Correlation Between ATLS Training and Junior Doctors’ Anatomical Knowledge of Intercostal Chest Drain Insertion Victor Y. Kong, PhD,* George V. Oosthuizen, FCS (SA),* Benn Sartorius, PhD,† Claire M. Keene, MBBCh,* and Damian L. Clarke, FCS (SA)* *
Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, University of KwaZulu-Natal, Pietermaritzburg, South Africa; and †Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa OBJECTIVE: To review the ability of junior doctors (JDs)
KEY WORDS: ATLS, chest drain, junior doctors
in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training inﬂuences this.
COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement
DESIGN: We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion. SETTING: This study was conducted in a large metropolitan
university hospital in South Africa. RESULTS: A total of 152 JDs participated in the study.
Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identiﬁed the site that was located within the accepted safe triangle. A signiﬁcantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p ¼ 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR ¼ 6.8, 95% CI: 3.712.5). CONCLUSIONS: Most of the JDs do not have sufﬁcient
anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe C 2015 Association of insertion site. ( J Surg 72:600-605. J Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
Correspondence: Inquiries to Victor Y. Kong, MSc, PhD, MRCS, Pietermaritzburg Metropolitan Trauma Service, Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; fax: (33) 395-4060; e-mail: [email protected]
INTRODUCTION Intercostal chest drain (ICD) insertion is a common procedure, and all doctors involved in the management of trauma are expected to be competent in performing this procedure.1,2 ICD insertion can be associated with signiﬁcant morbidity, and complications have been reported to be as high as 30%.3-5 A previous audit from our institution showed an overall complication rate of 19%, and it was noted that ICDs performed by junior doctors (JDs) were more likely to be associated with complications, most of which were related to insertion outside the commonly accepted “safe” anatomical site for insertion.5-7 The objective of this study was to assess the baseline anatomical knowledge of the “safe” site for ICD insertion among JDs at a university hospital in South Africa.
MATERIALS AND METHODS Setting This was a prospective, observational study performed in January 2014 at the Pietermaritzburg Metropolitan Hospital Complex (PMBC) in South Africa. Ethics approval to conduct this study was formally granted by the Umgungundlovu Health Ethics Review Board and the University of KwaZulu-Natal (reference number: BE083/14). The city of Pietermaritzburg is the capital of the KwaZulu-Natal province, and the PMBC provides deﬁnitive surgical care that covers the western part of the province. It also serves as the surgical referral center for 19 other district hospitals
Journal of Surgical Education & 2015 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2015.01.022
within the province and covers a total catchment population of more than 3 million. Our trauma service manages approximately 3000 inpatient cases per annum, with more than 40% penetrating trauma. This is a direct reﬂection of the high incidence of interpersonal violence and serious crime experience throughout the region. We perform more than 200 ICDs per year for trauma alone, most of which are performed in the trauma unit.5-7 Training The Department of Surgery is an academic department under the auspice of the University of KwaZulu-Natal and is responsible for both undergraduate and postgraduate training in general surgery. It is also one of the accredited institutions by the Health Professional Council of South Africa for internship training. Internship training in South Africa lasts for a period of 24 months, which spans 2 postgraduate years (PGYs) after qualiﬁcation from medical school. JDs refer to those in their postgraduate year 1 (PGY1) or year 2 (PGY2). License for full registration is granted only after satisfactory completion of the full 24 months' training, of which 4 months of mandatory training in general surgery is required. Only PGY2 doctors in this study would have had the opportunity to attend an ATLS provider course. The PGY1 doctors would not have had the opportunity to attend the ATLS course at the time of study on the induction day.
pectoralis major, anterior border of the latissimus dorsi, and ﬁfth intercostal space (or the nipple in men). In our opinion, the photograph is of sufﬁcient quality that would clearly allow distinction of the safe anatomical boundaries pertaining ICD insertion. Figure 2 shows the identical photograph, with the deﬁned “triangle of safety” in this study. We deﬁne the selected site as either within or outside the triangle of safety. This was further subdivided into 4 different sites: (A) within the triangle of safety, (B) outside and anterior to the triangle, (C) outside and posterior to the triangle, and (D) outside and inferior to the triangle. Figure 3 shows the further subdivision of selected sites classiﬁed into A, B, C, and D. A transparent copy of the photograph with the triangle of safety was used as a grid to assess the site marked by each JD. Each photograph was reviewed independently by the primary (V.K.) and secondary (C.K.) authors, and agreement was reached before documentation of the results. Statistics All collected data were entered into a Microsoft Excel spreadsheet for processing. Data were analyzed using Stata 13.0 SE (StataCorp, Stata Statistical Software: Release 13. College Station, TX: StataCorp LP, 2013). The Wilcoxon rank sum test was used to compare age across dichotomous variables (e.g., sex). Signiﬁcant differences in the site selected for ICD insertion and PGY level (and other
The Study A compulsory induction day for all JDs is held by the PMBC on the ﬁrst of January each year. All JDs who were currently working within the PMBC and attended the induction day were eligible for inclusion in this study. JDs were all either in their PGY1 or PGY2, who qualiﬁed from 1 of the 8 medical schools in South Africa. Basic demographic data were collected from the attendance registration book. Every JD was given a photograph and asked to indicate (marking a cross on the site) the exact location of where they would insert an ICD if it were their real patient encountered during their on-call duty when unsupervised. Figure 1 shows the original photograph used for this study. The task was completed by each JD as a part of the induction program. This was supervised by the primary author (V.K.); reference materials including cell phones, etc. were strictly prohibited. The standard for the safe insertion for ICD in PMBC closely follows the teaching from Advanced Trauma Life Support (ATLS).8 We only consider the open blunt dissection technique applicable to the trauma setting. In line with internationally accepted conventions regarding the optimal (or safe) site for ICD insertion, as described by the British Thoracic Society guideline,9 we used the following deﬁnition of the “triangle of safety”: lateral border of the Journal of Surgical Education Volume 72/Number 4 July/August 2015
FIGURE 1. Photograph used for this study. 601
Selected Sites for ICD Insertion Of the 152 JDs, 28% (42/152) indicated a site that was located within the safe triangle (correct site). The remaining 72% (110/152) indicated sites that were all outside the safe triangle (incorrect site). Of the 110 sites that were outside the safe triangle were B: 0% (0/110), C: 4% (6/110), and D: 68% (104/152).
Subgroups: PGY1 Doctors vs PGY2 Doctors
FIGURE 2. The conventionally used anatomical deﬁnition of the “triangle of safety.”
categorical characteristics) were assessed using the Pearson chi-square (χ2) test. If an expected cell count had fewer than 5 observations, then the Fisher Exact test was preferred. We also estimated ratios for selecting the correct site for insertion by the various characteristics with associated 95% exact conﬁdence intervals. A p o 0.05 was deemed statistically signiﬁcant. A sample size of 152 would achieve an 80% power to detect a small-to-medium effect size (W) of 0.23 using a 1 degree of freedom chi-square test with a signiﬁcance level (α) of 0.05 or 5%. Alternatively, this sample size achieved 80% power at 5% signiﬁcant level to detect a minimum relative ratio in the group (factors) proportions of correct responses of 1.50. This translates into a minimum detectable difference of 0.25 or 25% between both the groups regarding correct response percentages, assuming the baseline proportion correct in 1 group is 0.50 or 50%, i.e., assumes maximum variability.
Of the 90 PGY1 doctors, 20% (18/90) indicated a site that was within the safe triangle. The remaining 80% (72/90) indicated sites that were all outside the safe triangle. These sites were B: 0% (0/90), C: 3% (3/90), and D: 77% (69/ 90). Of the 62 PGY2 doctors, 39% (24/62) indicated a site that was within the safe triangle. The remaining 61% (38/ 62) indicated sites that were all outside the safe triangle. These sites were B: 0% (0/62), C: 5% (3/152), and D: 56% (35/62). There was a signiﬁcant difference between the PGY1 doctors and the PGY2 doctors regarding the site selected [the Fisher exact test, p ¼ 0.026]. A signiﬁcantly higher proportion of PGY2 doctors selected site A when compared with PGY1 doctors. There was no signiﬁcant difference in site selection by sex when stratiﬁed on PGY status (p ¼ 0.291 and 0.963 for PGY1 and PGY2, respectively).
RESULTS Demographics During the study period, 152 JDs completed the study. Among them, 41% (63/152) were men, and the mean age was 24 years. There were 90 PGY1 doctors (59%) and 62 PGY2 doctors (41%). 602
FIGURE 3. Subclassiﬁcation of selected locations for ICD insertion.
Journal of Surgical Education Volume 72/Number 4 July/August 2015
TABLE 1. Location Selected by the PGY1 Doctors and PGY2 Doctors
Site Correct (A) Incorrect (B, C, or D)
PGY2 PGY1 Doctors p Doctors (N ¼ 90) % (N ¼ 62) % Value* 18 72
39 0.026 61
*Fisher exact test.
Table 1 summarizes the site selected by the PGY1 doctors and PGY2 doctors. Subgroup: Correct vs Incorrect Site Selected Direct comparison between those who selected the correct site (42/152) and those who selected the incorrect site (110/ 152) showed as signiﬁcant difference PGY level and ATLS provider status. There was no signiﬁcant difference between sex and the completion of surgical rotation. PGY2 doctors were 1.9 times more likely to identify the correct site, while those with ATLS provider training were 6.8 times more likely. Table 2 summarizes the factors associated with correct site insertion and Table 3 summarizes the risk ratio for each factor.
DISCUSSION ICD insertion is an essential procedure in the management of trauma.1-4 It is inevitably performed by doctors with a wide variety of training backgrounds.10 ICD is a procedure that is associated with signiﬁcant morbidity, and fatal outcomes such as ventricular perforation have been reported.11 The correct “safe” insertion technique has been extensively taught in ATLS over the past 3 decades.8 However, international literature continues to report complication rates between 20% and 30%.2-4 A previous audit of experience in our trauma unit documented a
complication rate of 19% in 1054 ICDs inserted over a 4-year period.5 It was noted that more than 90% of the complications that occurred were related to JDs performing the procedure. However, adverse outcome from ICD is not conﬁned to the trauma settings. A report from the National Patient Safety Agency from the United Kingdom in 2008 reported 12 deaths and 15 cases of serious harm caused by ICDs over a 3-year period.12,13 The report highlighted that a lack of exposure and poor supervision of JDs were the key areas of concerns.13 Grifﬁths et al. surveyed 55 JDs in Shefﬁeld regarding knowledge of the safe anatomical insertion site. It was found that 45% would have inserted the ICD outside the safe triangle.14 The most common error was found to be choosing an insertion site that was far too low (up to 24%), and the ﬁndings in our study were consistent with this. This is likely a reﬂection of major deﬁcit in baseline anatomical knowledge of the procedure. Elsayed et al.15 conducted a similar study in Liverpool on 50 JDs from various specialties. It was found that only 44% indicated that they wound insert the drain within the safe triangle. Furthermore, only 25% knew where to insert the drain.15 To date, ours is the only study in South Africa and we have shown that only one-third of all JDs were able to correctly identify the safe insertion site, which was much lower than those reported in the international literature. A study by James et al.16 from Birmingham showed that 53% of trainees in nonrespiratory specialties admitted that they lack conﬁdence in performing the procedure and that 70% of the trainees had only inserted less than 10 large bore ICDs in their entire career. It would appear that a lack of basic anatomical knowledge is common among JDs, regardless of where they were required to insert ICDs in either trauma or nontrauma setting. Trauma in South Africa has been described as a malignant epidemic, and the excessive burden of disease has allowed for the rapid acquisition of a vast experience in many areas of trauma care.17 ATLS training has been widely embraced for more than 3 decades and has formed the
TABLE 2. Factors Associated With Correct Site Selection Factors
Sex Male Female PGY level PGY1 PGY2 ATLS provider status ATLS No ATLS Surgical rotation Completed Not completed †
Incorrect (N ¼ 110)
Correct (N ¼ 42)
*Pearson chi-square (2) test. Fisher exact test.
Journal of Surgical Education Volume 72/Number 4 July/August 2015
TABLE 3. Relative Risk for Each Factor Associated With Correct Site Selection Factors Sex (female vs male) PGY (PGY2 vs PGY1) ATLS provider status (ATLS vs no ATLS) Surgical rotation (completed vs not completed)
core of both undergraduate and postgraduate training.8 However, there is no uniform curriculum for training undergraduate basic trauma management, and speciﬁc training in emergency procedures is often an ad hoc event. Currently, it is not an absolute requirement that all JDs attend ATLS during their 2-year internship.18 Those who work in surgery often come from different backgrounds,15 and the lack of objective assessment of individual capability in performing ICD and supervised training often causes great difﬁculties in meeting training requirement and service delivery. Even beyond the PGY1 (and even PGY2), not all current staff are currently ATLS certiﬁed. Paradoxically, there is very little literature focusing speciﬁcally on the background knowledge of JDs in performing ICDs, and even less so in the context of trauma. Our study is somewhat limited by the lack of information regarding how many ICDs each PGY2 doctor had performed before the survey. However, it is unlikely that they would have had substantial exposure at the early stage of training. Furthermore, being able to identify the correct site for insertion is only one aspect for safe performance of the procedure, and attention to the correct dissection technique is just as important. What is clear from our study is that most of the JDs in our teaching hospital were unable to correctly identify the safe site for ICD insertion. There remains a need to assess the individual level of knowledge and competency at an early stage so that direct, supervised training, coupled with focused education initiatives, can be delivered.
Relative Risk (RR)
1.4 1.9 6.8 1.1
0.8-2.5 1.2-3.3 3.7-12.5 0.5-2.6
interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/ registrations, and grants or other funding.
ETHICAL STANDARDS Victor Kong, the corresponding author, conﬁrms that this study was formally approved by the Biomedical Research Ethics Committee (BREC) of the University of KwaZuluNatal (UKZN). The study's ethical approval reference number is BE 207/09. All parts of the study conform to the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. It was a retrospective study and all data were anonymized before inclusion.
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CONCLUSIONS ICDs are commonly performed but are often inappropriately delegated to JDs. Most of the JDs actually do not have sufﬁcient anatomical knowledge to be able to correctly identify the safe site for insertion. Successful completion of the ATLS course is correlated with higher likelihood of correct identiﬁcation of safe site for insertion. ATLS training, which focuses on the technical aspects of this procedure, must be strengthened and disseminated.
CONFLICT OF INTEREST There are NO ﬁnancial and personal relationships with other people or organizations that could inappropriately inﬂuence (bias) our work. Examples of potential conﬂicts of 604
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