCE] trauma stations) performances were compared among physicians who completed the ATLS course, subdividing them into groups treating more than 50 and fewer than 50 trauma patients per year. Both groups had 12 physicians from six periods (n = 144) related to time of course completion: immediate (0), 6 months, 2 years, 4 years, 6 years, and 8 years after ATLS. OSCE scores (maximum standardized: 20), the degree of adherence to priorities (priority score: range 1 to 7), the degree of organized approach (approach score: range from 1 to 5) were compared. The mean precourse MCQ scores (59.4% to 62.4%) were similar for both groups. Immediate and progressive cognitive skill attrition and detailed clinical skill attrition were worse in the low volume group. Global skills (organized approach and adherence to priorities) were preserved similarly for at least 8 years in all groups. Our data suggest that trauma volume affects trauma skills attrition.

Research paper thumbnail of Superior Performance of Atls Trained Senior Medical Students on Examinations Involving Simulated Trauma Patients

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

Research paper thumbnail of Demonstration of acquisition of trauma management skills by senior medical students completing the ATLS Program

The Journal of trauma, 1995

To assess the teaching effectiveness of the Advanced Trauma Life Support (ATLS) Program among sen... more To assess the teaching effectiveness of the Advanced Trauma Life Support (ATLS) Program among senior medical students. We used objective structured clinical examination (OSCE) and multiple choice question (MCQ) testing to assess 40 senior medical students (20 ATLS and 20 non-ATLS) at the University of Toronto. Pre- and post-ATLS, all students had four 15-minute OSCE stations and a 40-item MCQ test. The pre- and post-ATLS performance for the ATLS and non-ATLS group were compared. Cronbach's reliability coefficients were 0.81 and 0.93 for the pre- and post-ATLS OSCEs. The mean (+/- SD) OSCE scores at the four pre-ATLS OSCE stations were 7.6 +/- 2.8, 7.4 +/- 2.3, 8.3 +/- 2.7, and 10.5 +/- 3.4 for the ATLS group and 6.5 +/- 2.1, 7.0 +/- 2.2, 7.6 +/- 2.5, and 9.6 +/- 3.1 for the non-ATLS group (p = NS). Post-ATLS scores for the four OSCE stations were: 15.5 +/- 1.6, 14.1 +/- 3.2, 12.3 +/- 2.9, and 18.3 +/- 1.0 (ATLS group) and 7.9 +/- 3.5, 6.3 +/- 2.8, 7.6 +/- 2.3, and 10.9 +/- 3.3 (...

Research paper thumbnail of Predictors of laparotomy and mortality in polytrauma patients with pelvic fractures

Canadian journal of surgery. Journal canadien de chirurgie, 2009

BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing ... more BACKGROUND: The decision to perform laparotomy in blunt trauma patients is often difficult owing to pelvic fractures; however, once the decision is made, delay or failure to perform laparotomy could affect morbidity and mortality. We sought to identify predictors of laparotomy and mortality in polytrauma patients with pelvic fractures. METHODS: We divided 390 blunt polytrauma patients (Injury Severity Score [ISS] >/= 16) with pelvic fractures into laparotomy (n = 56) and nonlaparotomy (n = 334) groups. We assessed the role of the following variables in predicting laparotomy and mortality: age, sex, hypotension, fluid and blood transfusions, positive abdominal computed tomography (CT) scans or focused assessment with sonography for trauma (FAST) examination, pelvic fracture severity and ISS. We analyzed the data using Student t and chi(2) tests, followed by logistic regression analysis. RESULTS: Mortality was higher in the laparotomy group than the nonlaparotomy group (28.6% v. 12...

Research paper thumbnail of Is attrition of advanced trauma life support acquired skills affected by trauma patient volume?

American journal of surgery, 2002

We assessed the effect of trauma volume on skills attrition among physicians completing the advan... more We assessed the effect of trauma volume on skills attrition among physicians completing the advance trauma life support (ATLS) course. Cognitive (40 item multiple choice question [MCQ] examination) and clinical (4 objective structured clinical examinations [OSCE] trauma stations) performances were compared among physicians who completed the ATLS course, subdividing them into groups treating more than 50 and fewer than 50 trauma patients per year. Both groups had 12 physicians from six periods (n = 144) related to time of course completion: immediate (0), 6 months, 2 years, 4 years, 6 years, and 8 years after ATLS. OSCE scores (maximum standardized: 20), the degree of adherence to priorities (priority score: range 1 to 7), the degree of organized approach (approach score: range from 1 to 5) were compared. The mean precourse MCQ scores (59.4% to 62.4%) were similar for both groups. Immediate and progressive cognitive skill attrition and detailed clinical skill attrition were worse in ...

Research paper thumbnail of Effect of the Prehospital Trauma Life Support Program (PHTLS) on Prehospital Trauma Care

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

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

Research paper thumbnail of Effect of the Advanced Trauma Life Support Program on Medical Students' Performance in Simulated Trauma Patient Management

The Journal of Trauma: Injury, Infection, and Critical Care, 1998

Part of the senior medical students' examination at the University of Toronto inv... more Part of the senior medical students' examination at the University of Toronto involves testing with simulated patient management. We compared the performance in these simulations of senior medical students who received Advanced Trauma Life Support (ATLS) training with those who did not receive ATLS training. Thirty-two students (group I) completed a standard ATLS course, 12 students (group II) audited the ATLS course, and their performance in the trauma simulations was compared with 44 matched control students (group III) from the same class. Performance in the nontrauma patient simulation stations was also analyzed. The score on each station was standardized to a maximum of 20. The students were also graded on overall Approach (scale of 1 to 5) and pass status. The mean scores (+/-SD, *p < 0.05 compared with other groups) were as follows: Trauma Station, 17.5 +/- 1.02* for group I, 11.76 +/- 0.72* for group II, and 14.67 +/- 0.54* for group III; Nontrauma Station, 13.05 +/- 0.95 for group I, 12.25 +/- 0.72 for group II, and 11.88 +/- 0.80 for group III; Approach, 4.45 +/- 0.50* for group I, 2.09 +/- 0.60* for group II, 3.50 +/- 0.67* for group III. The ATLS-trained and ATLS-audit students had higher scores in the trauma stations than the control group, with the highest scores being in the ATLS-trained group. All ATLS-trained students passed with 62.5% honors and 37.5% passing grades. The ATLS-audit group had 33.3% honors and 66.6% passing grades, compared with the control group who had 84.09% pass, 9.09% borderline, and 6.82% failure in the trauma stations. The ATLS course, both complete and audit status, prepares students more appropriately for managing trauma patients as judged by trauma simulation scenarios. Consideration should be given for including ATLS as an integral part of the senior medical student curriculum.

Research paper thumbnail of Predictors of Fetal Mortality in Pregnant Trauma Patients

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

Fetal mortality after trauma is significant. This study was aimed at identifying factors responsi... more Fetal mortality after trauma is significant. This study was aimed at identifying factors responsible for this high fetal mortality. All pregnant trauma patients admitted to the two major Toronto trauma institutions during the period of November of 1991 to February of 1996 with an Injury Severity Score (ISS) > or = 12 were assessed. Data on age, gestation, hypotension, ISS, hemoglobin, blood transfusion, length of stay, disseminated intravascular coagulation (DIC), and specific maternal injury were analyzed retrospectively to determine predictors of fetal mortality by comparison of patients with and without fetal survival. Twenty of a total of 68 pregnant trauma patients qualified for entry into the trauma registry by having an ISS > or = 12. Overall fetal mortality was 65% (13 of 20) for ISS > or = 12, and there was one maternal death (age, 29 years; ISS, 66). There were no statistically significant differences between the fetal death and fetal survival groups in age (29.2 +/- 6.2 vs. 30.4 +/- 3.9 years), gestation (25.3 +/- 10.5 vs. 24.1 +/- 9.2 weeks), lowest systolic blood pressure (98.3 +/- 33.8 vs. 112 +/- 18.0 mm Hg), head injury rate (3 of 13 vs. 1 of 7), extremity injury rate (8 of 13 vs. 2 of 7), abdominal injury rate (4 of 13 vs. 0 of 7), pelvic fracture rate (6 of 13 vs. 1 of 7), and chest injury rate (5 of 13 vs. 3 of 7). However, ISS (27.7 +/- 3.5 vs. 14.2 +/- 11.4), lowest hemoglobin level (78.8 +/- 17.0 vs. 101.9 +/- 17.1), blood transfusions (10.8 +/- 6.3 vs. 0.9 +/- 1.6 units), length of stay (20.9 +/- 16.7 vs. 8.2 +/- 4.9 days), and the incidence of DIC (8 of 13 vs. 0 of 7) were statistically significantly different between the two groups (p < 0.05). All eight patients with abruptio placentae had associated fetal mortality. Apart from ISS, blood loss, and abruptio placentae; the presence of DIC was the most significant predictor of fetal mortality. This finding may represent stimulation of DIC by placental products entering the maternal circulation after significant intrauterine injury.

Research paper thumbnail of Trauma Patient Outcome after the Prehospital Trauma Life Support Program

The Journal of Trauma: Injury, Infection, and Critical Care, 1997

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

Research paper thumbnail of Comparison of Performance of Interns Completing the Old (1993) and New Interactive (1997) Advanced Trauma Life Support Courses

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as it... more The 1997 edition of the Advanced Trauma Life Support (ATLS) course emphasized interactivity as its major change. The impact of this change is assessed in this study. We compared two matched groups of 16 interns completing either the old (group I) or new (group II) ATLS course. Cognitive skills (40 standard ATLS questions plus 10 additional questions on airway and shock) and clinical trauma management skills (four trauma objective structured clinical examinations [OSCEs] on simulated trauma patients) were tested. OSCE station scores (standardized to a maximum of 20), priority scores (graded 1-7), organized approach global passing grades (graded 1-5), and initial assessment test station scores (graded 1-5) were compared. Using ATLS criteria, three interns failed in each group. Post-ATLS examination question scores were similar (84.5+/-6.9 for group I, 85.9+/-7.1 for group II); scores for the airway and shock questions were higher but not different between the two groups. The four OSCE station mean scores varied between 13.9+/-2.0 and 15.4+/-2.1 for group I and were higher (p < 0.05) for group II (17.9+/-1.6 to 19.1+/-1.0). Priority scores were similar (group I, 6.3+/-1.1; group II, 6.4+/-1.2), but approach scores (3.9+/-0.1 for group I and 4.9+/-0.8 for group II) were lower in group I, as were the initial assessment test scores (2.9+/-0.2 for group I and 4.9+/-0.8 for group II). There were 8 honors grades in group I and 40 (p < 0.05) in group II. Interactive teaching, adult education principles, opportunities for discussion, provision of feedback, and stimulation of self-learning were rated more highly in the new course. Using standard ATLS pass criteria, performance after the new and old ATLS courses was similar. Superior performances were measured using OSCE methodology for clinical trauma management skills after the new compared with the old ATLS course in this population of interns.

Research paper thumbnail of Acute Calculous Cholecystitis

Encyclopedia of Intensive Care Medicine, 2012

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Research paper thumbnail of Teaching Effectiveness of the Advanced Trauma Life Support Program as Demonstrated by an Objective Structured Clinical Examination for Practicing Physicians

World Journal of Surgery, 1996

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

Research paper thumbnail of Effect of Basic Prehospital Trauma Life Support Program on Cognitive and Trauma Management Skills

World Journal of Surgery, 1998

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

Research paper thumbnail of The effects of positive airway pressure and intra-abdominal pressure in diaphragmatic rupture

World Journal of Surgery, 1992

Arterial blood gases (80% oxygen), intraperitoneal pressure (IP), stomach position relative to th... more Arterial blood gases (80% oxygen), intraperitoneal pressure (IP), stomach position relative to the diaphragm (S/D by fluoroscopy), blood pressure, and cardiac output were monitored in 16 anaesthetized New Hampshire piglets with a 12 cm laceration of the left hemidiaphragm. Group I (8 animals) were spontaneously breathing. Group II (8 animals) had a pneumatic antishock garment (PASG) inflated to an IP of 40 torr for 15 mins followed by positive pressure ventilation (PPV) of 20 cm H2O for 15 min and PPV of 40 cm H2O (PPV-40) for 30 more minutes. All Group I animals survived. Three Group II animals died by 15 min after PASG inflation. Seven Group I animals showed no displacement of the stomach above the diaphragm. Blood pressure, cardiac output, and blood gases remained unchanged in Group I compared to baseline with pO2 varying from 436 +/- 44 torr to 417 +/- 31 torr, pCO2 from 38 +/- 1 torr to 39 +/- 1 torr, and pH 7.4 +/- 0.02. Blood pressure in Group I was 109 +/- 3 torr at baseline to 110 +/- 2 torr at 60 mins, and baseline cardiac output was 3.9 +/- 0.2 L/min and 3.8 +/- 0.2 L/min at 60 min. Group II animals had a baseline arterial pO2 of 423 +/- 15 torr and 100 +/- 15 torr at 15 min after PASG. With PPV-20 arterial pO2 increased to 178 +/- 13 torr and further increased to 230 +/- 9 torr at PPV-40.(ABSTRACT TRUNCATED AT 250 WORDS)

Research paper thumbnail of Is attrition of advanced trauma life support acquired skills affected by trauma patient volume?

The American Journal of Surgery, 2002

We assessed the effect of trauma volume on skills attrition among physicians completing the advan... more We assessed the effect of trauma volume on skills attrition among physicians completing the advance trauma life support (ATLS) course. Cognitive (40 item multiple choice question [MCQ] examination) and clinical (4 objective structured clinical examinations [OSCE] trauma stations) performances were compared among physicians who completed the ATLS course, subdividing them into groups treating more than 50 and fewer than 50 trauma patients per year. Both groups had 12 physicians from six periods (n = 144) related to time of course completion: immediate (0), 6 months, 2 years, 4 years, 6 years, and 8 years after ATLS. OSCE scores (maximum standardized: 20), the degree of adherence to priorities (priority score: range 1 to 7), the degree of organized approach (approach score: range from 1 to 5) were compared. The mean precourse MCQ scores (59.4% to 62.4%) were similar for both groups. Immediate and progressive cognitive skill attrition and detailed clinical skill attrition were worse in the low volume group. Global skills (organized approach and adherence to priorities) were preserved similarly for at least 8 years in all groups. Our data suggest that trauma volume affects trauma skills attrition.