Recipe for low-cost models for ultrasound training

One day this week, Andrew Smith came to my office and we talked about the fact that low-tech, low-cost simulation does not receive as much attention as the bells and whistles of computerized models.  Coincidentally, preparing for an upcoming  high-school science fair, one of our partner’s daughter (Dr. Mohamed Sheheta, Faculty of Engineering) presented on the topic of low-tech, low-cost solutions to the development of simulators to teach ultrasound skills.  This topic is very timely considering our work with development of simulation-augmented education in Haiti and for our own remote north.  In this issue of the newsletter we decided to give you 2 such recipes.

Low-cost homemade gel block for ultrasound training


Author: Dina Shehata
 (High school Student)

Context: Ultrasound is a valuable tool being increasingly integrated into a multitude of different disciplines of clinical medicine. Point of Care Ultrasound (PoCUS) improves patient safety when used to guide procedures such as central line placement, paracentesis, and thoracentesis. Training residents to be proficient in ultrasound needle guidance predominantly relies on the use of commercial phantoms or gel blocks. These simulators range in cost from $100-5000 per unit and facilitate a defined number of needle-sticks. Home-made phantoms are inexpensive ($5-10 per block) and have been cited in the literature as being of good quality.

Provided are recipes and preparation instructions for 2 such models.

Homemade “thick” gel block

This recipe is based on the link on YouTube: 

https://www.youtube.com/watch?v=u9_1md1f-NM&feature=youtu.be&noredirect=1

 

Ingredients

• Gelatin

• One mixing bowl

• Metamucil (sugar-free)

• Measuring cup

• 2 Tupperware containers of the same size (I used a 7 ½ x 4 ¾ x  2 ⅞ inch containers)

• 2 water pipes with different outer diameters (¾ inch pipe and 7/16 inch pipe)

• Spade drill bits that correspond with the water pipes

• Drill

• Cloth soaked in cooking oil

• Any preservative (I used 70% isopropyl alcohol)

• Hot water

• Hand mixer

• Spoon and sieve

 

Preparation

1. Take one of your Tupperware containers and drill two different sized holes on the left and right faces of the containers. Have each hole line up with the hole of the same size on the opposite sides of the containers. Note that these two holes will be made with the drill bits that are the same size as your water pipes.

2. Place the two water pipes in their corresponding holes through the container from end to end.

3. Then lubricate the pipes with your oil-soaked cloth so that they would be easier to take out later.

4. Take your mixing bowl and in it put 180 grams of gelatin powder, 1000 milliliters of water, 60 milliliters of preservative and 2 tablespoons of Metamucil.

5. Use the hand mixer for about 1-2 minutes and make sure all the powder dissolves.

6. Using the sieve remove the air bubbles and debris from the surface.

7. Pour liquid into container then place it in the refrigerator for around 3-4 hours.

8. Once the model is firm, remove the pipes but be a bit cautious as to not move them around too much so they won’t ruin the block.

9. Put the model in a new plastic container.

10. While it is in the container fill the two holes of the model with water.  Remove all excess air by tilting the container then pushing down on the model and squeezing the air out and refill until the vessel is full. Make sure there are no air bubbles.

 

Homemade ”thin” gel block

 

This recipe is based on the link on YouTube: https://www.youtube.com/watch?v=ypw8vjZ2DN0

 

Ingredients:

• Gelatin

• Two different sized plastic tubes (I used a ¼ inch plastic tube and ¾ inch plastic tube)

• Measuring cup

• Measuring spoons

• Whisk

• Tupperware container at least 2-3 inches in height (I used a 7 ½ x 4 ¾ x  2 ⅞ inch container)

• Non-stick spray or cooking oil

• Pot

• Paperclips or staples

 

Preparation

NOTE: There will be two different layers two this block.

Bottom Layer:

1. Put 250cc water into a pot and boil until you see little bubbles coming out the bottom of the pot.

2. Gently stir in 21 grams of gelatin.

3. Whisk rapidly so you won’t get clumps of gelatin.

4. Once the gelatin is added and dissolved, add in one tablespoon of Metamucil all the while still whisking.

5. Pour the mixture into your container and then place in your fridge for about an hour

6. Take your plastic tubes and tie off the ends with some string or knot them. Then fill them up with water and tie off or knot the top. Make sure that they are not leaking water. If they are leaking, something I did was to set fire to each end and mold them shut while they are still hot and are able to be easily shaped.

7. Take your container out of the fridge and put the plastic tubes on top of the mold. They should be a few cm away from each other. In order to secure Penrose Drain, I used paper clips and bent them into the shape of staples and tacked down the Penrose Drain.

Top Layer:

Note: This layer will actually be thicker than the bottom layer.

1. Put 425cc of water into a pot and make it boil until once again there are little bubbles reaching the surface of the water.

2. Mix in 35 grams gelatin and whisk it. Make sure it has dissolved and there are no clumps before adding in 1.5 tablespoons of Metamucil. Mix until completely smooth.

3. To make sure there are no clumps you can use a tissue as a sift to take out all clumps.

4. Let this mixture cool for about 20-25 minutes before pouring it onto the 1st layer. Every 5 minutes go and stir it to prevent clumps and so it can cool evenly.

5. Then pour mixture onto 1st layer and then take the whole thing and place it in the refrigerator for about two hours.

6. When you take it out you’ll notice that it is not completely solidified but it is still pretty firm.

7. Take a dull knife to go around the edges and the model should easily fall out.

8. Put the mold on wax paper, wrap the model, put the whole thing in a Ziploc bag and place it in the fridge overnight.

9. After that it will be ready for use.

Every practice is a simulation: Lots to learn from our coaches

By Heather Carnahan, Dean and Professor, School of Human Kinetics and Recreation, Memorial University
& Peter Benoit, Head Coach, Sea-Hawks Men’s Basketball, Memorial University

In the School of Human Kinetics and Recreation at Memorial University, kinesiology researchers and coaches from Sea-Hawks Athletics are working together to understand how to optimize performance in high stakes game situations. For example, as part of a post-game debriefing session, our coaches have been using SportsCode video analysis software to identify good performances as well as errors in team execution. SportsCode also allows our coaches to provide individualized feedback to players. Both positive and negative clips can be brought together to help players recognize the errors they are producing consistently, and to validate to the players through video demonstration, the coaches verbal feedback. This video review takes place under the supervision of the coach, and virtually, where athletes can download their edited videos to engage in their own analysis of their performances. We are currently collaborating on a program of research to understand how the errors generated during practice are related to the errors generated during game situations.

Why is this relevant to the health professions education community? There is emerging literature on the importance of coaching in health professions education.  There is also a longstanding literature on coaching best practices within the sports community.  There is much that can be learned from sport coaches ranging from how they develop talent, facilitate group dynamics, apply theories of motor learning to skill development, to training individuals and teams to achieve optimal levels of performance in high stakes situations.

While some learning takes place on game day, much of the athlete’s learning takes place during practice. While the language of simulation is not often used in the sports context, during practice, simulations of game play are executed and feedback is provided, using technology such as SportscCode.  Our research into how this feedback is best delivered, and how it relates to performance in the game or “real life” situation should have application to the type of training taking place in the simulation centre where health professionals are trained. It is hoped that a dialogue between the sports and health professions domains will be opened. We have much to learn from each other.

Throwing out Babies with the Bathwater: Guidelines for Simulation (Based) Research.

A number of recent publications about the state of the science in simulation research, as well as framework proposing ways to synchronize simulation research led to what would be the obvious next step: development of standardized reporting guidlines for simulation research. 

This step has been very recently undertaken by the INSPIRE network, which posted a call for participation in a collaborative project with the goal to develop standardized reporting guidelines for simulation-based research (see Haji et al., 2013 for an alternative view on the use of "based").  A guideline is a statement by which to determine a course of action and a structure put in place to streamline a particular processes according to a set routine or sound practice. 

Curently, there are numerous reporting guidelines (CONSORT, STROBE, SQUIRE etc) for various types of studies.  Unfortunately, a reporting guideline does not exist for simulation research.  As a result, the nature of how simulation studies are reported is highly variable. By developing a standardize reporting guideline, INSPIRE is hoping to raise the bar for simulation research.

I usually do not take the "devil's advocate" position, but in this case I will.  The proposal calls for guidelines for standardized reporting for simulation research.  The questions I pose are: Are we ready for such guidelines?  Education, which simulation is a part of, is a complex system, which needs to be researched using multiple lenses, methodologies, experimental paradigms.  Do we know what methods are best to research this complex system? Are we running into the danger of following , perhaps prematurely formed guidelines and thus not accepting unorthodox approaches that do not fit with the guidelines?  Throwing a babies with the bathwater.

If anyone is wishing to participate in the INSPIRE project feel free to contact me and I will relay the information.  I would also like to read what our community has to say about this initiative.  Perfect timing? Premature? If developed, these guidlines will have a very direct effect on what we do, how we do it, and how we report on what we did? Thankfully, by definition following a guideline is never mandatory as guidelines are not binding and are not enforced.  Perhaps this guideline building exercise will lead all of us to a better understating of where we currently stand in simulation research.

I think it is worth having a conversation about...

Video Based Debriefings: Can Simulation Learn from Sports?

In sports, the margin between winning and losing is very narrow.  

A team must execute a winning strategy in a matter of seconds and players must make real-time decisions that determine the outcome of a game.  Coaches develop these strategies and abilities in their teams through carefully analyzing past performance in training and competition.  

Many simulation practitioners are beginning to use similar models of performance analysis in an effort to improve outcomes.

In sports players’ physical skills have been perfected over thousands of hours of practice and game time.  What separates winning and losing teams are not only physical skills and athleticism, but cognitive and communication skills executed under intense pressure.

The best coaches are the ones who prepare their teams to analyze and assess relevant game factors, make the correct decision at the right time, and execute.  They make certain their players explicitly understand expected performance measures.   Players must communicate effectively, accept and perform assigned roles, working as a team toward the desired outcome.  

In order to minimize errors, a coach will spend hours analyzing the performance of their own team. They may, for example, look for breakdowns in communication and execution, searching for ways to eliminate them. 

Over the last 50 years, coaches have relied on advances in technology to improve performance analysis.  During the last 10 years, SportsCode, developed by Sportstec, has been embraced at the highest levels of sport. This and similar technologies enable coaches to annotate or “code” their observations into game footage for the purposes of analyzing performance, determining opponents’ tendencies, and generating video evidence of best practices. 

Globally, many practitioners of simulation have embraced a similar analysis model.  Educators in the health care and marine training sectors are beginning to use similar technologies (for example Studiocode) for exactly the same reasons as coaches – to identify and reduce risks and to improve educational processes.  The key analysis is the same the environments differ. 

Healthcare professionals as well as off shore workers face more varied and serious situations than do sports coaches, despite what the fans may argue.  The goal of simulation is to minimize risk to safety by improving team and individual skills.  

The simulation educator is the Head Coach.

Coaches minimize risk to give their teams the best chance to win.  The goals of simulation practitioners are similar to those of sports coaches; immerse learners in critical scenarios, provide several variables that are possible to occur and train the team to respond correctly.

Simon Reynolds

What would Frank Sinatra do (if he led TSRC)?

"To do is to be.” Socrates

We can all agree that this is true. How does it relate to Tuckamore Simulation Research Collaborative (TSRC)?  To date, we have mounted a number of activities that we can DO together in order to BE the collaborative.  We have workshops, mentorships, research and living labs, and our chop shop under Andrew’s guidance is offering research meetings and presentations.  In addition, we have presented our work at meetings locally, nationally and internationally, and participated in community outreach activities such as MUNbuttoned.  We hope that in 8 months these are enough of ‘DOs’ in order to start to ‘BE’?

"To be is to do." Sartre

One interpretation of what Jean-Paul Sartre meant when he wrote "To be is to do", and as it relates to TSRC, is that if we over-focus on the DO there is a good chance that we would be delivering workshops to empty rooms, mentoring no one, and would have no research to talk about at research meetings.  Therefore we need to focus first and foremost on building the “feeling” of being a community.

If possible, I would like to hear or read about your ideas on how to achieve this goal. You can comment on this blog and hopefully we can have a conversation (which would be an indication of a BE rather than DO).

"Do-be-do-be-do.” Sinatra

To DO is to BE and to BE is to DO are polarities that are both filled with pathways to successes and failures if we focus too intensely on either one.  As a collaborative, we need to focus on how to ensure that we grow our identity, our feeling of community in order to do things together that are meaningful to us, to more strongly identify with TRSC and to discover new things to do…. One way to think about this situation is in terms of polarity management.  We deal with managing polarities every day (e.g., we inhale and exhale) and once we solve the porblem of how to BE, we can use this model to be mindful of keeping a healthy balance between DO and BE.

Sinatra wins for best polarity management!

[Polarity Management is a concept that institutions, including academic institutions should be more aware of. I’d suggest the work of Barry Johnson and Bonnie Wesorick as a starter.]

Welcome

Dear Tuckamore Partners,

We are pleased to invite submissions to our blog, as well as "analog" version of the blog to appear in the newsletter starting as of October 2014.

This is a new initiative and we will be looking for short monthly blogs and articles that focus on the innovative use of simulation modalities, as well as related research in the field of simulation-based education.  The articles will appear in the blog and will be published in our newsletter.  

Submissions should be between 250 and 500 words and a picture or a video clip can be included.  This is a great opportunity to voice your opinions, present your points of view and new ideas and directions, while building your portfolio.  It  also provides a great opportunity for the trainees to start building their research and scholarship potential.

The deadline for submissions is October 18th, 2014 for the newsletter that will come out during the last week of September.

The potential themes for the blogs and articles could include, but are not limited to:

•        Simulation in global health
•        Human factors
•        Simulation and gaming
•        Simulation in rural area
•        Assessments
•        Low cost simulation
•        Pedagogy across professions
•        Patient safety
•        Innovation
•        New applications
•        Tips for successful simulation
•        Program development frameworks
•        Research

Please send your submission to adam.dubrowski@med.mun.ca.