Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance

Augmented-reality telementoring for leg fasciotomy: a proof-of-concept study

BACKGROUND

Prolonged field care is required when casualty evacuation to a surgical facility is delayed by distance, weather or tactical constraints. This situation can occur in both civilian and military environments. In these circumstances, there are no established treatment options for extremity compartment syndrome. Telementoring by a surgeon may enable the local clinician to perform a fasciotomy to decompress the affected compartments.

METHODS

Six military clinicians were asked to perform a two-incision leg fasciotomy in synthetic models under the guidance of an orthopaedic surgeon located 380 km away. Communication occurred through commercially available software and smartglasses, which also allowed the surgeon to send augmented-reality graphics to the operators. Two blinded surgeons evaluated the specimens according to objective criteria. Control specimens were added to ensure the integrity of the evaluation process.

RESULTS

The six study participants were military physician assistants who had extensive clinical experience but had never performed a fasciotomy. The average duration of the procedure was 53 min. All six procedures were completed without major errors: release of all four compartments was achieved through full-length incisions in the skin and fascia. The only surgical complication was a laceration of the saphenous vein. All three control specimens were correctly assessed by the evaluators. None of the participants experienced adverse effects from wearing the smartglasses. Four dropped calls occurred, but the connection was re-established in all cases.

CONCLUSION

All six surgical procedures were completed successfully. We attribute the dropped calls to a mismatch between the size of the graphic files and the available bandwidth. A better technical understanding of the software by the mentoring surgeon would have avoided this problem. Important considerations for future research and practice include protocols for dropped communications, surgical skills training for the operators and communication training for the surgeons.

Piloting the FIRE: A Novel Error Management Training Simulation Curriculum for Fasciotomy Instruction

BACKGROUND

Multiple studies have demonstrated poor performance of lower extremity fasciotomy (LEF), highlighted by missed and/or inadequately released compartments. Incorporating error management training (EMT) into surgical simulation has been promoted as a way to gain deeper understanding of procedural errors and overall performance. The purpose of this study was to evaluate LEF performance using a Fasciotomy Improvement through Recognition of Errors (FIRE) simulation training curriculum to train novice surgical trainees.

METHODS

A mastery learning-based EMT curriculum was developed, and surgical residents were enrolled and pretested with a multiple-choice question (MCQ) written test, and a simulated fasciotomy using a lower leg model. Each trainee then watched a 15-minute narrated presentation followed by 2 rounds of fasciotomy error recognition and management training exercises to a mastery standard. During each round, trainees performed hands-on assessment of unique premade fasciotomy leg models containing a variable number of procedural errors. They were required to identify and propose corrective action for all errors. Serial rounds of remediation were implemented until the mastery standard was attained on both error identification rounds. All trainees were post-tested with the same MCQ and another simulated fasciotomy.

RESULTS

All 14 residents had minimal experience with only 0.3 ± 0.6 fasciotomies performed prior to instruction. There were 3 ± 1.6 missed or inadequately released compartments on the pretest. Residents examined 14 ± 2.5 legs, including 2 ± 2.5 legs during remediation to attain mastery. All residents demonstrated significant improvement following the FIRE of Error curriculum for the MCQ (57% ± 16% vs 78% ± 13%; p = 0.01; Cohen's d = 1.4), fasciotomy score (10 ± 7.1 vs 28 ± 1.9; p < 0.001; Cohen's d = 3.6), and achieving a complete fasciotomy (14% ± 36% vs 93% ± 27%; p < 0.001; Cohen's d = 2.5). Only a single cumulative compartment was missed on post-testing.

CONCLUSIONS

Implementation of a mastery learning-based EMT curriculum for fasciotomy simulation training results in significant improvement in fasciotomy technique without reliance on repeated procedure performance nor clinical fasciotomy exposure. This curriculum is a highly effective option for surgical trainees lacking fasciotomy training during residency.