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Trauma Anesthesiology as Part of the Core Anesthesiology Residency Program Training: Expert Opinion of the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness (ASA COTEP)

Kaslow, Olga MD, PhD*; Kuza, Catherine M. MD; McCunn, Maureen MD, MIPP, FCCM; Dagal, Armagan MD, FRCA§‖¶; Hagberg, Carin A. MD#; McIsaac, Joseph H. III MD, MS**; Mangunta, Venkat R. MD††; Urman, Richard D. MD, MBA‡‡; Fox, Chris A. PhD*; Varon, Albert J. MD, MHPE, FCCM§§

doi: 10.1213/ANE.0000000000002330
The Open Mind: The Open Mind
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From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Anesthesiology and Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Anesthesiology, University of Maryland School of Medicine Divisions of Trauma Anesthesiology and Surgical Critical Care R Adams Cowley Shock Trauma Center, Baltimore, Maryland; Departments of §Anesthesiology and Pain Medicine, Orthopedic Surgery and Sport Medicine, and Neurological Surgery (Adj.), Harborview Medical Center, University of Washington, Seattle, Washington; #Division of Anesthesiology and Critical Care, UT MD Anderson Cancer Center, Houston, Texas; **Department of Anesthesiology, University of Connecticut School of Medicine, Quinnipiac University, Frank H. Netter MD School of Medicine, Hartford, Connecticut; ††Cardiothoracic Anesthesia, Texas Heart Institute, Baylor College of Medicine, Houston, Texas; ‡‡Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and §§Department of Anesthesiology, University of Miami Miller School of Medicine, Ryder Trauma Center at Jackson Memorial Hospital, Miami, Florida.

Accepted for publication May 31, 2017.

Funding: Dr Kaslow received funding from the Educational fund of the Department of Anesthesiology, Medical College of Wisconsin.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Olga Kaslow, MD, PhD, Department of Anesthesiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226. Address e-mail to ozakharo@mcw.edu.

Management of acutely injured trauma patients is one of the most advanced clinical competencies required by a trauma care team physician. In the United States, the majority of multispecialty trauma care training of anesthesiology residents occurs at level 1 trauma centers. These are primarily academic teaching hospitals with a high trauma case volume, that admits severely injured patients, and who provides 24-hour in-house coverage of anesthesiology services. The anesthesiology service plays an integral role in the management of severely injured patients.1

In contrast to the training, according to the National Anesthesia Clinical Outcome Registry (NACOR) from the Anesthesia Quality Institute (AQI), most trauma and emergency patients are cared for at nonacademic, medium-sized community hospitals.2 All anesthesiologists should acquire the basics of resuscitation for a patient after traumatic injury because even those clinicians who do not practice at level 1 trauma centers may still care for patients with traumatic injuries after residency.2

Trauma anesthesiology (TA) education during residency has been under-recognized and underemphasized. Currently, anesthesiology residency programs offer rotations in a variety of anesthesia subspecialties including ambulatory, transplant, neurosurgery, cardiothoracic, vascular, pediatric, regional, pain management, critical care, and even bariatric surgery. However, a trauma rotation is typically not offered. The Residency Review Committee (RRC) of the American Board of Anesthesiology (ABA) has established that residents must achieve competence in the delivery of anesthetic care for a minimum 20 patients “undergoing procedures for complex, immediate life-threatening pathology,” which may include trauma. The RRC, however, does not specify a minimum number of trauma cases nor the trauma knowledge or skills to be acquired. The mission statement of the ABA declares: “Because of the nature of anesthesiology, the ABA diplomate must be able to manage emergent life-threatening situations in an independent and timely fashion.”3 Nevertheless, the content outline of the (ABA/American Society of Anesthesiologists [ASA]) Joint Council on In-Training Examinations does not offer guidance on a trauma curriculum for anesthesiology training programs to be followed. As a result, many anesthesiology residents graduate with a lack of experience, confidence, and the ability to resuscitate patients with life-threatening or multiorgan trauma.

Given the high number of graduating residents who may provide care for trauma patients in the private and community practice, adequate trauma and acute care education should be offered to equip them with the skills and knowledge to care for polytrauma patients.

Committee on Trauma and Emergency Preparedness (COTEP) believes that there is an insufficient emphasis on trauma training in anesthesiology residency programs and that the knowledge and skills of graduating residents for managing trauma patients are inadequate and below international standards. For example, TA training has been described in detail in the Royal College of Anesthetists advanced level training manual since 2010.4 We believe that there is a need for focused training and education on managing trauma patients during residency training.

To explore the attitudes of anesthesiologists regarding the need for training in TA, we solicited opinions of anesthesiology residents, residency program directors (PDs) and practicing anesthesiologists. Additionally, we invited trauma surgeons to share their views of anesthesiologists’ performance in trauma cases and their thoughts on implementing a dedicated TA curriculum.

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METHODS

Four different online survey questionnaires were sent via SurveyMonkey (Palo Alto, California) to 4 groups of participants. Responses for all participants were anonymous.

  1. Anesthesiology residents: Chief residents from 133 US anesthesiology residency programs were contacted and asked to distribute the resident survey to the categorical residents (CA-1, CA-2, and CA-3) at their programs.
  2. Anesthesiology residency PDs: The PD survey was distributed to 133 PDs via e-mail.
  3. Practicing anesthesiologists: We asked presidents and/or secretaries of all the anesthesiology state component societies to distribute the survey to their members.
  4. Trauma surgeons: The survey was e-mailed to all members of Western Trauma Association (WTA) and active, senior, and associate members of the Eastern Association for Surgery of Trauma (EAST).

Survey questions for all groups were designed by the ASA COTEP. The questions related to the following:

  • Demographics (year of residency training)
  • Availability and duration of residency training at a level 1 trauma center
  • Availability of a formal TA rotation and curriculum
  • Participants’ exposure to trauma during their residency and perceived benefit of a TA rotation for their education and practice

Trauma surgeons were also asked to comment on the importance of the anesthesiologist’s role as part of the trauma team, as well as their opinion on anesthesiologists’ adequacy of training when managing trauma patients. The surgeons were also asked to comment on anesthesiologists’ skills and knowledge in trauma care. The surveys were designed to take <5 minutes to complete and consisted of 6 to 8 questions. All responses were anonymous. Completion of survey was voluntary and without remuneration.

We applied descriptive statistics to evaluate our result. Results are expressed as number (%) and the lower and upper limits of 95% confidence intervals were calculated. The qualitative data collected as free-text comments were analyzed for thematic content.

Institutional review board exemption status was requested by the EAST Research and Scholarship Section; therefore, the survey was reviewed by the Medical College of Wisconsin institutional review board and was deemed exempt from further review.

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RESULTS

The response rates for the surveyed groups were as follows:

  • Residents: Of the total 4652 US categorical residents (2014–2015 Accreditation Council for Graduate Medical Education [ACGME] data book), 212 residents completed the survey (4.5% response rate). Among the respondents, 28% identified themselves as CA-1, 37% as CA-2, and 34% as CA-3 residents.
  • Program directors: We received 35 responses from 133 PDs (26.3% response rate).
  • Practicing anesthesiologists: Of the 49 anesthesiology state societies (Alaskan state society’s email was invalid), which consisted of 31 389 active members, 433 practicing anesthesiologists responded (1.4% response rate).
  • Trauma surgeons: Of the 1937 WTA and EAST members, 455 responded (23.5% response rate); 95% (430/454) were surgeons, 0.9% (4/454) emergency medicine physicians, 1.5% (7/454) anesthesiologists, 2.2% (10/454) nonphysicians, and 0.66% (3/454) other.

The results of the surveys are presented in the Tables 1, 2, 3, and 4 and Supplementary survey result charts for residents, PDs, anesthesiologists, and surgeons (Supplemental Digital Content 1–4, Figures 1–4, http://links.lww.com/AA/B901, http://links.lww.com/AA/B902, http://links.lww.com/AA/B903, http://links.lww.com/AA/B904).

Table 1.

Table 1.

Table 2.

Table 2.

Table 3.

Table 3.

Table 4.

Table 4.

  • Residents: A clear majority of residents (98.6%) reported having their training at a level 1 trauma center and 81.5% felt they had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 40.5% of them had a formal rotation in TA. The majority of the residents saw a benefit of trauma rotation for their education (87%) and for their future practice (76.5%).
  • Program directors: Most of the PDs (94.3%) reported their training occurring at the level 1 trauma center and 81.3% believed that their residents had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 41.9% offered a formal TA curriculum but only 20% offered a formal TA rotation. Only 32.1% of PDs saw a benefit of TA rotation for their residents’ education and less than half (46.9%) believed that it would be helpful to track ACGME case logs regarding their residents’ exposure to emergency surgery for life-threatening or multiorgan trauma.
  • Practicing anesthesiologists: A majority of anesthesiologists (88.9%) recalled that their residency training occurred at a level 1 trauma center and 85% felt that they had sufficient exposure to the emergency surgery for life-threatening or multiorgan trauma. Forty one percent recalled that their residency program had focused training in TA and 78.2% believed that it was beneficial to have had such training in their current practice. Whereas only 43.1% of them felt that anesthesiologists employed at level 1 trauma centers should have dedicated training in trauma, and the majority (91.2%) felt that it was important to have the necessary skills and knowledge to perform anesthesia for life-threatening or multiorgan trauma in their current practice.
  • Trauma Surgeons: Most of the surgeons practiced at level 1 (75.6%) and level 2 (20.6%) trauma centers. Ninety-eight percent of the surgeons believed that an anesthesiologist is an essential partner in a multidisciplinary trauma team. Ninety-six percent agreed that anesthesiologists should receive dedicated training for life-threatening or multiorgan trauma during their anesthesiology residency, but only 68.6% of them felt that anesthesiologists are adequately trained to manage these cases in their centers.

The survey responders (total of 1.135) submitted 417 free-text comments. The most common topics were duration and kinds of trauma training provided in anesthesia residency, sufficiency of exposure to emergency surgery for life-threatening or multiorgan trauma, opinion on a benefit of trauma anesthesia rotation for anesthesiologist’s education and practice, and skills missing with anesthesiologists working in trauma centers.

To present data more completely, we calculated the lower and upper limits of the 95% confidence interval. This, along with percentages, should help readers understand the strengths and weaknesses of the data. Since the responses did not contain a numerical range (eg, 1–5), we could not evaluate them based on a Likert scale.

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DISCUSSION

We present the large spectrum of opinions appraising the current state of TA education during anesthesiology residency training, its challenges, and the need for this training among 4 groups of physicians—the key participants in the current US trauma care systems—anesthesiology residents, anesthesiology residency PDs, practicing anesthesiologists, and trauma surgeons.

Our study was subject to several limitations; the main limitation is a low response rate in 2 surveyed groups (the anesthesia residents and practicing anesthesiologists). This low response rate was expected as the survey links had to be distributed to large target audiences (4652 US anesthesiology residents and 31, 389 anesthesiologists who were active members of anesthesiology state societies) via intermediaries (chief residents and state society presidents/secretaries). The cooperation of the intermediaries was unpredictable; therefore, the response rates in these 2 groups could not be accurately calculated. Additionally, there was potential for recall bias in the responses of the practicing anesthesiologists, as there was variability in the time since their graduation from residency.

Most of the anesthesiologists surveyed (residents, practicing anesthesiologists, and PDs) confirmed being trained at level 1 trauma centers and felt they had adequate exposure to emergency surgery for life-threatening or multiorgan trauma during their training. However, less than half recalled being offered a formal TA rotation or curriculum. Interestingly, while residents and practicing anesthesiologists saw a benefit in having a dedicated rotation in TA, PDs did not.

Although most of the residents, PDs, and practicing anesthesiologists agreed that, overall, level 1 trauma centers provide residents with sufficient exposure to a variety trauma cases, they also commented on several barriers to TA training including insufficient volume of penetrating trauma and the sporadic nature and unpredictable timing of trauma, making it interspersed throughout their training. Furthermore, a majority of practicing anesthesiologists felt they could apply principles of managing other complex cases requiring resuscitation of shock and coagulopathies to trauma management (eg, liver transplants, ruptured abdominal aortic aneurysm, and major cardiac and spine cases).

We specifically queried the practicing anesthesiologists on benefits of a TA fellowship.5 The majority of them were critical toward the idea of this fellowship. They felt that creating another anesthesiology subspecialty would “not be feasible,” was “not practical,” was “too restrictive,” and “would create new barriers.” At the same time, some responders saw the value of employing fellowship-trained faculty to provide high-quality TA education.

Members of the ASA COTEP believe that providing the anesthesiology residents with structured training by a well-designed TA rotation with a focused curriculum is the best method to educate and prepare them for taking care of trauma patients. To address this concern, COTEP developed a model TA curriculum, which identified the ACGME core competencies and outlined the goals and objectives for junior residents (categorical anesthesia CA-1 and -2) and another for senior residents.6–8

Many anesthesiologists surveyed favored the implementation of required documentation of high trauma caseload during residency and competency training for trauma anesthesiologists to practice at a level 1 trauma center. However, the latest version of the ACGME resident case logs no longer lists trauma as one of the data entry items. More than half of the surveyed PDs felt that trauma cases should not be tracked in the ACGME resident case logs. The reasons provided by PDs for not tracking trauma cases included insufficient case numbers and confusion with the definition of “trauma cases.” Additionally, PDs believed that the ACGME case log is already tracking life-threatening pathology, providing experiences similar to trauma (eg, liver transplant, emergency major vascular surgery, and obstetric hemorrhagic complications), which require massive transfusion. Nevertheless, to ensure the success of a TA education, COTEP strongly believes that the number of trauma cases should be documented and the definition of trauma cases should be classified as “life-threatening or multiple-organ trauma.” Without these data, it would be impossible to assess the residents’ trauma experience.

Although there are conflicting views among anesthesiologists, residents, and PDs with respect to TA education and training, both COTEP members and trauma surgeons share the belief that a dedicated TA curriculum is warranted and needed. The vast majority of surgeons believe in required TA education for those anesthesiologists providing care to trauma patients at level 1 trauma centers. However, less than half of the anesthesiologists saw the need for this training. Many of the anesthesiologists believed that the TA skills “could be learned on the job” and that a practicing anesthesiologist “should be able to get up to speed with focused additional training, such as continued medical education (CME).” Moreover, the trauma surgeons emphasized the importance of the rotation on trauma and critical care service for anesthesiologists providing care for trauma patients. They felt this rotation should take longer than what is currently offered at anesthesiology training programs and include 3 months of intensive care unit training during CA-3 year. The surgeons also stressed the value of both high-fidelity (mannequin-based) and low-fidelity simulation (case discussion) training. Additional skills suggested to be incorporated into training included fostering leadership and team-building skills in trauma patient resuscitation.

Both anesthesiologists and trauma surgeons agreed on the importance of the Advanced Trauma Life Support course, interdisciplinary conferences (including morbidity and mortality) with the anesthesiology, surgical, and emergency medicine departments, and hands-on practice sessions to master techniques (eg, cricothyrotomy, intraosseous line placement).

There is a concerning disconnect between the trauma surgeons and the anesthesiologists around the latter’s knowledge and skill level to manage patients with life-threatening or multiorgan trauma. While 91% of practicing anesthesiologists believed that they had the necessary skill level, only 69% of the trauma surgeons felt that the anesthesiologists at their institutions had been adequately trained to manage these types of cases. Of the 450 trauma surgeons who responded to the survey, 135 (30%) reported skills that were deficient in anesthesiologists providing trauma care, including poor teamwork and coordination of care, as illustrated by the representative statement: “anesthesiologists need to be daily members of the trauma team, not every once in a while”; reluctance in responding to trauma alerts; an inability to expedite access for emergent procedures and to coordinate aggressive trauma resuscitation; the overuse of nurse anesthetists; and lack of communication with the surgeon regarding hemodynamics during intraoperative resuscitation were also concerns expressed by the surgeons.

Trauma surgeons felt anesthesiologists lacked understanding of modern concepts of shock and trauma and evidence-based resuscitation strategies, such as damage control resuscitation, permissive hypotension, and hemostatic resuscitation.9,10 They felt that in general, anesthesiologists were slow to implement massive transfusion protocols and goal-directed management of acute traumatic coagulopathy based on viscoelastic methods, such as thromboelastography and rotational thromboelastometry.11 This is in agreement with data that anesthesiologists have gathered from their own practices.12 The surgeons also felt that anesthesiologists have not been adequately trained in intravascular volume assessment, minimizing the use of crystalloid solutions and avoiding the use of colloids in trauma scenarios. Other comments included statements such as, “anesthesiologists fail to recognize that ‘normal’ hemoglobin in an actively hemorrhaging patient is meaningless”; “unwilling to transfuse blood based on abnormal base deficit”; “use pressers without communication with surgeon.” Other respondents suggested more focused education on resuscitative endovascular balloon occlusion of the aorta, emergency thoracotomy, and emergency cricothyrotomy.

A very critical point made by the trauma surgeons was that anesthesiologists may treat trauma patients just like elective patients with hemorrhage and hemodynamic instability. They made concerning comments regarding the common assumption apparently made by anesthesiologists that trauma required the same resuscitation as open heart, liver transplant, aortic surgery, and other cases with intraoperative hemorrhage, believing themselves to be equipped to care for trauma patients “because they deal with sick patients every day,” without any specific knowledge of current concepts in trauma resuscitation.

Therefore, although most of the residency program training is performed at level 1 trauma hospitals and most surveyed anesthesiologists do not perceive a benefit in focused TA education, trauma surgeons disagreed. Trauma surgeons felt that practicing anesthesiologists lacked the knowledge and skills to appropriately manage trauma patients. These beliefs are shared by the authors and members of ASA COTEP, who realize the value of and support the implementation of a TA curriculum.

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CONCLUSIONS

Our survey results revealed that a majority of anesthesiology residency programs conduct their training at the level 1 trauma hospitals, which ensures an adequate exposure of their residents to emergency surgery for life-threatening or multiorgan trauma. However, less than half of the programs that responded to our survey augment the exposure with a regimented education, such as didactic curriculum or formal rotation in TA. Furthermore, most of the residency PDs do not see the benefits of such education, unlike their current trainees and graduated anesthesiologists in various stages of their practice.

Such a disconnect and a lack of formal education in TA could explain serious gaps in knowledge of unique physiology of shock and trauma and in understanding the principles of resuscitation. These deficiencies were stressed in numerous comments of the trauma surgeons, the largest group of responders and with one of the highest response rates.

Our survey revealed substantial differences in perception of abilities of the anesthesiologists employed by the level 1 trauma centers—while practicing anesthesiologists were confident they were more than adequately trained to provide anesthesia to the trauma patients, the surgeons felt that they were inept to do this job. Thus, the vast majority of trauma surgeons supported the need of dedicated training in anesthesiology for life-threatening or multiorgan trauma during anesthesiology residency.

These concerns raised by trauma surgeons highlight the premise that perhaps our current TA training is inadequate and support the COTEP’s viewpoint that implementing a dedicated TA curriculum in all anesthesiology training programs would be a stepping stone toward improving the knowledge and skill sets needed to care for trauma patients.

TA is not just a mere practice of massive blood transfusion and coagulation management, but it requires a certain aptitude and mastery to efficiently deliver safe and effective multidisciplinary acute and trauma care in and out of the operating room environment, as well as national and international disaster preparedness. Dedicated training will give the authority to anesthesiologists to become academic and administrative leaders in an ever-growing acute and trauma care specialty.

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DISCLOSURES

Name: Olga Kaslow, MD, PhD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Dr Kaslow has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.

Conflicts of Interest: None.

Name: Catherine M. Kuza, MD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Maureen McCunn, MD, MIPP, FCCM.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Armagan Dagal, MD, FRCA.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Carin A. Hagberg, MD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: Dr Carin A. Hagberg has a financial relationship with Ambu, Cadence Pharmaceuticals, Karl Storz Endoscopy, and MedCom Flow in the form of funded research and is an unpaid consultant for Ambu, Covidien, and SonarMed.

Name: Joseph H. McIsaac, III, MD, MS.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Venkat R. Mangunta, MD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Richard D. Urman, MD, MBA.

Contribution: This author helped analyze the data and prepare the manuscript.

Conflicts of Interest: None.

Name: Chris A. Fox, PhD.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

Name: Albert J. Varon, MD, MHPE, FCCM.

Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Richard P. Dutton, MD.

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REFERENCES

1. American College of Surgeons. Resources for the optimal care of the injured patient: 2014. 2016.6th ed. Chicago, IL: American College of Surgeons.
2. McCunn M, Galvagno S, Dutton R. Acute care anesthesiology: a national anesthesia database study of emergency cases. American Society of Anesthesiologists Annual Meeting, October 2014, New Orleans, LA.
3. StagedExaminations. Available at: http://www.theaba.org/PDFs/BOI/StagedExaminations-BOI. Accessed October 16, 2016.
4. Annex E—Advanced Level Training. Available at: http://www.rcoa.ac.uk/system/files/TRG-CCT-ANNEXE.pdf. Accessed April 09, 2017.
5. McCunn M, Dutton R, Dagan A, et al. Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the “Acute Care” Anesthesiologist? Anesth Analg. 2015;121:1668–1673.
6. Varon A, McCunn M. The need for a Trauma Anesthesia curriculum: First steps. ASA Newsletter. 2012;76:38–39.
7. Tobin JM. Developing a trauma curriculum for anesthesiology residents and fellows. Curr Opin Anaesthesiol. 2014;27:240–245.
8. American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness. Trauma Anesthesiology Curriculum. Available at: https://www.asahq.org/resources/resources-from-asa-committees/committee-on-trauma-and-emergency-preparedness/trauma-anesthesiology. Accessed April 4, 2017.
9. Fouche Y, Sikorski R, Dutton R. Changing paradigms in surgical resuscitation. Crit Care Med. 2010;38:S411–S420.
10. Parr M, Buehner U. Smith C. Damage control in severe trauma. In: Trauma Anesthesia. 2015.2nd ed. Cambridge, UK: Cambridge University Press
11. McCunn M. The role of the anesthesiologist in management of patients following traumatic injury. ASA Monitor. 2013;77:16–19.
12. McCunn M, Vavilala M, Speck RM, Dutton R. ASA trauma care survey: Anesthesiology practices demonstrate poor guidelines implementation and need for education. American Society of Anesthesiology Annual Meeting, October 2011, Chicago, IL.

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