Trauma Video Review: Advancing the Goals of the Academic Trauma Center

Daniel N. Holena MD, David J. Milia MD

Imagine an untelevised sporting event played in an empty stadium, except for those participating in the game. There are no fans, no cameras, no sportscasters. The home team is a heavy favorite, with a roster loaded with talent and a string of dominating wins. At the end of this unwitnessed game, the score is announced: the home team has lost by an overwhelming margin. Outside the stadium in the darkening sky, the team captain is interviewed by the press. The fans are upset. What happened in there they ask, and what can we do to make sure this does not happen again?

“Well,” says the captain “It’s true that we lost, but there were some problems with our equipment, and the trainers weren’t really as helpful as they could have been, and of course we got some really bad calls from the referees. Led by my shining example of athleticism, we as a team played to the best of our outstanding ability, as we always do, so there wasn’t really anything we could have done better.”

Nodding and murmuring, the fans and reporters appear satisfied with the response, except for one who speaks up.

“What you say is most certainly true,” she says, “but isn’t there some more objective information you can provide about what happened in there?”

“Of course!” says the team captain cheerfully. “Later today I’ll write a note that contains my recollection of the game. Well, a game anyway. It’s actually a templated note, but I’ll be sure to update the relevant details!”

In the real world, of course, major athletic events are not just experienced by the team members but are often videorecorded. Reviewing footage of these games is a key element of performance improvement, so coaches and players can understand where the team is performing well and where improvement is needed. So important is this practice that players in the National Football League may review up to 4 hours of game tape per day and even veteran players report that this endeavor helps them to improve their game. If such a practice is in widespread use to help professional sports teams play at the top of their game, then it is perhaps counterintuitive that this method of performance improvement is vanishingly rare in medicine, where so much more is on the line.

There is, however, one area in healthcare where audiovisual review has taken root: the initial evaluation and management of injured patients. In fact, the audiovisual review of trauma resuscitations, or Trauma Video Review (TVR, Figure 1), has been a practice at high-performing centers for over three decades.[1] This is perhaps unsurprising given the strong alignment between the benefits of TVR and the clinical care, educational, and research missions of the academic trauma center.[2]

Figure 1. Typical view from a TVR platform.

As a principle in quality improvement, it is difficult to demonstrate improvement in that which is not measured. For example, experienced trauma providers know that intravascular access in patients in hemorrhagic shock can be extremely difficult; once-plump veins are collapsed, resisting the efforts of the needle to find them. How then to best get access to allow for volume resuscitation? One could review the medical record to see what methods were most often employed, how long they took, and what their success rates were, but even under the best circumstances such information is recorded only sporadically. In contrast, TVR can provide granular data not available in the medical record (Figure 2). Using such data from a TVR quality improvement program, one study found that only 43% of attempts at peripheral intravenous access were successful in patients in extremis. Similarly, only 44% of central venous access attempts were successful with the added drawback of taking a median of ~3 minutes per attempt. In contrast, intraosseus attempts were successful in 92% of cases and only took ~30 seconds per attempt.[3] Using TVR to measure the timing and success rates of these access attempts informed a change in practice at the study site for patients in extremis arriving without access. Early attempts at central venous catheter insertion were all but abandoned and insertion of two intraosseous access devices quickly became the first line of therapy.

Figure 2. Data from TVR: an alluvial plot of intravascular access attempts over time during trauma resuscitation. PIV = Peripheral IV; IO = Intraosseous device; CVC = Central Venous Catheter.

When it comes to surgical education, there is an old aphorism that the worst thing about every other night call is missing half the cases. This need not be true when there is a TVR program in place, as learners may still find educational benefit, even from cases where they were not physically present. This education can come in the form of personalized feedback provided to learners in individual review sessions but can also take the form of a multidisciplinary conference in which challenging and interesting cases are reviewed in a group setting. Indeed, survey data from participants of one such TVR educational conference demonstrates that attendees find the experience to be of high educational value.[4]

From a research perspective, a critical barrier to study of processes of care during trauma resuscitation is data collection. For instance, high impact low frequency procedures such as resuscitative thoracotomy occur only sporadically, even at busy trauma centers. Studying such procedures using prospective data collection would require continuously present and available research personnel, a resource beyond the means of most trauma centers. Audiovisual review systems can eliminate this barrier, while at the same time providing data that is subject to far less missingness and measurement bias than prospective or retrospectively collected data. Such efforts have led to insights into both the technical and non-technical aspects of resuscitative thoracotomy.[5,6]

Although the benefits of TVR programs are manifold, only about one-third of U.S. Level 1 and 2 trauma centers have such programs. When surveyed, centers cited staff concerns, perceived medicolegal risk, and financial constraints as barriers to the institution of TVR programs. The division of trauma at the Medical College of Wisconsin was an early adopter of TVR technology and first instituted a program in the 1990s. This was taken offline secondary to regulatory concerns, but fortunately was able to be reinstated in 2015.7 Since that time, the trauma video review program at the Medical College of Wisconsin has continued to execute the clinical care, education, and research aims of the academic trauma center.

FOR ADDITIONAL INFORMATION on this topic, visit mcw.edu/ surgery or contact Dr. Daniel Holena at dholena@mcw.edu.

REFERENCES

1. Hoyt DB, Shackford SR, Fridland PH, Mackersie RC, Hansbrough JF, Wachtel TL, Fortune JB. Video recording trauma resuscitations: an effective teaching technique. The Journal of trauma. Apr 1988;28(4):435-40.doi:10.1097/00005373198804000-00003

2. Vella MA, Dumas RP, Holena DN. Supporting the Educational, Research, and Clinical Care Goals of the Academic Trauma Center: Video Review for Trauma Resuscitation. JAMA Surg. Mar 1 2019;154(3):257-258. doi:10.1001/ jamasurg.2018.5077

3. Chreiman KM, Dumas RP, Seamon MJ, Kim PK, Reilly PM, Kaplan LJ, Christie JD, Holena DN. The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. Conference Paper. Journal of Trauma and Acute Care Surgery. 2018;84(4):558-562. doi:10.1097/TA.0000000000001795

4. Davis L, Johnson L, Allen SR, Kim PK, Sims CA, Pascual JL, Holena DN. Practitioner perceptions of trauma video review. Article. Journal of trauma nursing : the official journal of the Society of Trauma Nurses. 2013;20(3):150-154. doi:10.1097/ JTN.0b013e3182a172b6

5. Dumas RP, Chreiman KM, Seamon MJ, Cannon JW, Reilly PM, Christie JD, Holena DN. Benchmarking emergency department thoracotomy: Using trauma video review to generate procedural norms. Article. Injury. 2018;49(9):16871692. doi:10.1016/j.injury.2018.05.010

6. Dumas RP, Vella MA, Chreiman KC, Smith BP, Subramanian M, Maher Z, Seamon MJ, Holena DN. Team Assessment and Decision Making Is Associated With Outcomes: A Trauma Video Review Analysis. Article. Journal of Surgical Research. 2020;246:544-549. doi:10.1016/j.jss.2019.09.033

7. Williams KS, Pace C, Milia D, Juern J, Rubin J. Development of a Video Recording and Review Process for Trauma Resuscitation Quality and Education. West J Emerg Med. Mar 2019;20(2):228-231. doi:10.5811/westjem.2018.12.40951