Robert McIntyre has been a practicing surgeon for nearly 25 years. Early last month, he became a student again.

It wasn’t a requirement but rather a choice for McIntyre, director of Trauma and Acute Care Surgery Services (TACS) at University of Colorado Hospital. He helped to organize a two-day ASSET (Advanced Surgical Skills for Exposure in Trauma) course Nov. 7 and 8 in the CU School of Medicine’s Center for Surgical Innovation (CSI). McIntyre worked with CSI Executive Director Sarah Massena to handle the logistics and setup.

The ASSET course was developed by the American College of Surgeons (ACS) to allow surgeons to practice procedures they rarely perform but would have to handle quickly in cases of trauma (see box). Data from the American Board of Surgery, for example, show that over the 10-year period from 2004 to 2014, graduating chief surgical residents rarely or never performed procedures exposing the brachial artery, the major vessel supplying blood to the upper arm.

“There are some skills I haven’t had to use since I was a resident,” said McIntyre, who completed his training at UCH in 1992. “I will do them more quickly and effectively having practiced them.”

Bodies of work

The sessions were heavily tilted toward the hands-on. A total of 16 surgeons (eight each day) from UCH, UCHealth partner Medical Center of the Rockies, and other hospitals around the state practiced a variety of surgical procedures on cadavers in the CSI’s large simulation area.

Mark Bowyer, MD, FACS, chief of the Division of Trauma and Combat Surgery and surgical director of simulation at Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center, led the course as guest director. Bowyer presented the anatomical considerations for various cases, along with short video presentations displayed on high-definition television screens that hang above operating tables in the CSI. The students, draped in blue gowns, then went to work in teams of two, four surgeons per cadaver.

For six-and-a-half hours each day, they hunched over the cadavers as they practiced making incisions to find and expose nerves, veins and arteries in the arms and legs, head, neck, chest, stomach and pelvis.

Zachary Hartman, MD, chief surgical resident at UCH, was among the students the second day. He said he relished the opportunity to perform dissections while getting tips and advice from seasoned trauma surgeons who have encountered and learned to avoid procedural pitfalls.

“As a resident I’ve done some of the procedures in a piecemeal way, but I’ve never had the opportunity to do every vascular procedure systematically,” he said. For example, exposing the inferior vena cava, the vein that drains blood from the lower part of the body, was a new surgical experience, Hartman said.

New paths

The participants came in from across Colorado. In addition to those from the Denver metro, Colorado Springs and Fort Collins-Loveland areas, surgeons from Livermore, Delta and Alamosa attended. Hartman and UCH surgical fellows Lauren Steward, MD, and Scott, Moore, MD, rounded out the group.

“This helps to build a community of surgeons,” McIntyre said. “No other trauma center in Colorado is doing this.”

The CSI is now an ACS-approved site to offer the ASSET course, Bowyer said. In addition, he noted, Warren Dorlac, MD, of Medical Center of the Rockies, and Ryan Lawless, MD, of Denver Health Medical Center, MD, were approved as course directors. Frank Wright, MD, and Catherine Velopulos, MD, of UCH; Julie Dunn, MD, of Medical Center of the Rockies; and Clay Burlew, MD, of Denver Health, were approved as course instructors.

The approvals open the door to reprising the ASSET training at the CSI, McIntyre said.

“My goal is to continue to offer the course to practicing surgeons, fellows and residents,” he said. McIntyre envisions residents getting the training during their first three post-graduate years. Those who complete it would then serve as instructors during their fourth and fifth years to the next wave of junior residents.

Hartman’s participation was an initial step toward that goal. His assessment of the course? “It rocked,” he said.

“I think it’s a helpful and valuable experience for any surgeon who has to manage trauma patients,” Hartman explained. “In the majority of major vascular injuries, having the maximum impact as surgeons is important to patients’ survival. These are also some of the rarest injuries, so being able to practice the exposures that will keep people living is a major asset.”

The average number of selected cases over five years of training reported by graduating surgical chief residents. The data were supplied as part of case logs submitted to the American Board of Surgery. The numbers cover the years from 2004 to 2014. All of the skills were practiced during ASSET training at the Center for Surgical Innovation Nov. 7 and 8.

• Thoracic Aorta, Subclavian: 0.1
• Abdominal aorta or inferior vena cava: 0.1
• Brachial artery exposures: 0.1
• Manage cardiac injury: 0.2
• Fasciotomy for injury: 0.8
• Neck exposure for trauma: 1.1
• Thoracotomy for trauma: 2.0
• Major vascular trauma cases: 2.3