Last month Tuckamore Monthly took us to Africa, where Adam and his research team worked with Malawi colleagues in order to deliver simulation-augmented health professions education. Some of the challenges they encountered resemble those of our distributed province: like educators in Malawi, those in rural and remote areas of NL need proper training to deliver good simulation teaching. However, they may be lone clinical providers serving a large population, and are therefore hard pressed to leave their communities and attend a course.

This month our blog goes to sea. I recently worked as a ship’s doctor in remote parts of Atlantic Canada, and along the way I thought about rural and remote health professional education. Here’s the story.

Last summer aboard MV Akademik Ioffe, I accompanied 102 passengers to beautiful remote places like Sable Island (Nova Scotia) and François (Newfoundland). I was the Expedition Physician, but I was also an observer. Places like Sable Island and François pose questions: how do we deliver health care in remote areas, and how do we teach students to practice in them?

In academic centres, we teach our students about sophisticated technology to diagnose and treat their patients. In fact we often use sophisticated technology like computerized human mannequins, to teach them how to use sophisticated technology! However neither option is applicable in rural and remote areas. If somebody is injured in François where there is no road, for instance, caring for them is a far different proposition than in an academic emergency centre. Clinicians in remote areas must be prepared to make critical decisions and perform critical procedures without access to technology. They must rely solely upon their clinical judgment. How can we best teach this?

And what about practitioners in even more isolated locations like ships and oil installations, or those who work in the air, transporting ill patients? They too must rely on clinical judgment and be prepared to perform critical procedures. But they also have to consider the logistics of evacuation, particularly in harsh environments where distance, sea conditions and weather are serious considerations. There may be times when these factors preclude definitive care for hours or days.

Since it is impractical and even potentially unsafe for learners to experience these extreme environments firsthand, we can use simulation as a vehicle to provide this kind of training. Low-tech simulation may be especially useful for teaching low-frequency high-stakes events (like a surgical airway) that one may encounter only occasionally in remote places. Perhaps we should transport this teaching to learners in remote areas since they cannot easily travel to academic centres for courses. It is logical to use locally available material for making simple task trainers that can be left in place, and it seems ideal to use mobile simulation or tele-simulation to augment face-to-face instruction.

Ships’ logs reveal a variety of illnesses and injuries at sea. On this voyage, I had some suturing to do, and I evacuated one passenger with a potentially serious condition. A fit but elderly gentleman, he had flown many hours to join the expedition. While aboard the ship, he suddenly became breathless. When consulting in his cabin, I noticed he could not comfortably walk from his bed to his bathroom. It was too risky for him to continue sailing with us. The remote regions we would visit have few emergency resources, so I transported him to a nearby emergency department when I had the chance. In this case, context was everything.  I had to consider the likelihood of a pulmonary embolus or a heart attack and weigh those odds against travelling further and further from definitive care. To complicate matters, I had to consult with the ship’s Captain to check the weather and our planned itinerary. Finally, since the rest of us continued our voyage, I had to communicate between the patient, his family, the shipping operators, and the emergency physician who treated him ashore, with a cell service that was available only when we approached land.

I had no available diagnostic tests to help me with this case, but I did have years of rural and remote clinical experience on my side, as well as current training in performing critical procedures. (Well, a bit. It’s been a long time since I did a surgical airway, even though I usually work in a tertiary care emergency department.) The situation reminded me that we must teach our students to make purely clinical decisions, and we must also ensure that both learners and practitioners can confidently and competently perform occasional critical procedures.

Simulation is one way to go about it, and it poses many research questions: what kinds of teaching do rural and remote practitioners feel they need? Is tele-simulation feasible in NL? How often do we need to provide critical skills re-training? How can we teach students to rely on clinical judgment in a society that so values technology?

I am back on shore now. But most days at work in the academic emergency department, I take calls from rural and remote physicians with fewer resources than mine. I hope I can serve them usefully, and I look forward to hearing their thoughts on education!

Hope to see you at our upcoming Rural and Remote Emergency Medicine Conference! http://www.med.mun.ca/Emergency-Medicine/Upcoming-Courses-and-Updates.aspx

-----------------------------

Read the entire article at:

http://www.cureus.com/articles/5146-emergency-medicine-in-remote-regions

Simulation played a key role in the recent launch of the “Building a Healthy Tomorrow”^TM fundraising campaign for Memorial University’s Faculty of Medicine.

Learning through simulation has an impact on medical education by improving the skills and confidence of learners in a safe environment. The hands-on experience enabled and obtained by using simulation allows for unique opportunities outside the classroom setting and provides a safer transition into clinical rotations. Aside from medical students, many other health care professionals also benefit from simulation by acquiring new skills and reinforcing what they already know. The “Building a Healthy Tomorrow” campaign presents the opportunity to provide support in acquiring costly medical simulation technologies to ensure that Memorial University’s Faculty of Medicine continues to produce world-class physicians.

During the recent launch of the fundraising campaign, we provided a sample of what simulation, and related educational technologies can offer to learners and seasoned health care professionals.  In the spirit of simulation, our displays were interactive, hands-on experiences with live standardized patients (trained actors portraying patient encounters), tele-simulation and ultrasound guided approaches, and pediatric computerized mannequins that respond in a human-like fashion to a number of treatments.

Here is what the experience looked like for those running the simulation stations:

First, we asked Jacqueline Turner, a Standardized Patient Educator at the Clinical Learning and Simulation Centre (CLSC) to tell us what it means to her to be able to participate in simulation-based education – both in general as well as during the campaign.

Jacqueline:

Pictured John O’dea(left) Kerry lynn Willams(center) and Jackueline Turner(right).

“This ability to share feedback from the patient’s perspective is paramount in the development of student learning”

“As a former Standardized Patient (SP) I had the opportunity to experience many medical student/resident encounters.  I was trained to realistically portray the history, physical, and emotional findings of patients.  Through these encounters, I was able to witness the important role that simulation plays in the teaching of all medical students. 

From the early days of medical school, students are taught about patient centered care and the importance of listening to the patient and their story.  They are taught how to ask some of the most difficult questions, how to demonstrate active listening and how to express empathy and understanding.  While the students understand that the SP’s are portraying a role and that the story is not real, it is amazing to see how the students become so engaged and “wrapped” up in the scenario and there are moments when they truly feel the encounter is real. I have witnessed students crying during many of these encounters after hearing a patient’s story.

Furthermore, while SPs are trained to portray various roles to enhance student encounters in a safe environment, they are also trained to provide effective feedback to the learner. This ability to share feedback from the patient’s perspective is paramount in the development of student learning.  When a patient goes to see their own doctor, how often does the doctor ask the patient for feedback on their experience as their patient? When the SP shares their thoughts to the learner from the patient’s perspective, identifying to the student what they did well and what needs improvement, the students remember the feedback and it does have a valuable impact on their learning. 

As a Standardized Patient Educator, I have a more direct link to the medical students and one of the best parts of the job is hearing the feedback from the students about how much they enjoy their SP encounters and how comforting it is to have the opportunity to practice both their communication and clinical skills on SP’s in such a safe environment. 

Several years ago, I was approached by a former student who was going through her clerkship and she shared with me that she often relies on her memorable experiences of working with faculty facilitators and SP’s to help her in her dealings with real patients on the floor.  She commented that many of her peers felt that their experience of working hands-on with SPs was the highlight of their medical school training.  As an Educator working with the CLSC, I could not wish for better feedback”.

Evidently, there are numerous benefits involved with using SPs to train new students. The unique features of SP encounters and relevant feedback help to enhance and maintain the high quality of health care that is currently being delivered.  

To increase the perception of realism, we often re-create clinical environments, such as a doctor’s office or emergency room, in order to immerse both the learners and the SP in the experience.  In addition, we often combine SP’s with inanimate simulators (also known as a fake body part), enabling the learners to attempt invasive procedures, such as suturing (see photo) without harming the SP.  This is known as hybrid simulation and allows us to address many learning objectives, such as showing compassion, taking history and performing a psychomotor skill, all at once. 

Another interactive station offered to the participants during the recent campaign launch  was the chance to insert needles into simulated patient’s necks!  This station was led by Dr. Andrew Smith, one of the leading innovators within the Faculty of Medicine.

Dr. Smith:

Pictured is Dr. Smith demonstrating an ultrasound assisted intravenous procedure

“…..skills training using simulation and ultrasound is improving patient safety one line at a time”.

“The philosophy of “see one, do one, teach one” is still the most common means by which most medical students and residents learn to perform procedures such as placement of central venous catheters, even though serious concerns have been raised regarding this approach. Traditionally, these specialized catheters have been placed blindly. There is clear evidence that the use of ultrasound decreases number of attempts, increases success rates and decreases complication rates when used to guide central line placement. Incorporating simulation into training programs is another mechanism to improve patient safety by developing resident comfort and skill prior to placing lines in clinical practice. The benefits to health authorities are also quite substantial. A formal training program provides a mechanism to train residents in the evidence-based infection control practices along with other quality initiatives.

It is estimated that catheter-related blood stream infections (CR-BSI) result in system costs of $7,000 - $18,000 while increasing patient length of stay in hospital. Formal training along with other infection control practices has been shown to decrease the rate of CR-BSI. Skills training using simulation and ultrasound is improving patient safety one line at a time”.

As a potential patient, hearing Dr. Smith talk about having to insert sharp objects into my neck or arm blindly truly emphasizes the benefits of being able to use ultrasound guided approaches.  This is no longer really an option but more so a standard of practice and we should all exercise the right to request a health care provider who is well trained in these novel approaches.

If simulation is one of the pathways to training competent heath care professionals, we should spare no efforts in making sure we have all the necessary resources and infrastructure to achieve our training goals.

Finally, many students and volunteers also took part in our simulation stations (Kerry-Lynn Williams, Cody Dunne, Emily Moores, Ben Ryan, Kristopher Hoover, Megan Pollard, Tate Skinner. We have asked Kerry-Lynn Williams, a medical student, what simulation offers to her development:

Kerry-Lynn:

“For most of us medical students, when starting out in medical school, it is the first time we are on the other side of a clinical encounter. Along with all the new information comes a plethora of new skills to learn, and often the learning is done on each other or on patients. Thankfully, here at Memorial University, simulation helps bridge that gap. 

I am a medical student about to start clerkship, and I have been involved with the Tuckamore Simulation Research Collaborative since my first year. Simulation has been, and will continue to be integrated in all aspects of our curriculum - communicating with patients, practicing physical exams, mock codes and trauma codes. 

Simulation provides a valuable opportunity to practice and learn in a safe environment with no risk to patients. It helps us build confidence in our new skills and knowledge, and provides us with a means to practice these skills. This allows us, when transitioning back to the clinical encounter, to focus on patient-centered care, not worrying if our technical skills are up to par, because through simulation and practice, we know they are”.

Kerry-Lynn’s words echo the words of those involved in running simulations (Jacqueline Turner) and of those involved in designing simulations (Dr. Smith).

All in all, simulation, as an educational tool is here to stay.  It is no longer an option or luxury, it is a necessary part of the training, and lifelong maintenance of skills, knowledge and attitudes of all involved in the health care sector.  Increasingly, it is also becoming part of quality improvement and patient safety initiatives. 

In saying that, it’s important to note that simulation is an expensive educational tool. Therefore, we need to ensure that as academics, we exercise every effort to use this tool appropriately.  We need to be sure we “use the right tool for the right job”.  For example, when we teach students how to insert needles, we use low cost simulators that are built to withstand many pokes and pricks.  When we teach communication skills, we employ our Standardized Patients.  When we teach elements of health care team behavior, we use highly sophisticated mannequins. 

But, despite the best efforts, equipment still breaks. It has an “expiry date” and needs to be replaced sooner or later.  As an academic director of the Clinical Learning and Simulation Centre here at the Memorial University, I am extremely happy that the importance of simulation in the educational process, as well as some of the barriers to simulation, have been recognized and are currently an area of focus for the “Building A Healthy Tomorrow”^TM fundraising campaign for Memorial University’s Faculty of Medicine.

Simulation Research Papers September - October 2016

Fam Med. 2016 Oct;48(9):696-702.

Effectiveness of Vaginal Delivery Simulation in Novice Trainees.

The “Empty Chairs” Approach to Learning: Coast-to-Coast Canadians Run a Simulation-Based Train the Trainer Program in Mzuzu, Malawi.

By Adam Dubrowski

 

Introduction

Together, with a group of my Canadian colleagues from Calgary, Alberta (some via Doha) and London, Ontario I was privileged to represent MUN’s Faculty of Medicine during the first Train the Trainer in Simulation-Based Learning (TTT-SBL) program in Mzuzu Central Hospital and Mzuzu University in Malawi.  Our team, led by Elaine Sigalet (Doha) and consisting of Ian Wishart (Calgary) and Faizal Haji (London), was invited to Malawi by Norman Lufesi, to conduct a 2-day TTT-SBL course for facilitators who teach an Emergency Triaging, Assessment of Trauma (ETAT) course.

The TTT-SIM facilitator team (from left to right): Adam Dubrowski, Elaine Sigalet, Norman Lufesi, Ian Wishart, and Faizal Haji.

Why?

This course was developed in response to an evolving partnership between the International Pediatric Simulation Society (IPSS), the World Federation of Pediatric Intensive Care Societies (WFPICCS), and the Ministry of Health. The long-term objective of this partnership is to decrease pediatric morbidity and mortality through the introduction of context specific faculty development programs focused on pedagogy and administration of simulation programs. It is anticipated that such programs will lead to the improvement of on-going health care educational efforts and the development of effective future programs, subsequently improving health service delivery for patients in Malawi. 

What?

This was our third visit to Malawi.  The first, in 2012, was primarily an environmental scan for us to understand the health care system as a whole and to listen to the relevant stakeholders about their needs for simulation.  Together with the Malawians, we identified that their on-going ETAT course would provide the right context for implementing simulation-based learning (SBL).  The second visit in 2014, consisted of observations of ETAT courses and mapping the TTT-SBL course.  Our most recent visit’s purpose was to implement the TTT-SBL course and to observe how the newly trained facilitators performed.

Norman Lufesi, who works for the Malawi Ministry of Health and is responsible for delivery of the ETAT courses in Malawi, had a vision for revising the current format of the ETAT to include more simulation.  Although elements of simulation are already used during the ETAT, he articulated that there are a number of shortcomings.  First, the local ETAT facilitators are not trained in how to use simulation effectively.  Secondly, the simulation that is used focuses on the development of technical skills by an individual health care professional. Finally, the course now is mainly 4.5 day long filled with didactic lectures.  Norman strongly believes that ETAT should also focus on the development of team-based learning, specifically elements of leadership, team communication, and resource management.  In his opinion, improving the teaching skills of the facilitators, and adding team training as part of the ETAT course offerings will make the course more effective and shorter (aiming at 2.5 days).  He adds that at this moment ETAT is a multi-professional course, where nurses, doctors, and clinical officers work in collaboration with each other.  By including team-based training, Norman hopes that the course will become an inter-professional course where all these health professions will learn with and about each other.  Furthermore, in his vision Norman hopes that this shift towards inter-professional education will cascade into inter-professional practice, ultimately leading to improved clinical outcomes.

Over the past 2 years, our group focused on the development of a 2-day TTT-SBL course.  The scope of this course includes providing the fundamental knowledge and skills necessary to prepare learners for SBL, for designing and running simulations, and for providing proper debriefing and feedback.  During the course the learners were provided with ample opportunities to actively implement the newly gained skills and knowledge.  The inaugural TTT-SBL course, conducted in September 2016, was strategically timed just prior to an ETAT course, where the newly trained facilitators were able to test their simulation teaching skills with 30 ETAT learners.  In the spirit of experiential learning and deliberate practice, the Canadian team hung out until the end of the course to provide these new ETAT facilitators with feedback.    

The TTT-SIM facilitators, ETAT facilitators, and the cohort of the Mzuzu ETAT students.

But our work is not done yet!  Together with Norman, the Canadian team has committed to a long-term mentor-ship plan that includes four initiatives.  First, the Canadian mentor team has re-written one of the modules of the current ETAT course to minimize the amount of didactic lectures, and when appropriate, to provide more simulation experiences, especially in the areas of critical thinking, leadership and team work.  Next, as a follow-up exercise, the newly trained ETAT facilitators have been tasked with re-writing the other modules of the ETAT course.  Third, the facilitators were asked to produce a TTT-SBL manual and supporting materials that can be used as a local resource for future TTT-SBL courses.  Finally, the facilitators were asked to establish a group of dedicated individuals to formulate a process for organizing TTT-SBL courses in other parts of Malawi and conduct a review of the existing materials.

Two way street

Working on and delivering the TTT-SBL made me realize the parallels between Malawi and rural and remote Newfoundland.  Our problems are very similar.  Rural and remote areas do not have access to high fidelity, high technology simulation.  Even with low tech substitutes, the health care professionals may lack the educational skills to make it most effective, and finally these health care professionals are often the only ones available to the local patient population and taking them away from their patients can be hard.  Is there a role for a version of this 2-day TTT-SBL course in rural an d remote Newfoundland? 

I left Malawi with mixed feelings of being home sick and longing for more - the excitement and energy during both the TTT-SBL and the ETAT courses were very stimulating and rewarding. But, I know this will not be my last trip to Malawi.

Acknowledgments: I would like to thank the Tuckamore Simulation Research Collaborative, and the Dean’s office for supporting this work. I would also like to thank the other members of our team for making this happen!

Top Simulations for Aug-Sept

by Tate Skinner and Adam Dubrowski

1. BMC Med Educ. 2016 Aug 12;16(1):203. doi: 10.1186/s12909-016-0726-x.

Does video feedback analysis improve CPR performance in phase 5 medical students?

Spence AD1, Derbyshire S2, Walsh IK2, Murray JM2.

Author information:

1The Clinical Skills Education Centre, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK. andy.spence@gmail.com.

2The Clinical Skills Education Centre, Medical Biology Centre, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.

Abstract

BACKGROUND:

The use of simulation in medical education is increasing, with students taught and assessed using simulated patients and manikins. Medical students at Queen's University of Belfast are taught advanced life support cardiopulmonary resuscitation as part of the undergraduate curriculum. Teaching and feedback in these skills have been developed in Queen's University with high-fidelity manikins. This study aimed to evaluate the effectiveness of video compared to verbal feedback in assessment of student cardiopulmonary resuscitation performance.

METHODS:

Final year students participated in this study using a high-fidelity manikin, in the Clinical Skills Centre, Queen's University Belfast. Cohort A received verbal feedback only on their performance and cohort B received video feedback only. Video analysis using 'StudioCode' software was distributed to students. Each group returned for a second scenario and evaluation 4 weeks later. An assessment tool was created for performance assessment, which included individual skill and global score evaluation.

RESULTS:

One hundred thirty eight final year medical students completed the study. 62 % were female and the mean age was 23.9 years. Students having video feedback had significantly greater improvement in overall scores compared to those receiving verbal feedback (p = 0.006, 95 % CI: 2.8-15.8). Individual skills, including ventilation quality and global score were significantly better with video feedback (p = 0.002 and p < 0.001, respectively) when compared with cohort A. There was a positive change in overall score for cohort B from session one to session two (p < 0.001, 95 % CI: 6.3-15.8) indicating video feedback significantly benefited skill retention. In addition, using video feedback showed a significant improvement in the global score (p < 0.001, 95 % CI: 3.3-7.2) and drug administration timing (p = 0.004, 95 % CI: 0.7-3.8) of cohort B participants, from session one to session two.

CONCLUSIONS:

There is increased use of simulation in medicine but a paucity of published data comparing feedback methods in cardiopulmonary resuscitation training. Our study shows the use of video feedback when teaching cardiopulmonary resuscitation is more effective than verbal feedback, and enhances skill retention. This is one of the first studies to demonstrate the benefit of video feedback in cardiopulmonary resuscitation teaching.

PMID: 27519273 [PubMed - in process]

2. Br J Surg. 2016 Aug 18. doi: 10.1002/bjs.10236. [Epub ahead of print]

Systematic review of e-learning for surgical training.

Maertens H1, Madani A2, Landry T3, Vermassen F1, Van Herzeele I1, Aggarwal R2,4.

Author information:

1Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium.

2Department of Surgery, McGill University, Montreal, Canada.

3Montreal General Hospital Medical Library, McGill University Health Centre, Montreal, Canada.

4Steinberg Centre for Simulation and Interactive Learning, Faculty of Medicine, McGill University, Montreal, Canada.

Abstract

BACKGROUND:

Internet and software-based platforms (e-learning) have gained popularity as teaching tools in medical education. Despite widespread use, there is limited evidence to support their effectiveness for surgical training. This study sought to evaluate the effectiveness of e-learning as a teaching tool compared with no intervention and other methods of surgical training.

METHODS:

A systematic literature search of bibliographical databases was performed up to August 2015. Studies were included if they were RCTs assessing the effectiveness of an e-learning platform for teaching any surgical skill, compared with no intervention or another method of training.

RESULTS:

From 4704 studies screened, 87 were included with 7871 participants enrolled, comprising medical students (52 studies), trainees (51 studies), qualified surgeons (2 studies) and nurses (6 studies). E-learning tools were used for teaching cognitive (71 studies), psychomotor (36 studies) and non-technical (8 studies) skills. Tool features included multimedia (84 studies), interactive learning (60 studies), feedback (27 studies), assessment (26 studies), virtual patients (22 studies), virtual reality environment (11 studies), spaced education (7 studies), community discussions (2 studies) and gaming (2 studies). Overall, e-learning showed either greater or similar effectiveness compared with both no intervention (29 and 4 studies respectively) and non-e-learning interventions (29 and 22 studies respectively).

CONCLUSION:

Despite significant heterogeneity amongst platforms, e-learning is at least as effective as other methods of training.

© 2016 BJS Society Ltd Published by John Wiley & Sons Ltd

3.Auris Nasus Larynx. 2016 Aug 17. pii: S0385-8146(16)30225-5. doi: 10.1016/j.anl.2016.07.017. [Epub ahead of print]

Papercraft temporal bone in the first step of anatomy education.

Hiraumi H1, Sato H2, Ito J3.

Author information:

1Department of Otolaryngology, Head and Neck Surgery, Iwate Medical University, Morioka, Japan; Department of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Kyoto College of Medical Health, Kyoto, Japan. Electronic address: hhiraumi@iwate-med.ac.jp.

2Department of Otolaryngology, Head and Neck Surgery, Iwate Medical University, Morioka, Japan.

3Department of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.

Abstract

OBJECTIVE:

(1) To compare temporal bone anatomy comprehension taught to speech therapy students with or without a papercraft model. (2) To explore the effect of papercraft simulation on the understanding of surgical approaches in first-year residents.

METHODS:

(1) One-hundred and ten speech therapy students were divided into three classes. The first class was taught with a lecture only. The students in the second class were given a lecture and a papercraft modeling task without instruction. The third class modeled a papercraft with instruction after the lecture. The students were tested on their understanding of temporal bone anatomy. (2) A questionnaire on the understanding of surgical approaches was completed by 10 residents before and after the papercraft modeling. The papercraft models were cut with scissors to simulate surgical approaches.

RESULTS:

(1) The average scores were 4.4/8 for the first class, 4.3/8 for the second class, and 6.3/8 for the third class. The third class had significantly better results than the other classes (p<0.01, Kruskal-Wallis test). (2) The average scores before and after the papercraft modeling and cutting were 2.6/7 and 4.9/7, respectively. The numerical rating scale score significantly improved (p<0.01, Wilcoxon signed-rank test).

CONCLUSION:

The instruction of the anatomy using a papercraft temporal bone model is effective in the first step of learning temporal bone anatomy and surgical approaches.

Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

4.Pediatr Radiol. 2016 Aug 25. [Epub ahead of print]

Evaluation of a pediatric fluoroscopy training module to improve performance of upper gastrointestinal procedures in neonates with bilious emesis.

Benya EC1,2, Wyers MR3,4, O'Brien EK5.

Author information:

1Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave. #9, Chicago, IL, 60611, USA. ebenya@luriechildrens.org.

2Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. ebenya@luriechildrens.org.

3Department of Medical Imaging, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave. #9, Chicago, IL, 60611, USA.

4Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

5Department of Medical Education, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.

Abstract

BACKGROUND:

Life-threatening midgut volvulus usually occurs in infants with malrotation and requires rapid diagnosis and surgical treatment to prevent bowel necrosis and death. However, because of the low frequency of upper gastrointestinal studies performed in infants younger than 1 month, many diagnostic radiology residents finish their residency training having limited or no opportunity to perform or observe an upper gastrointestinal (GI) series for evaluation of bilious emesis in a neonate.

OBJECTIVE:

To determine whether adding simulated upper GI series on neonates with bilious emesis to the curriculum improves residents' skill and accuracy in diagnosing midgut volvulus.

MATERIALS AND METHODS:

We assessed the performance of 12 residents in training whose curriculum included simulated upper GI series (study group) and 10 traditionally trained residents (control group) using a multiple-choice test, checklist procedure evaluation and diagnostic accuracy scores for 3 randomly selected simulated upper GI series. We then compared the results from the study group that had simulation curriculum to the scores for the control group using the Mann-Whitney test. We also analyzed the scores for the study group obtained prior to and after simulation curriculum using Wilcoxon signed rank test.

RESULTS:

There was a significant difference in test scores (study group median = 84.5%, control group median = 67.2%, P=0.001), overall diagnostic accuracy (study group median = 100%, control group median = 50%, P=0.011) and checklist evaluation (study group median = 83.3%, control group median = 70.8%, P=0.025) for the residents in the study group who completed simulation curriculum compared with the control group. There was also a significant difference in multiple-choice test scores for the study group before and after completion of simulation curriculum (before simulation curriculum median = 56.9%, after simulation curriculum median = 84.5%, P=0.002), checklist evaluation (before simulation curriculum median = 58.3%, after simulation curriculum median = 83.3%, P=0.002) and overall diagnostic accuracy scores (before simulation curriculum median = 50%, after simulation curriculum median = 100%, P=0.024).

CONCLUSION:

Radiology residents had significantly higher scores on a multiple-choice test, checklist procedure evaluation and overall diagnostic accuracy after completing a structured pediatric fluoroscopy curriculum that included simulated neonatal upper GI series and when compared to a control group of traditionally trained residents.

5.Gut Liver. 2016 Sep 15;10(5):764-72. doi: 10.5009/gnl16044.

The Efficacy of a Newly Designed, Easy-to-Manufacture Training Simulator for Endoscopic Biopsy of the Stomach.

Ahn JY1, Lee JS1, Lee GH1, Lee JW1, Na HK1, Jung KW1, Lee JH1, Kim do H1, Choi KD1, Song HJ1, Jung HY1, Kim JH1.

Author information:

1Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.

Abstract

BACKGROUND/AIMS:

We developed a new endoscopic biopsy training simulator and determined its efficacy for improving the endoscopic biopsy skills of beginners.

METHODS:

This biopsy simulator, which presents seven biopsy sites, was constructed using readily available materials. We enrolled 40 participants: 14 residents, 11 first-year clinical fellows, 10 second-year clinical fellows, and five staff members. We recorded the simulation completion time for all participants, and then simulator performance was assessed via a questionnaire using the 7-point Likert scale.

RESULTS:

The mean times for completing the five trials were 417.7±138.8, 145.2±31.5, 112.7±21.9, and 90.5±20.0 seconds for the residents, first-year clinical fellows, second-year clinical fellows, and staff members, respectively. Endoscopists with less experience reported that they found this simulator more useful for improving their biopsy technique (6.8±0.4 in the resident group and 5.7±1.0 in the first-year clinical fellow group). The realism score of the simulator for endoscopic handling was 6.4±0.5 in the staff group.

CONCLUSIONS:

This new, easy-to-manufacture endoscopic biopsy simulator is useful for biopsy training for beginner endoscopists and shows good efficacy and realism.

PMID: 27563021 [PubMed - in process]

6.Med Educ. 2016 Sep;50(9):969-78. doi: 10.1111/medu.13107.

Influence of learner knowledge and case complexity on handover accuracy and cognitive load: results from a simulation study.

Young JQ1, van Dijk SM2, O'Sullivan PS3, Custers EJ2, Irby DM3, Ten Cate O2.

Author information:

1Department of Psychiatry, Hofstra Northwell School of Medicine, Hofstra University, Hempstead, NY, USA.

2Centre for Research and Development of Education, University Medical Centre Utrecht, Utrecht, The Netherlands.

3Research and Development of Medical Education, School of Medicine, University of California San Francisco, San Francisco, CA, USA.

Abstract

CONTEXT:

The handover represents a high-risk event in which errors are common and lead to patient harm. A better understanding of the cognitive mechanisms of handover errors is essential to improving handover education and practice.

OBJECTIVES:

This paper reports on an experiment conducted to study the effects of learner knowledge, case complexity (i.e. cases with or without a clear diagnosis) and their interaction on handover accuracy and cognitive load.

METHODS:

Participants were 52 Dutch medical students in Years 2 and 6. The experiment employed a repeated-measures design with two explanatory variables: case complexity (simple or complex) as the within-subject variable, and learner knowledge (as indicated by illness script maturity) as the between-subject covariate. The dependent variables were handover accuracy and cognitive load. Each participant performed a total of four simulated handovers involving two simple cases and two complex cases.

RESULTS:

Higher illness script maturity predicted increased handover accuracy (p < 0.001) and lower cognitive load (p = 0.007). Case complexity did not independently affect either outcome. For handover accuracy, there was no interaction between case complexity and illness script maturity. For cognitive load, there was an interaction effect between illness script maturity and case complexity, indicating that more mature illness scripts reduced cognitive load less in complex cases than in simple cases.

CONCLUSIONS:

Students with more mature illness scripts performed more accurate handovers and experienced lower cognitive load. For cognitive load, these effects were more pronounced in simple than complex cases. If replicated, these findings suggest that handover curricula and protocols should provide support that varies according to the knowledge of the trainee.

© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

PMID: 27562896 [PubMed - in process]

7.Med Educ. 2016 Sep;50(9):955-68. doi: 10.1111/medu.13086.

Thrive or overload? The effect of task complexity on novices' simulation-based learning.

Haji FA1,2,3, Cheung JJ1,2, Woods N1, Regehr G4, de Ribaupierre S3, Dubrowski A5.

Author information:

1Wilson Centre, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

2SickKids Learning Institute, Hospital for Sick Children, Toronto, Ontario, Canada.

3Division of Clinical Neurological Sciences, Faculty of Medicine, Western University, London, Ontario, Canada.

4Centre for Health Education Scholarship, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.

5Division of Emergency Medicine, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland, Canada.

Abstract

CONTEXT:

Fidelity is widely viewed as an important element of simulation instructional design based on its purported relationship with transfer of learning. However, higher levels of fidelity may increase task complexity to a point at which novices' cognitive resources become overloaded.

OBJECTIVES:

In this experiment, we investigate the effects of variations in task complexity on novices' cognitive load and learning during simulation-based procedural skills training.

METHODS:

Thirty-eight medical students were randomly assigned to simulation training on a simple or complex lumbar puncture (LP) task. Participants completed four practice trials on this task (skill acquisition). After 10 days of rest, all participants completed one additional trial on their assigned task (retention) and one trial on a 'very complex' simulation designed to be similar to the complex task (transfer). We assessed LP performance and cognitive load on each trial using multiple measures.

RESULTS:

In both groups, LP performance improved significantly during skill acquisition (p ≤ 0.047, f = 0.29-0.96) and was maintained at retention. The simple task group demonstrated superior performance compared with the complex task group throughout these phases (p ≤ 0.002, d = 1.13-2.31). Cognitive load declined significantly in the simple task group (p < 0.009, f = 0.48-0.76), but not in the complex task group during skill acquisition, and remained lower at retention (p ≤ 0.024, d = 0.78-1.39). Between retention and transfer, LP performance declined and cognitive load increased in the simple task group, whereas both remained stable in the complex task group. At transfer, no group differences were observed in LP performance and cognitive load, except that the simple task group made significantly fewer breaches of sterility (p = 0.023, d = 0.80).

CONCLUSIONS:

Reduced task complexity was associated with superior LP performance and lower cognitive load during skill acquisition and retention, but mixed results on transfer to a more complex task. These results indicate that task complexity is an important factor that may mediate (via cognitive overload) the relationship between instructional design elements (e.g. fidelity) and simulation-based learning outcomes.

© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

PMID: 27562895 [PubMed - in process

8.Am J Surg. 2016 Aug 1. pii: S0002-9610(16)30380-4. doi: 10.1016/j.amjsurg.2016.06.024. [Epub ahead of print]

Predicting surgical skill acquisition in preclinical medical students.

Martin AN1, Hu Y1, Le IA1, Brooks KD1, Mahmutovic A1, Choi J1, Kim H1, Rasmussen SK2.

Author information:

1Department of Surgery, University of Virginia, Charlottesville, VA, USA.

2Department of Surgery, University of Virginia, Charlottesville, VA, USA. Electronic address: skr3f@virginia.edu.

Abstract

BACKGROUND:

The purpose of this study was to identify factors that predict medical student success in acquiring invasive procedural skills. We hypothesized that students with interest in surgery and with prior procedural experience would have higher rates of success.

METHODS:

Preclinical students were enrolled in a simulation course comprised of suturing, intubation, and central venous catheterization. Students completed surveys to describe demographics, specialty interest area, prior experience, and confidence. Using linear regression, variables predictive of proficiency were identified.

RESULTS:

Forty-five participants completed the course. Under univariate analysis, composite pretest score was inversely associated with confidence (P = .039). Under multivariable analysis, female gender was associated with higher pretest suturing score (P = .016). Male gender (P = .029) and high confidence (P = .021) were associated with greater improvement in suturing.

CONCLUSIONS:

Among novices, higher confidence can predict lower baseline technical proficiency. Although females had higher pretest suturing scores, high confidence and male gender were associated with the greatest degree of improvement.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27567113 [PubMed - as supplied by publisher

9.GMS J Med Educ. 2016 Aug 15;33(4):Doc56. doi: 10.3205/zma001055. eCollection 2016.

Mastery learning improves students skills in inserting intravenous access: a pre-post-study.

Friederichs H1, Brouwer B1, Marschall B2, Weissenstein A1.

Author information:

1University of Muenster, Studienhospital, Muenster, Germany.

2University of Muenster, Institute of Medical Education - IfAS, Muenster, Germany.

Abstract

OBJECTIVE:

Inserting peripheral venous catheters (PVCs) has been identified as a core competency for medical students. Because the performance - even of hygienic standards - of both students and novice physicians is frequently inadequate, medical faculties must focus on competence-based learning objectives and deliberate practice, features that are combined in mastery learning. Our aim was to determine the competency of students in inserting PVCs before and after an educational intervention.

DESIGN:

This study comprised a skills assessment with pre- and post-tests of a group of third-year students who received a simulation-based intervention. A newly established curriculum involved one hour of practice at inserting PVCs on simulators. Students were required to pass a test (total 21 points, pass mark 20 points) developed on the concept of mastery learning. An unannounced follow-up test was performed one week (8 days) after the intervention.

SETTING:

The simulation center of the medical faculty in Muenster.

PARTICIPANTS:

Third-year students who received the intervention.

RESULTS:

One hundred and nine complete data sets were obtained from 133 students (82.5%). Most students (97.2%) passed the test after the intervention (mean score increase from 15.56 to 20.50, P<0.001). There was a significant decrease in students' performance after one week (8 days): only 74.5% of participants passed this retest (mean score reduction from 20.50 to 20.06, P<0.001).

CONCLUSION:

Mastery learning is an effective form of teaching practical skills to medical students, allowing a thorough preparation for the challenges of daily clinical practice.

PMID: 27579356 [PubMed - in process]

10.Arq Bras Cir Dig. 2015 Jul-Sep;28(3):204-6. doi: 10.1590/S0102-67202015000300015.

White box: low cost box for laparoscopic training.

[Article in English, Portuguese]

Martins JM1, Ribeiro RV1, Cavazzola LT1.

Author information:

1Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.

Abstract

BACKGROUND:

Laparoscopic surgery is a reality in almost all surgical centers. Although with initial greater technical difficulty for surgeons, the rapid return to activities, less postoperative pain and higher quality aesthetic stimulates surgeons to evolve technically in this area. However, unlike open surgery where learning opportunities are more accessible, the laparoscopic training represents a challenge in surgeon formation.

AIM:

To present a low cost model for laparoscopic training box.

METHODS:

This model is based in easily accessible materials; the equipment can be easily found based on chrome mini jet and passes rubber thread and a webcam attached to an aluminum handle.

RESULTS:

It can be finalized in two days costing R$ 280,00 (US$ 90).

CONCLUSION:

It is possible to stimulate a larger number of surgeons to have self training in laparoscopy at low cost seeking to improve their surgical skills outside the operating room

11.World J Emerg Surg. 2016 Aug 31;11(1):45. doi: 10.1186/s13017-016-0104-3. eCollection 2016.

Ex-vivo and live animal models are equally effective training for the management of a penetrating cardiac injury.

Izawa Y1, Hishikawa S2, Muronoi T3, Yamashita K3, Maruyama H4, Suzukawa M3, Lefor AK5.

Author information:

1Center of Development for Advanced Medical Technology, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan ; Department of Emergency and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan.

2Center of Development for Advanced Medical Technology, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan ; Department of Emergency and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan ; Department of Digestive Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan.

3Department of Emergency and Critical Care Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan.

4Department of Digestive Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan.

5Center of Development for Advanced Medical Technology, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan ; Department of Digestive Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsukeshi, Tochigiken 329-0498 Japan.

Abstract

BACKGROUND:

Live tissue models are considered the most useful simulation for training in the management for hemostasis of penetrating injuries. However, these models are expensive, with limited opportunities for repetitive training. Ex-vivo models using tissue and a fluid pump are less expensive, allow repetitive training and respect ethical principles in animal research. The purpose of this study is to objectively evaluate the effectiveness of ex-vivo training with a pump, compared to live animal model training. Staff surgeons and residents were divided into live tissue training and ex-vivo training groups. Training in the management of a penetrating cardiac injury was conducted for each group, separately. One week later, all participants were formally evaluated in the management of a penetrating cardiac injury in a live animal.

RESULTS:

There are no differences between the two groups regarding average years of experience or previous trauma surgery experience. All participants achieved hemostasis, with no difference between the two groups in the Global Rating Scale score (ex-vivo: 25.2 ± 6.3, live: 24.7 ± 6.3, p = 0.646), blood loss (1.6 ± 0.7, 2.0 ± 0.6, p = 0.051), checklist score (3.7 ± 0.6, 3.6 ± 0.9, p = 0.189), or time required for repair (101 s ± 31, 107 s ± 15, p = 0.163), except overall evaluation (3.8 ± 0.9, 3.4 ± 0.9, p = 0.037). The internal consistency reliability and inter-rater reliability in the Global Rating Scale were excellent (0.966 and 0.953 / 0.719 and 0.784, respectively), and for the checklist were moderate (0.570 and 0.636 / 0.651 and 0.607, respectively). The validity is rated good for both the Global Rating Scale (Residents: 21.7 ± 5.6, Staff: 28.9 ± 4.7, p = 0.000) and checklist (Residents: 3.4 ± 0.9, Staff Surgeons: 3.9 ± 0.3, p = 0.003). The results of self-assessment questionnaires were similarly high (4.2-4.9) with scores in self-efficacy increased after training (pre: 1.7 ± 0.8, post: 3.2 ± 1.0, p = 0.000 in ex-vivo, pre: 1.9 ± 1.0, post: 3.7 ± 0.7, p = 0.000 in live). Scores comparing pre-training and post-evaluation (pre: 1.7 ± 0.8, post: 3.7 ± 0.9, p = 0.000 in ex-vivo, pre: 1.9 ± 1.0, post: 3.8 ± 0.7, p = 0.000 in live) were increased.

CONCLUSION:

Training with an ex-vivo model and live tissue training are similar for the management of a penetrating cardiac injury, with increased self-efficacy of participants in both groups. The ex-vivo model is useful to learn hemostatic skills in trauma surgery.

12.West J Emerg Med. 2015 Nov;16(6):907-12. doi: 10.5811/westjem.2015.10.26974. Epub 2015 Nov 22.

Correlation of Simulation Examination to Written Test Scores for Advanced Cardiac Life Support Testing: Prospective Cohort Study.

Strom SL1, Anderson CL2, Yang L3, Canales C 3, Amin A4, Lotfipour S2, McCoy CE2, Langdorf MI2.

Author information:

1University of California Irvine School of Medicine, Department of Anesthesia and Perioperative Care, Irvine, California.

2University of California Irvine School of Medicine, Department of Emergency.

3Medicine, Irvine, California.

4University of California Irvine, Irvine, CaliforniaUniversity of California Irvine School of Medicine, Department of Medicine, Irvine, California.

Abstract

INTRODUCTION:

Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been used in many specialties as a training resource as well as an evaluative tool. There are no data to our knowledge that compare simulation examination scores with written test scores for ACLS courses.

OBJECTIVE:

To compare and correlate a novel high-fidelity simulation-based evaluation with traditional written testing for senior medical students in an ACLS course.

METHODS:

We performed a prospective cohort study to determine the correlation between simulation-based evaluation and traditional written testing in a medical school simulation center. Students were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario. Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome was comparison of simulation-based vs. written outcome scores.

RESULTS:

The composite average score on the written evaluation was substantially higher (93.6%) than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6-14.0%], p<0.00005). We found a statistically significant moderate correlation between simulation scenario test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new evaluation method.

CONCLUSION:

Simulation-based ACLS evaluation methods correlate with traditional written testing and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and challenging testing method, as students scored higher on written evaluation methods compared to simulation.

13.BMC Health Serv Res. 2016 Sep 7;16:475. doi: 10.1186/s12913-016-1683-0.

The impact of web-based and face-to-face simulation on patient deterioration and patient safety: protocol for a multi-site multi-method design.

Cooper SJ1, Kinsman L2, Chung C3, Cant R3, Boyle J4, Bull L5, Cameron A6, Connell C7, Kim JA3, McInnes D8, McKay A2, Nankervis K5, Penz E9, Rotter T10.

Author information:

1School of Nursing Midwifery and Healthcare, Federation University Australia, Churchill, Victoria 3842 and Mt. Helen, Victoria 3350, Australia. s.cooper@federation.edu.au.

2School of Nursing, The University of Tasmania, PO Box 1322, Launceston, Tasmania, 7250, Australia.

3School of Nursing Midwifery and Healthcare, Federation University Australia, Churchill, Victoria 3842 and Mt. Helen, Victoria 3350, Australia.

4St John of God Health Care Berwick, Gibb St, Berwick, Victoria, 3806, Australia.

5Department of Nursing and Midwifery Education and Strategy, Monash Health, Clayton Rd, Clayton, Victoria, 3168, Australia.

6Latrobe Regional Hospital, 10 Village Ave, Traralgon, VIC, 3844, Australia.

7Nursing and Midwifery, Monash University, McMahons Rd, Frankston, Victoria, 3199, Australia.

8Central Gippsland Health Service, 155 Guthridge Parade, Sale, VIC, 3850, Australia.

9College of Medicine, University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada.

10College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, SK, S7N 5E5, Canada.

Abstract

BACKGROUND:

There are international concerns in relation to the management of patient deterioration which has led to a body of evidence known as the 'failure to rescue' literature. Nursing staff are known to miss cues of deterioration and often fail to call for assistance. Medical Emergency Teams (Rapid Response Teams) do improve the management of acutely deteriorating patients, but first responders need the requisite skills to impact on patient safety.

METHODS/DESIGN:

In this study we aim to address these issues in a mixed methods interventional trial with the objective of measuring and comparing the cost and clinical impact of face-to-face and web-based simulation programs on the management of patient deterioration and related patient outcomes. The education programs, known as 'FIRST(2)ACT', have been found to have an impact on education and will be tested in four hospitals in the State of Victoria, Australia. Nursing staff will be trained in primary (the first 8 min) responses to emergencies in two medical wards using a face-to-face approach and in two medical wards using a web-based version FIRST(2)ACTWeb. The impact of these interventions will be determined through quantitative and qualitative approaches, cost analyses and patient notes review (time series analyses) to measure quality of care and patient outcomes.

DISCUSSION:

In this 18 month study it is hypothesised that both simulation programs will improve the detection and management of deteriorating patients but that the web-based program will have lower total costs. The study will also add to our overall understanding of the utility of simulation approaches in the preparation of nurses working in hospital wards. (ACTRN12616000468426, retrospectively registered 8.4.2016).

PMID: 27604599 [PubMed - in process]

14.AJR Am J Roentgenol. 2016 Sep 9:1-5. [Epub ahead of print]

Simulation-Based Training May Improve Resident Skill in Ultrasound-Guided Biopsy.

Fulton N1, Buethe J1, Gollamudi J1, Robbin M1.

Author information:

11 Department of Radiology, University Hospitals Case Medical Center, 11100 Euclid Ave, Cleveland, OH 44106.

Abstract

OBJECTIVE:

The purpose of this study was to determine whether simulation-based training can improve resident performance in ultrasound-guided biopsy.

SUBJECTS AND METHODS:

Forty radiology residents from a single academic institution enrolled in the study. Each resident performed an initial biopsy on an abdominal imaging phantom using direct ultrasound guidance. Twenty of the residents underwent a 30-minute training session with the phantom device, and 20 residents received no additional training. The residents performed a repeat biopsy of the same lesion and were graded on overall procedure time, number of skin surface punctures, number of gross needle adjustments, and subjective performance as determined by a blinded grader.

RESULTS:

Residents who participated in the training had a statistically significant 92.3-second reduction in procedure time (68% improvement, p = 0.01), 1.1 reduction in number of skin punctures per biopsy (50% improvement, p = 0.05), 2.5 reduction in number of needle adjustments (66% improvement, p = 0.04), and an increase of 0.85 points in score on a 5-point Likert grading scale (23% improvement, p < 0.01). Residents who did not receive any additional training did not improve in any performance metric.

CONCLUSION:

Simulation-based training improves overall procedure time, number of skin punctures and needle adjustments, and subjective performance.

15.World Neurosurg. 2016 Sep 6. pii: S1878-8750(16)30802-6. doi: 10.1016/j.wneu.2016.08.118. [Epub ahead of print]

Coconut Model for Learning First Steps of Craniotomy Techniques and CSF Leak Avoidance.

Braga BD1, Peleja SB2, Macedo G3, Drummond CR4, Costa PH5, Garcia-Zapata MT6, Oliveira MM7.

Author information:

1Santa Casa da Misericórdia de Goiânia and Pontificial Catholic University of Goiás, Brazil; Goiânia General Hospital, Goiás, Brazil; Federal University of Goiás, Brazil. Electronic address: bernardodrummond@yahoo.com.br.

2Santa Casa da Misericórdia de Goiânia and Pontificial Catholic University of Goiás, Brazil; Goiânia General Hospital, Goiás, Brazil.

3 Santa Casa da Misericórdia de Goiânia and Pontificial Catholic University of Goiás, Brazil.

4Goiânia General Hospital, Goiás, Brazil.

5Department of Surgery, Federal University of Minas Gerais, Brazil.

6Federal University of Goiás, Brazil.

7Federal University of Goiás, Brazil; Department of Surgery, Federal University of Minas Gerais, Brazil.

Abstract

INTRODUCTION:

Neurosurgery simulation has gained attention recently due to changes in the medical system. First-year neurosurgical residents in low-income countries usually perform their first craniotomy on a real subject. Development of high-fidelity, cheap, and largely available simulators is a challenge in residency training. An original model for the first steps of craniotomy with cerebrospinal fluid (CSF) leak avoidance practice using a coconut is described.

MATERIAL AND METHODS:

The coconut is a drupe from Cocos nucifera L. (coconut tree). The green coconut has four layers and some similarity can be seen between these layers and the human skull. The materials used in the simulation are the same as those used in the operating room.

PROCEDURE:

The coconut is placed on the head holder support with the face up. The burr holes are made until endocarp is reached. The mesocarp is dissected, and the conductor is passed from one hole to the other with the Gigli saw. The hook handle for the wire saw is positioned, and the mesocarp and endocarp are cut. After sawing the four margins, mesocarp is detached from endocarp. Four burr holes are made from endocarp to endosperm. Careful dissection of the endosperm is done, avoiding liquid albumen leak. The Gigli saw is passed through the trephine holes. Hooks are placed, and the endocarp is cut. After cutting the four margins, it is dissected from the endosperm and removed. The main goal of the procedure is to remove the endocarp without fluid leakage.

DISCUSSION:

The coconut model for learning the first steps of craniotomy and CSF leak avoidance has some limitations. It is more realistic while trying to remove the endocarp without damage to the endosperm. It is also cheap and can be widely used in low-income countries. However, the coconut does not have anatomical landmarks. The mesocarp makes the model less realistic because it has fibers that make the procedure more difficult and different from a real craniotomy.

CONCLUSION:

The model has a potential pedagogic neurosurgical application for freshman residents before they perform a real craniotomy for the first time. Further validity is necessary to confirm this hypothesis.

Copyright © 2016 Elsevier Inc. All rights reserved.

PMID: 27613497 [PubMed - as supplied by publisher]

16. Revisiting ‘A critical review of simulation-based medical education research: 2003–2009’

Authors

William C McGaghie,

S Barry Issenberg,

Emil R Petrusa,

Ross J Scalese

First published: 15 September 2016Full publication history

DOI: 10.1111/medu.12795View/save citation

Objectives

This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

Methods

This Qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective critical review of SBME research and scholarship published during 2003-2009.

Results

The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii)deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity;(vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training; and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

Conclusions

Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.