Use of personal digital assistants by adolescents with severe asthma: can they enhance patient outcomes?

Despite the emphasis placed on asthma education, asthma mortality is on the increase, with rates of disability higher in adolescents. Technology provides unprecedented opportunities for developing means to manage, control, and prevent acute episodes in chronic illnesses. This article describes the use of handheld wireless computer devices (eg, personal digital assistant or pocket personal computer) to prevent emergency department visits and to improve outcomes for patients with severe persistent asthma. The uses of personal digital assistants and challenges encountered in their use are described. Recommendations regarding nurses' contribution in the design, implementation, and evaluation of the program patient outcomes are provided.     

Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients

OBJECTIVE: We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. DESIGN: Randomized, controlled trial of immediate vs. delayed ultrasound. SETTING: Urban, tertiary emergency department, census >100,000. PATIENTS: Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS: Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. MEASUREMENTS AND MAIN RESULTS: Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). CONCLUSIONS: Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.     

Leveraging palm technology in the advanced practice nursing environment

The use of personal digital assistants (PDAs) in healthcare has expanded exponentially in the past several years. In addition to common feature functions such as contact lists, calculators, calendars, and expense logs, current PDAs boast a wide variety of practical healthcare-related applications such pharmacologic databases, infectious disease programs, medication calculators, and patient scheduling and billing applications. This article examines PDAs in general and the Palm series of handheld devices in particular for use in the advanced practice setting. These devices have several implications for advanced practice nursing including support of both differential diagnosis and diagnostic reasoning, reduction of medication errors, and development of effective treatment protocols. Personal digital assistant technology will inevitably become part and parcel of advanced practice nursing. The rapid, almost daily, changes in the healthcare environment require immediate access to the myriad resources and databases used by advanced practice nurses. Personal digital assistant technology provides such access.     

Doing unto Others? Emergency Medicine Residents' Willingness to Be Treated by Moonlighting Residents and Nonphysician Clinicians in the Emergency Department

OBJECTIVE: Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients. METHODS: A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity. RESULTS: A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid-level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid-level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one-third (34%) of the residents view mid-level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (> or =$75,000). CONCLUSIONS: When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.     

Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit

OBJECTIVE: Numerous factors can cause delays in transfer to an intensive care unit for critically ill emergency department patients. The impact of delays is unknown. We aimed to determine the association between emergency department "boarding" (holding admitted patients in the emergency department pending intensive care unit transfer) and outcomes for critically ill patients. DESIGN: This was a cross-sectional analytical study using the Project IMPACT database (a multicenter U.S. database of intensive care unit patients). Patients admitted from the emergency department to the intensive care unit (2000-2003) were included and divided into two groups: emergency department boarding >or=6 hrs (delayed) vs. emergency department boarding <6 hrs (nondelayed). Demographics, intensive care unit procedures, length of stay, and mortality were analyzed. Groups were compared using chi-square, Mann-Whitney, and unpaired Student's t-tests. SETTING: Emergency department and intensive care unit. PATIENTS: Patients admitted from the emergency department to the intensive care unit (2000-2003). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Main outcomes were intensive care unit and hospital survival and intensive care unit and hospital length of stay. During the study period, 50,322 patients were admitted. Both groups (delayed, n = 1,036; nondelayed, n = 49,286) were similar in age, gender, and do-not-resuscitate status, along with Acute Physiology and Chronic Health Evaluation II score in the subgroup for which it was recorded. Among hospital survivors, the median hospital length of stay was 7.0 (delayed) vs. 6.0 days (nondelayed) (p < .001). Intensive care unit mortality was 10.7% (delayed) vs. 8.4% (nondelayed) (p < .01). In-hospital mortality was 17.4% (delayed) vs. 12.9% (nondelayed) (p < .001). In the stepwise logistic model, delayed admission, advancing age, higher Acute Physiology and Chronic Health Evaluation II score, male gender, and diagnostic categories of trauma, intracerebral hemorrhage, and neurologic disease were associated with lower hospital survival (odds ratio for delayed admission, 0.709; 95% confidence interval, 0.561-0.895). CONCLUSIONS: Critically ill emergency department patients with a >or=6-hr delay in intensive care unit transfer had increased hospital length of stay and higher intensive care unit and hospital mortality. This suggests the need to identify factors associated with delayed transfer as well as specific determinants of adverse outcomes.     

Assessment of Emergency Medicine Residents' Computer Knowledge and Computer Skills: Time for an Upgrade?

OBJECTIVE: To describe emergency medicine residents' (EMRs') personal computer (PC) use and educational needs and to compare their perceived and actual PC skills. METHODS: This was a prospective, cross-sectional study. Subjects were all EMRs at seven midwestern Accreditation Council for Graduate Medical Education (ACGME) residency programs. The EMRs completed a questionnaire about their PC use and ability to perform 23 tasks derived from two national retail-training programs. The tasks covered word processing, slide making, and Internet use. The EMRs then took a three-part test performing the skills in the questionnaire. Two independent raters scored the tests. Frequencies with 95% confidence intervals (95% CIs) were calculated for categorical data. Positive and negative predictive values were used to report information comparing residents' performance with their self-assessment of skills. Cohen's kappa was used to test agreement between raters. RESULTS: One hundred twenty-four of 158 (79%) eligible EMRs participated. Since not all participants engaged in all parts of the study, the sample size varies between 121 and 124. One hundred one of 122 (83%; 95% CI = 75 to 89) owned a PC. The EMRs use home PCs a mean of 3.8 hours/week for physician duties and use residency PCs 1.9 hours/week (range 0-20). Ninety-six of 122 (79%; 95% CI = 70 to 86) EMRs reported no formal PC training during residency. Thirty-five percent (43/122; 95% CI = 27 to 44) passed the word-processing test and 50% (62/123; 95% CI = 41 to 60) passed the slide-making test. Reasons for failure were because of errors and not having a presentable product. Thirty-eight of 122 (31%; 95% CI = 23 to 40) failed the literature search, including 33 who said they could perform it. One hundred fifteen of 123 (94%; 95% CI = 88 to 98) EMRs were able to find an Internet address, including ten who stated they could not. Twenty-one percent of the residents who attempted any test (26/124; 95% CI = 14 to 29) passed all three tests. There was no association between year of training and success on the tests (p = 0.374). Thirty-seven of 115 (32%; 95% CI = 24 to 42) EMRs said they had insufficient PC training to meet their physician needs. CONCLUSIONS: Emergency medicine residents have much access to computer technology and possess some computer skills; however, many are unable to produce a usable product or conduct a literature search. Emergency medicine residents have not had sufficient computer training prior to residency. The computer skills of EMRs should be assessed through skills testing rather than self-assessment, and computer training during residency should be improved.     

The use of personal digital assistants by nurse practitioner students and faculty

PURPOSE: To describe the prevalence and patterns of use of personal digital assistants (PDAs) by nurse practitioner (NP) students and faculty, examine relationships between patterns of use of PDAs and demographic characteristics of NP students and faculty, and describe patterns of use of PDAs that support evidence-based practice (clinical scholarship). DATA SOURCES: Responses to a 20-item questionnaire administered via electronic or postal mail from 227 NP students and faculty. CONCLUSIONS: A majority (67%) of the participants used PDAs. Use was higher among men (82%) than women (64%) (p < .05). On average, respondents who used a PDA (N = 153) had been using it just over a year (M = 13 months). Respondents reported using a PDA most days of the week (M = 5 days). The top three medical software programs identified by respondents as the most useful in clinical practice were ePocrates Rx (82%), Griffith's 5-Minute Clinical Consult (26%), and MedCalc (22%). Most participants (96%) related that PDA use supported clinical decision making. IMPLICATIONS FOR PRACTICE: Personal digital assistants may facilitate the application of evidence-based knowledge to practice. However, until there is evidence that PDA software is valid and reliable, clinicians should continue to use a multitude of references to assure the quality and safety of care provided.     

Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing.

OBJECTIVE: Patients, emergency department staff and hospital managers are often confronted with a prolonged length of stay of emergency department patients, with resulting overcrowding in the emergency department. We hypothesized that additional medical personnel would reduce the length of stay. METHODS: We prospectively studied consecutive patients managed in a medical emergency department by internal medicine residents during the evening shift. Data were collected on patients managed before (n=200) and after (n=160) the addition of a second physician on the shift. RESULTS: The addition of a physician in the busy evening shift decreased the length of stay from 176+/-137 to 141+/-86 min (mean+/-SD, P=0.012) for outpatients discharged after evaluation and management in the emergency department. The length of stay for emergency department inpatients admitted for hospitalization was not significantly reduced. CONCLUSION: An additional physician significantly reduced the length of stay of medical emergency department outpatients.     

Discharge from the accident and emergency department after smoke inhalation: influence of clinical factors and emergency investigations.

OBJECTIVES: Smoke inhalation has become the principal cause of death in burns patients. There are few guidelines for the management of smoke inhalation in the accident and emergency department. The aim was to identify what factors influence immediate management. METHODS: A retrospective case note review using data from three west of Scotland accident and emergency departments in 1999. Computerized record systems were used to identify suitable patients. RESULTS: Of 120 patients, 63 patients had incomplete data and were excluded. A total of 57 patients were classified into one of five categories: no burns, normal vital signs and examination (group 1, n=23); no burns, abnormal vital signs or examination (group 2, n=26); minor burns (<15% total body surface area) with or without abnormal vital signs or examination (group 3, n=5); major burns (>15% total body surface area) (group 4, n=2); in cardiac arrest on arrival (group 5, n=1). In groups 1 and 3, the result of two investigations significantly influenced management. In group 2, arterial blood gases and carboxyhaemoglobin levels were abnormal in 25% of cases, but only on one occasion did it influence an admission decision. CONCLUSION: Arterial blood gases, chest radiography and carboxyhaemoglobin estimation rarely influence immediate management. Patients presenting with normal vital signs and examination and short smoke exposure may be safe to discharge from the accident and emergency department without further investigation.     

临床科室设置行政助理岗位的方法与效果

目的探讨在临床科室设置行政助理岗位的具体做法及效果。方法在确定临床科室设置行政助理岗位后,由医院出台临床行政助理管理办法和岗位职责等一系列管理举措,经自愿报名及考试,聘任了25名行政助理,经岗前培训后上岗,并制订了岗位职责和激励考评方法。结果设置行政助理岗位后病人综合满意度提高（P〈O．01）,医护人员对行政助理工作满意度较高。结论设置行政助理岗位,得到了医护人员的认可,提高了病人综合满意度。     

Surrogate markers for adverse outcomes in normotensive patients with pulmonary embolism

BACKGROUND: Although echocardiography has proven utility in risk stratifying normotensive patients with pulmonary embolism, echocardiography is not always available. OBJECTIVE: Test if a novel panel consisting of pulse oximetry, 12-lead electrocardiography, and serum troponin T would have prognostic equivalence to echocardiography and to examine the prognostic performance of age, previous cardiopulmonary disease, D-dimer, brain natriuretic peptide, and percentage of pulmonary vascular occlusion on chest computed tomography. DESIGN: Prospective cohort study. PATIENTS AND SETTING: Normotensive (systolic blood pressure of >100 mm Hg) emergency department and hospital inpatients with diagnosed pulmonary embolism who underwent cardiologist-interpreted echocardiography and other measurements within 15 hrs of anticoagulation. MEASUREMENTS AND MAIN RESULTS: End points were in-hospital circulatory shock or intubation, or death, recurrent pulmonary embolism, or severe cardiopulmonary disability (defined as echocardiographic evidence of severe right ventricular dysfunction with New York Heart Association class III dyspnea or 6-min walk test of <330 m) at 6-month follow-up. The two-one-sided test tested the hypothesis of equivalence with one-tailed alpha = 0.05 and Delta = 5%. Of 200 patients enrolled, data were complete for 181 (88%); 51 of 181 patients (28%) had an adverse outcome, including in-hospital complication (n = 18), death (n = 11), recurrent pulmonary embolism (n = 2), or cardiopulmonary disability (n = 20). Right ventricular dysfunction on initial echocardiogram was 61% sensitive (95% confidence interval, 46-74%) and 57% specific (48-66%). The panel was 71% sensitive (56-83%) and 62% specific (53-71%). The two-one-sided procedure demonstrated superiority of the panel to echocardiography for both sensitivity and noninferiority for specificity. No other biomarker demonstrated equivalence, noninferiority, or superiority for sensitivity and specificity. CONCLUSION: Normotensive patients with pulmonary embolism have a high rate of severe adverse outcomes during 6-month follow-up. A panel of three widely available tests can be used to risk stratify patients with pulmonary embolism when formal echocardiography is not available.     

Referent d-dimer enzyme-linked immunosorbent assay testing is of limited value in the exclusion of thromboembolic disease: result of a practical study in an ED

OBJECTIVE: The aim of this study was to assess in clinical practice the accuracy of a referent d-dimer enzyme-linked immunosorbent assay for the exclusion of venous thromboembolic disease (VTED). PATIENTS AND METHODS: An observational prospective study took place in an emergency department; 205 consecutive outpatients suspected of having VTED were included. Blood samples were collected at admission for VIDAS DD measurement. Venous thromboembolic disease was confirmed by standard clinical imaging. All patients were followed up at 3 months. RESULTS: Venous thromboembolic disease was confirmed in 57 patients (28%). The sensitivity and negative predictive value of a DD assay lower than 500 ng/mL were 78% (95% confidence interval = 67%-87%) and 84% (95% confidence interval = 73%-90%), respectively. Twelve patients had a false-negative DD with one or more of the following: (a) symptoms reported for more than 15 days (n = 2), (b) prior anticoagulation (n = 3), (c) distal VTED (n = 5), or (d) high clinical probability (n = 3). CONCLUSION: In our cohort of patients, DD was less accurate than previously reported, with an upper estimate of the sensitivity of only 87%.     

Doctor's assistants--do we need them?

OBJECTIVE: To investigate the potential for the doctor's assistant role within an accident and emergency (A&E) department in relation to consultant workload. METHODS: A time and motion evaluation of the activities of four A&E consultants before and after a doctor's assistant was established as a team member within our department. A review of the literature was undertaken to allow comparisons with the American model of the physician assistant within the emergency department. RESULTS: The initial evaluation indicated that over 20% of the consultant's time could have been saved if an assistant were available to perform a variety of non-medical tasks. The restudy performed once the assistant was in post indicated less time was spent by the doctors in "medical" clerical duties (6.7% v 11.5% time), telephone use (5.6% v 7.7%), and venepuncture/cannula insertion (0.4% v 2.1%), and more time was spent on consultation over cases (15.3% v 11.3%) and supervision of other staff (9.3% v 4.1%). These five areas changed significantly (p = 0.005 by paired t test). CONCLUSIONS: The doctor's assistant may have a role in reprofiling the workload of senior doctors in A&E departments in the UK. They may also have a role in reducing the pressure on junior doctors, though this effect was not evaluated.     

Use of personal digital assistants to support clinical reasoning in undergraduate baccalaureate nursing students

The utility of personal digital assistant resources in healthcare practice and education presents new challenges for faculty due to changing device capabilities and software availability. Although there is a plethora of personal digital assistant resources available for use by healthcare providers, little is known about the effect on clinical reasoning in nursing students. The complexity of the healthcare arena precludes reliance on memory as a sole resource for problem solving because it can be unreliable. A personal digital assistant provides instant access to information on medical treatment options so reliance on memory alone is avoided. The aims of this study are to assess clinical reasoning when personal digital assistants are used as an information resource for nursing students. These findings have implications for the future nursing work force, including accurate differential diagnosis and diagnostic reasoning, reduction of medication errors, reduction of healthcare costs, and development of effective treatment protocols.     

Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality

OBJECTIVE: The purpose of this study was to examine the outcome implications of implementing a severe sepsis bundle in an emergency department as a quality indicator set with feedback to modify physician behavior related to the early management of severe sepsis and septic shock. DESIGN: Two-year prospective observational cohort. SETTING: Academic tertiary care facility. PATIENTS: Patients were 330 patients presenting to the emergency department who met criteria for severe sepsis or septic shock. INTERVENTIONS: Five quality indicators comprised the bundle for severe sepsis management in the emergency department: a) initiate central venous pressure (CVP)/central venous oxygen saturation (Scvo2) monitoring within 2 hrs; b) give broad-spectrum antibiotics within 4 hrs; c) complete early goal-directed therapy at 6 hrs; d) give corticosteroid if the patient is on vasopressor or if adrenal insufficiency is suspected; and e) monitor for lactate clearance. MEASUREMENTS AND MAIN RESULTS: Patients had a mean age of 63.8 +/- 18.5 yrs, Acute Physiology and Chronic Health Evaluation II score 29.6 +/- 10.6, emergency department length of stay 8.5 +/- 4.4 hrs, hospital length of stay 11.3 +/- 12.9 days, and in-hospital mortality 35.2%. Bundle compliance increased from zero to 51.2% at the end of the study period. During the emergency department stay, patients with the bundle completed received more CVP/Scvo2 monitoring (100.0 vs. 64.8%, p < .01), more antibiotics (100.0 vs. 89.7%, p = .04), and more corticosteroid (29.9 vs. 16.2%, p = .01) compared with patients with the bundle not completed. In a multivariate regression analysis including the five quality indicators, completion of early goal-directed therapy was significantly associated with decreased mortality (odds ratio, 0.36; 95% confidence interval, 0.17-0.79; p = .01). In-hospital mortality was less in patients with the bundle completed compared with patients with the bundle not completed (20.8 vs. 39.5%, p < .01). CONCLUSIONS: Implementation of a severe sepsis bundle using a quality improvement feedback to modify physician behavior in the emergency department setting was feasible and was associated with decreased in-hospital mortality.     

Midregional pro-A-type natriuretic peptide measurements for diagnosis of acute destabilized heart failure in short-of-breath patients: comparison with B-type natriuretic peptide (BNP) and amino-terminal proBNP

BACKGROUND: The aim of the present study was to assess the utility of amino-terminal pro-A-type natriuretic peptide (NT-proANP) measurements for the emergency diagnosis of acute destabilized heart failure (HF), using a novel sandwich immunoassay covering midregional epitopes (MR-proANP). METHODS: The retrospective analysis comprised 251 consecutive patients presenting to the emergency department of a tertiary care hospital with dyspnea as a chief complaint. The diagnosis of acute destabilized HF was based on the Framingham score for HF plus echocardiographic evidence of systolic or diastolic dysfunction. A commercially available immunoluminometric assay was used for measurement of MR-proANP plasma concentrations. RESULTS: Median MR-proANP plasma concentrations were significantly higher in patients with dyspnea attributable to acute destabilized HF (338 pmol/L; n = 137) than in patients with dyspnea attributable to other reasons (98 pmol/L; n = 114; P <0.001). The area under the curve for MR-proANP was 0.876 (SE = 0.022; 95% confidence interval, 0.829-0.914), and the cutoff concentration with the highest diagnostic accuracy was 169 pmol/L (sensitivity, 89%; specificity, 76%; diagnostic accuracy, 83%). In the setting evaluated, diagnostic information obtained by MR-proANP measurements was similar to that obtained with B-type natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) measurements. CONCLUSIONS: MR-proANP measurements may be useful as an aid in the diagnosis of acute destabilized HF in short-of-breath patients presenting to an emergency department. The diagnostic value of MR-proANP appears to be comparable to that of BNP and NT-proBNP.     

Doctor's assistants--do we need them?

OBJECTIVE: To investigate the potential for the doctor's assistant role within an accident and emergency (A&E) department in relation to consultant workload. METHODS: A time and motion evaluation of the activities of four A&E consultants before and after a doctor's assistant was established as a team member within our department. A review of the literature was undertaken to allow comparisons with the American model of the physician assistant within the emergency department. RESULTS: The initial evaluation indicated that over 20% of the consultant's time could have been saved if an assistant were available to perform a variety of non-medical tasks. The restudy performed once the assistant was in post indicated less time was spent by the doctors in "medical" clerical duties (6.7% v 11.5% time), telephone use (5.6% v 7.7%), and venepuncture/cannula insertion (0.4% v 2.1%), and more time was spent on consultation over cases (15.3% v 11.3%) and supervision of other staff (9.3% v 4.1%). These five areas changed significantly (p = 0.005 by paired t test). CONCLUSIONS: The doctor's assistant may have a role in reprofiling the workload of senior doctors in A&E departments in the UK. They may also have a role in reducing the pressure on junior doctors, though this effect was not evaluated.     

Emergent cricothyroidotomies for trauma: training considerations

Background

Emergent cricothyroidotomy remains an uncommon, but life-saving, core procedural training requirement for emergency medicine (EM) physician training. We hypothesized that although most cricothyroidotomies for trauma occur in the emergency department (ED), they are usually performed by surgeons.

Methods

We conducted a retrospective analysis of all emergent cricothyroidotomies for trauma presentations performed at 2 large level I trauma centers over 10 years. Operators and assistants for all procedures were identified, as well as mechanism of injury and patient demographics were examined.

Results

Fifty-four cricothyroidotomies were analyzed. Patients had a mean age of 50 years, 80% were male, and 90% presented as a result of blunt trauma. The most common primary operator was a surgeon (n = 47, 87%), followed by an emergency medical services (EMS) provider (n = 6, 11%) and an EM physician (n = 1, 2%). In all cases, except those performed by EMS, the operator or assistant was an attending surgeon. All EMS procedures resulted in serious complications compared with in-hospital procedures (P < .0001).

Conclusions

(1) Prehospital cricothyroidotomy results in serious complications. (2) Despite the ubiquitous presence of EM physicians in the ED, all cricothyroidotomies were performed by a surgeon, which may present opportunities for training improvement.