A comparison of live tissue training and high-fidelity patient simulator: A pilot study in battlefield trauma training

Exploring the Scientific Conversation Regarding Live Tissue Training in Trauma Surgery: A Bibliometric Analysis

INTRODUCTION

Live tissue training (LTT), use of a living anaesthetized animal to practice surgical skills, is a continuing practice, despite controversy and ethical concern. The scientific literature appears polarized in terms of supporting or refuting the practice. This bibliometric analysis of the literature maps and explores the academic conversation regarding LTT including potential influences associated with authorship.

METHOD

Literature identified via the process conducted during a previously published systematic review was used for analysis. 84 literature sources were included. Bibliometric data were manually extracted for analysis, and visually mapped.

RESULTS

The scientific conversation about LTT use in trauma is centered on surgery, trauma and emergency medicine specialties, published in clinical journals, with significant influence noted from military authors and organizations. Few authors published work in simulation or education-based journals. Publications are considered to be generally supportive of, or ambivalent to, the use of LTT; those with notable objections to LTT tended to be affiliated to animal activist organizations.

CONCLUSION

There is academic conversation apparent within the literature, in the form of citations, although this is used to affirm or rebuke a given perspective, rather than engage with, or learn from, the content. There is potential benefit to increased interactivity between researchers. The conversation could also be informed by authors broadening the outlook to wider medical educational literature and other disciplines, rather than focusing on application to clinical training, to improve trauma education for all, regardless of modality.

Trauma surgical simulation: discussing the replacement of live animals used as human patient simulators

BACKGROUND

Despite advances in simulator technology, live anaesthetised animals continue to be used as human patient simulators for medical professionals to practice techniques in the management of surgical trauma. This article describes the process of convening a working group of individuals with a professional interest in simulation to discuss the use of live animals and consider if and how they can be replaced in the future.

MAIN BODY

A working group was formed of voluntary attendees to a workshop held at the SESAM 2023 conference. Iterative discussions reflecting on the topic were used to produce statements summarising the working group's opinions. The working group determined that live animals are used as human patient simulators due to the presence of accurate and responsive physiology in the presence of bleeding, realistic tissue tactility and an emotional response experienced by the learner due to interaction with the animal. They were unable to reach a consensus on replacement, determining that there is currently no single model which is able to provide all the learning aspects which a live animal model can provide. Several suggestions were made regarding development of technologies and pedagogical change.

CONCLUSION

Replacement of live animals in surgical simulation is not straightforward but should be an aspiration, if possible. For the ongoing development of trauma surgical simulation models, it is important to combine the knowledge, skills and perspectives of medical stakeholders and educators, academic researchers and industry experts in producing alternative options to the use of live animal simulators.

Simulation in airway management teaching and training

There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.

Development of a Low-Cost, High-Fidelity, Reusable Model to Simulate Clamshell Thoracotomy

OBJECTIVE

Clamshell thoracotomy (CST) is an emergency procedure performed during traumatic cardiac arrest. Emergency physicians and surgeons are expected to perform this procedure in the Emergency Department. However, the procedure has a low occurrence rate, therefore physicians are often poorly prepared. Current teaching methods include expensive simulators and anatomically inaccurate animal models. The goal of this study was to design, produce and test, a low-cost, high-fidelity model for the teaching of CST.

DESIGN, SETTING AND PARTICIPANTS

The model was produced from inexpensive, commercially available materials as well as ADAMgel; a custom, recyclable, inexpensive tissue analogue. The model was tested across 19 physicians, mostly consultants and senior registrars in emergency medicine, anaesthesia and surgery. Participants completed comparative questionnaires before and after testing the model. The questionnaires were adapted from previous anaesthetic-based simulation studies and used a modified Likert scale to assess prior knowledge, anatomical realism and the teaching benefits of the model.

RESULTS

Participants had varied prior knowledge and experience before testing the model. Results showed that 89.47% (n = 17) of trainees felt the model was a reasonable substitute for practice and 100% (n = 19) agreed that the model was a good training aid for inexperienced trainees and would recommend it to others.

CONCLUSIONS

The model proved a successful teaching tool, improving physicians' knowledge and confidence with performing CST. This high fidelity, low cost model demonstrated that a high standard simulation teaching tool can be made which improves teaching of CST.

A Systematic Review of Live Animal Use as a Simulation Modality ("Live Tissue Training") in the Emergency Management of Trauma

INTRODUCTION

Live anaesthetized animals are used as simulation models to teach techniques in the emergency management of trauma. We aimed to explore how "live tissue training" (LTT) is designed, delivered and evaluated in order to better understand and characterize aspects of educational merit.

METHODS

A systematic review was performed using PRISMA guidance. A combined approach, involving a 3-stage modified narrative synthesis process and reflexive thematic analysis was used to identify key concepts across the published literature.

FINDINGS

Qualitative synthesis of 48 selected articles suggests that LTT is mainly used to teach military and civilian physicians and military medical technicians. The procedures trained vary with the learner population, from simple pre-hospital trauma tasks to advanced operative surgical skills. Many courses use a combination of didactic and practical training, with an animal model used to train practical application of knowledge and procedural skills. Descriptions of the learning interventions are limited, and explicit use of educational theory or pedagogic frameworks were absent within the literature. Four themes were identified regarding aspects of LTT that are valued by learners: "recreating the experience," relating to fidelity and realism; "tick tock" "dynamics of hemorrhage", encompassing the impact of bleeding and urgent pressure to act; "emotional impact" of conducting the training, and "self-efficacy: I believe I can do it."

CONCLUSION

Thematic analysis of published literature suggests that there may be educational benefit in the use of live tissue models due to time criticality and bleeding, which creates a real-life event. LTT also invokes an emotional response, and learners experience an increase in self-efficacy from participation. We consider that these aspects and associated pedagogy should be addressed when researching and developing alternative simulation modalities, in order to intelligently replace, reduce and refine the use of animals in training practitioners in the emergency management of trauma.

Expanding scope of Kirkpatrick model from training effectiveness review to evidence-informed prioritization management for cricothyroidotomy simulation

Modified Kirkpatrick model has been adopted to evaluate training effectiveness by 6 categories, including activity accounting (training objectives/success in organization change) at Level-0, reaction (satisfaction) at Level-1, learning (acquisition of surgical airway skills) at Level-2, behavior (post-training change in personal strengths) at Level-3, result (organizational or clinical outcomes) at Level-4, and Return on Investment (ROI) or Expectation (ROE) (monetary and societal values following training and other quality and safety related measures) at Level-5. The purpose of this hospital-based prospective observational study was twofold: i) To evaluate potential impacts on monetary and societal values and successful organization change following implementation of advanced Cricothyroidotomy simulator and standardized curriculum in healthcare simulation training, ii) To inform decisions of resource allocation by reviewing overall values and prioritization strategies for i) general surgeon/emergency physician ii) with seniority >5 years and iii) prior porcine training experience based on findings at Kirkpatrick Level-0, Level-4, and Level-5. Seventy doctors and 10 nurses completed Cricothyroidotomy training and follow-up questionnaires within 2021/22. All training usability scoring measured by Scales of Emergency Surgical Airway Simulator (SESAS-17) achieved over 4 out of 5 (Level-4) with effects in favor of emergency physicians or general surgeons (p < .5), regardless of seniority and prior training experience. Success in organization change (Level-0) and cost-effectiveness (Level-5) were hypothetically established using theoretical framework of Gleicher's formula and Roger's Diffusion of Innovation Theory. Overall training effectiveness, in terms of advantage in usability, cost-benefits and successful organizational changes, provided sound evidence to support continuous investment of new curriculum and innovative simulator and "Surgeon-and-emergency-physician-first" policy when it comes to resources allocation strategies for Cricothyroidotomy training. [ACGME competencies: Practice Based Learning and Improvement, Systems Based Practice.].

Evaluating Medic Performance in Combat Casualty Care Simulation and Training: A Scoping Review of Prospective Research

INTRODUCTION

Combat medics are required to perform highly technical medical procedures in austere environments with minimal error. Effective means to quantify medic performance in field and simulated environments are critical to optimize medic training procedures as well as to evaluate the influence of medical equipment and other supportive technologies on medic performance. Human performance evaluation in combat casualty care presents many unique challenges due to the unique environment (battlefields) and population (medics) that must be represented. Recent advances in simulation and measurement technology have presented opportunities to improve simulation fidelity and measurement quality; however, it is currently unclear to what extent these advances have been adopted in this domain.

METHODOLOGY

In this work, a scoping review of recent (2011-2021) prospective research on Army medic (68 W and Special Operations) performance is presented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines served as the framework for the review. The goal of this work was to summarize recent trends and practices and to illuminate opportunities for future work. Two human factors experts performed an exhaustive review of relevant, peer-reviewed literature and systematically identified articles for inclusion in the final analysis. The articles were examined in detail, and data elements of interest were extracted.

RESULTS

Forty-eight articles were identified based on the defined inclusion criteria. Thirty three of the articles focused on technological evaluation, 25 focused on medic training procedures, and 5 focused on evaluating medical techniques. Study contributions were predominantly related to medic training materials/procedures and simulator technology. Supportive medical technologies, including telemedical systems, hemorrhage control devices, and ultrasound devices, also received significant attention. Timing was the most common metric used to quantify medic performance, followed by skill pass/fail ratings. There was a notable lack of neurophysiological data used to examine medic physical/cognitive workload during procedures, a growing practice in many other related domains. The most commonly simulated procedures were hemorrhage control, airway management, and thoracostomy. Notable limitations cited across articles were insufficient simulation fidelity, inadequate sample size or sample representativeness, and poor study design.

CONCLUSIONS

This work provided a summary of recent peer-reviewed research related to medic simulation and training, and performance evaluation. This article should be used to contextualize existing research and inspire new research questions. Expanding and advancing research on medic simulation and training will help to ensure optimal casualty care at the front lines.

Experiences of medical practitioners in the Australian Defence Force on live tissue trauma training

INTRODUCTION

Care of battle casualties is a central role of military medical practitioners. Historically, certain trauma procedural skills have been learnt through live tissue training. However, faced with opposition from community members and academics, who argue equivalence of non-animal alternatives, this is now being phased out. This study explores Australian military medical practitioners' experiences of and attitudes towards live tissue training.

METHOD

We performed a phenomenologically driven qualitative exploration of individuals' experiences of live tissue trauma training. 32 medical officers volunteered for the study. In-depth interviews were conducted with 15 practitioners (60% Army, 20% Air Force, 20% Navy; 33% surgical, 53% critical care, 13% general practice). Qualitative data were subjected to content analysis, with key themes identified using manual and computer-assisted coding.

RESULTS

Live tissue training was valued by military medical practitioners, particularly because of the realistic feel of tissues and physiological responsiveness to treatment. Learner-perceived value of live tissue training was higher for complex skills and those requiring delicate tissue handling. 100% of surgeons and critical care doctors regarded live tissue as the only suitable model for learning repair of penetrating cardiac injury. Live tissue training was felt to enhance self-efficacy, particularly for rarely applied skills. Though conscious of the social and ethical context of live tissue training, >90% of participants reported positive emotional responses to live tissue training.

CONCLUSION

In contrast to published research, live tissue training was thought by participants to possess characteristics that are not yet replicable using alternative learning aids. The experienced positive values of live tissue training should inform the decision to move towards non-animal alternatives.

Harnessing power of simulation training effectiveness with Kirkpatrick model in emergency surgical airway procedures

Objectives

Training effectiveness indicates how good a program has met pre-set training objectives or organizational goals for the best benefit of healthcare professionals and service users in the community. The study aimed to evaluate training effectiveness following implementation of new training curriculum of emergency surgical airway procedures (Cricothyroidotomy) organized by the Queen Elizabeth Hospital.

Design

This training evaluation relied on observational descriptive study design. Timed task on Cricothyroidotomy procedures and standardized post-training questionnaire were applied to assess the first 3 levels of Kirkpatrick's model: (Level-1) Reaction by training satisfaction; (Level-2) Learning by acquisition of knowledge and skills assessment passing rate; (Level-3) Behavior by personal strengths.

Setting

This program was operated in the Multi-Disciplinary Simulation and Skills Centre, a hospital-based high-fidelity simulation training center accredited by the Society for Simulation in Healthcare.

Participants

The study recruited 80 trauma service providers, including 35 general surgeons, 15 emergency physicians, 10 anesthesiologists or intensivists, 6 neurosurgeons, 4 orthopedic surgeons, and 10 emergency nurses from five trauma centers under the Hospital Authority. All underwent the Advanced Trauma Life Support training in advance.

Results

Compared with reference score from previous training sessions, the result of program using new training curriculum and simulator demonstrated significant training satisfaction of participants (Level-1), and high level of assertiveness, mental preparedness, self-efficacy, and internal locus of control and responsibility (p < .01, for all in Level-3). All participants (N = 80) completed entire Cricothyroidotomy procedure in 2 min without technical errors (Assessment passing rate = 100%) (Level-2).

Conclusions

Under Kirkpatrick model, simulation training in Cricothyroidotomy procedure using new curriculum and simulators has been proven to be useful for healthcare professionals involved in trauma service management. The result suggests that application of a state-of-the-art training tools to advanced surgical skills training could improve training satisfaction, knowledge and skills acquisition, and personal strengths transferable to clinical practice.

ACGME competencies

Practice Based Learning and Improvement.

Monthly Trauma Training and Simulation Are Associated With Improved Resident Skill and Leadership

BACKGROUND

Training for trauma procedures has been limited to infrequent courses with little data on longitudinal performance, and few address procedural and leadership skills with granular assessment. We implemented a novel training program that emphasized an assessment of trauma resuscitation and procedural skills.

OBJECTIVE

This study aimed to determine whether this program could demonstrate improvement in both skill sets in surgical trainees over time.

METHODS

This was a prospective, observational study at a Level I trauma center between November 2018 and May 2019. A procedural skill and simulation program was implemented to train and evaluate postgraduate year (PGY) 1-5 residents. All residents participated in an initial course on procedures such as tube thoracostomy and vascular access, followed by a final evaluation. Skills were assessed by the Likert scale (1-5, 5 noting mastery). PGY 3s and above were additionally evaluated on resuscitation. A paired t test was performed on repeat learners.

RESULTS

A total of 40 residents participated in the structured procedural skills and simulation program. Following completion of the program, PGY-2 scores increased from a Mdn [interquartile range, IQR] 3.0 [2.5-4.0] to 4.5 [4.2-4.5]. The PGY-3 scores increased from a Mdn [IQR] 3.95 [3.7-4.6] to 4.8 [4.6-5.0]. Eighteen residents underwent repeat simulation training, with Mdn [IQR] score increases in PGY 2s (3.7 [2.5-4.0] to end score 4.47 [4.0-4.5], p = .03) and PGY 3s (3.95 [3.7-4.6] to end score 4.81 [4.68-5.0], p = .04). Specific procedural and leadership skills also increased over time.

Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians

BACKGROUND

Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.

METHODS

Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.

RESULTS

Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.

CONCLUSIONS

Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

[Prehospital application of tourniquets for life-threatening extremity hemorrhage : Systematic review of literature]

INTRODUCTION

The effectiveness of a tourniquet in the case of life-threatening hemorrhages of the extremities is well recognized and led to the recommendations on "Tourniquet" of the German Society of Anaesthesiology and Intensive Care (DGAI) in 2016. The aim of this systematic review was to re-evaluate the current medical literature in relation to the published DGAI recommendations.

MATERIAL AND METHODS

Based on the analysis of all studies published from January 2015 until January 2018 in the PubMed databases, the publicized recommendations for action on "Tourniquet" of the DGAI were critically re-evaluated. For this purpose, 17 questions on 6 subjects were formulated in advance. The systematic review followed the PRISMA recommendations and is registered in PROSPERO (International prospective register of systematic reviews, Reg.-ID: CRD42018091528).

RESULTS

Of the 284 studies identified with the keywords tourniquet and trauma in the period from January 2015 to January 2018 in PubMed, 50 original papers discussing the prehospital application of tourniquet for life-threatening hemorrhage of the extremities were included. The overall level of evidence is low. No article addressed any of the formulated questions with a prospective randomized interventional study. Scientific deductions could be found only in an indirect way in a descriptive manner.

CONCLUSION

The 50 original articles included in this qualitative, systematic review revealed that the recommendations "Tourniquet" of the DGAI published in 2016 are mostly still up to date despite an inhomogeneous study situation. A deviation occurred in the conversion of a tourniquet but due to the short prehospital treatment time in the civilian setting this is of little importance; however, in the future a strict distinction should be made between tourniquets which were placed for tactical reasons and those placed as a medical necessity.

Lifesaving interventions in blackout conditions using night vision technology: Come to the dark side

BACKGROUND

During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform lifesaving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions.

METHODS

Using a crossover design, six surgeons performed 11 different procedures on six swine, three in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups.

RESULTS

Blackout conditions were confirmed with ambient light reading of 0.2 lux during BC versus 3962.9 lux for LC (p < 0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous resuscitative endovascular balloon occlusion of the aorta placement. The following procedures took significantly longer in BC vs. LC: Focused Assessment with Sonography for Trauma examination (98 seconds vs. 62 seconds), peripheral IV placement (140 seconds vs. 35 seconds), intraosseous access (51 seconds vs. 26 seconds), jugular vein cut-down and access (237 seconds vs. 104 seconds), laparotomy and packing (71 seconds vs. 51 seconds), stapled splenectomy (137 seconds vs. 74 seconds), resuscitative endovascular balloon occlusion of the aorta placement via cutdown (1,008 seconds vs. 338 seconds), and cricothyroidotomy (177 seconds vs. 109 seconds) (all p < 0.05).

CONCLUSION

Lifesaving interventions can be safely and effectively performed in blackout conditions using NODs, although increased difficulty with select procedure types was identified. Focused training and technological improvements to currently available devices are needed.

LEVEL OF EVIDENCE

Basic science.

Perceptions of Simulator- and Live Tissue-Based Combat Casualty Care Training of Senior Special Operations Medics

The relative effectiveness of live tissue (LT)- and inanimate simulation (SIM)-based training of combat medics is the subject of intense debate. A structured interview was utilized to determine the training modality preferences and the perceived value of LT- and SIM-based combat casualty care training of 25 senior special operations medics. Participant demographics and training experience, Likert scale-based assessment of training modality value, selection of preferred training modality for 11 combat casualty care procedures, and 12 open-ended questions probing opinions of the limitations and benefits of LT- and SIM-based training were collected from this convenience sample. All participants indicated significant combat medic experience and training. Of the 11 procedures questioned, LT was identified as superior for seven with mixed responses for the remaining four. LT was consistently identified as an essential training modality with tactile sensation and the physiologic responses of animal models to injury and therapy as primary benefits. Across procedures, 100% of participants felt that LT should be used in combat casualty care training and 96% felt that SIM should also be utilized. Repeatability and accuracy of size/weight were identified as key benefits of SIM training. Respondents reported that capability, self-confidence, success, and resilience of the combat medic all benefitted from LT training. The overriding theme was the general superiority of LT with recognition of the unique and complementary benefits of SIM.

Tourniquet Training Program Assessed by a New Performance Score

Introduction

Application of a tourniquet is the cornerstone in management of combat-related extremity hemorrhages. Continuous and appropriate training is required to use tourniquets correctly.

Hypothesis

The aim of this study was to analyze the impact of a refresher training session, conducted directly in the theater of military operations, on the performance of tourniquet use.

Methods

During their deployment (October 2015-April 2016) in the Central African Republic, a first simulation session evaluated soldiers from two combats platoons for the application of the SOFFT (Special Operation Forces Tactical Tourniquet; Tactical Medical Solutions; Anderson, South California USA) tourniquet. After randomization, a R (+) group underwent a refresher training session, while a R (−) group did not. Two months later, a second simulation session was conducted for both groups: R (+) and R (−). A dedicated score (one to seven points), including delay and effectiveness, evaluated the soldiers’ performance for tourniquet application.

Results

Twenty-six subjects were included in the R (+) group and 24 in the R (−) group. Between the two assessments, the score improved for 61.5% of subjects of the R (+) group and 37.5% subjects of the R (−) group (P=.09). More particularly, the performance score increased from 4.2 (SD=1.4) to 5.5 (SD=0.9; P=.002) in subjects of the R (+) group whose last training for tourniquet application was over six months prior.

Conclusion

A refresher tourniquet training session, conducted directly in a combat zone, is especially effective for soldiers whose last training session was over six months prior. A dedicated score can assess appropriately the performance of tourniquet training.

MartinezT, DuronS, SchaalJV, BaudoinY, BarbierO, DabanJL, BoutonnetM, AussetS, PasquierP. Tourniquet training program assessed by a new performance score. Prehosp Disaster Med. 2018;33(5):519–525.

Randomized Comparative Assessment of Three Surgical Cricothyrotomy Devices on Airway Mannequins

BACKGROUND

Airway obstruction is the second leading cause of preventable battlefield death, at least in part because surgical cricothyrotomy (SC) failure rates remain unacceptably high. Ideally, SC should be a rapid, simple, easily-learned, and reliably-performed procedure. Currently, 3 SC devices meet Tactical Combat Casualty Care (TCCC) standards: The Tactical CricKit® (TCK), Control-Cric^TM(CC), and Bougie-assisted Technique (BAT). However, no previous studies have compared these devices in application time, application success, user ratings, and user preference.

METHODS

United States Navy Corpsmen (N = 25) were provided 15 minutes of standardized instruction, followed by hands-on practice with each device on airway mannequins. Participants then performed SC with each of the 3 devices in a randomly assigned sequence. In this within-subjects design, application time, application success, participant ratings, and participant preference data were analyzed using repeated-measures ANOVA, regression, and non-parametric statistics at p < 0.05.

RESULTS

Application time for CC (M = 184 sec, 95% CI 144-225 sec) was significantly slower than for BAT (M = 135 sec, 95% CI 113-158 sec, p < 0.03) and TCK (M = 117 sec, 95% CI 93-142 sec, p < 0.005). Success was significantly greater for BAT (76%) than for TCK (40%, p < 0.02) and trended greater than CC (48%, p = 0.07). CC was rated significantly lower than TCK and BAT in ease of application, effectiveness, and reliability (each p < 0.01). User preference was significantly (p < 0.01) higher for TCK (58%) and BAT (42%) than for CC (0%). Improved CC blade design was the most common user suggestion.

CONCLUSION

While this study was limited by the use of mannequins in a laboratory environment, present results indicate that none of these devices was ideal for performing SC. Based on slow application times, low success rates, and user feedback, the Control-Cric^TM cannot be recommended until improvements are made to the blade design.

High-Fidelity Emergency Department Thoracotomy Simulator With Beating-Heart Technology and OSATS Tool Improves Trainee Confidence and Distinguishes Level of Skill

OBJECTIVE

Resuscitative Thoracotomy or Emergency Department Thoracotomy (EDT) is a time-sensitive and potentially life-saving procedure. Yet, trainee experience with this procedure is often limited in both clinical and simulation settings. We sought to develop a high-fidelity EDT simulation module and assessment tool to facilitate trainee education.

DESIGN

Using the Kern model for curricular development, a group of expert trauma surgeons identified EDT as a high-stakes, low-frequency procedure. Task analysis identified 5 key steps of EDT: (1) opening chest/rib spreader utilization; (2) pericardiotomy/cardiac repair; (3) open cardiac massage; (4) clamping aorta; and (5) control of pulmonary hilum. A high-fidelity simulator with beating-heart technology was built. The previously validated Objective Structured Assessment of Technical Skills (OSATS) was adapted to create the "EDT-OSATS" which assessed performance along several domains: (1) Surgical technique (key steps); (2) general skills; and (3) global rating. A pilot test was performed to compare board-certified trauma surgeons (i.e., Experts) with categorical general surgery interns (i.e., Novices). Each subject received preparatory materials, completed a presimulation quiz, performed a videotaped procedure on the EDT simulator, and completed a postmodule survey. Two independent raters scored performances using the EDT-OSATS. Groups were compared in descriptive and unadjusted analyses. We hypothesized that our EDT simulation module would distinguish between expert vs novice performance and improve trainee confidence.

SETTING

Simulation laboratory at Massachusetts General Hospital in Boston, MA.

PARTICIPANTS

Trauma surgeons (Experts, n = 6) and categorical general surgery interns (Novices, n = 8).

RESULTS

Experts scored significantly higher than Novices on nearly all components of the EDT-OSATS, including: (1) surgical technique: pericardiotomy (4.2 vs 3.4, p = 0.040), cardiac massage (3.6 vs 2.4, p = 0.028), clamping aorta (4.1 vs 3.3, p = 0.035), control of pulmonary hilum (4.8 vs 3.4, p < 0.001); (2) general skills: time/motion (4.1 vs 2.9, p = 0.011), knowledge and handling of instruments (4.3 vs 3.1, p = 0.004), and (3) global rating (3.9 vs 2.9, p = 0.026). There was no statistical difference between groups on opening chest/rib spreader utilization (3.8 vs 3.3, p = 0.352) or procedure time (204sec vs 227sec, p = 0.401), though Experts scored numerically higher than Novices on every measure. Novices reported significantly increased confidence after the simulation (3.1 vs 1.4, p = 0.001). Ninety-three percent (13/14) of participants found the simulator realistic.

CONCLUSIONS

Our novel high-fidelity beating-heart EDT simulator is realistic and improves trainee confidence in this low-frequency, high-stakes emergency procedure. The EDT-OSATS tool differentiates between performances of experienced surgeons vs novice trainees on the beating-heart simulator. This training module and accompanying assessment instrument hold promise as a learning tool for clinicians who may perform emergency department thoracotomy.

Is live-tissue training ethically justified? An evidence-based ethical analysis

Trauma training is a crucial element of medical education in the civilian sector, as well as in the military sector. Its aim is to prepare physicians, medics and nurses for stressful and demanding emergency situations. Training methods include live-tissue training (LTT) on animal models and simulation-based trauma education. For LTT, blast, gunshot or stab wounds are inflicted on anaesthetised animals, mostly goats and pigs, but sometimes non-human primates. This training method raises ethical concerns, especially in the light of increasingly sophisticated simulation-based methods. Despite these non-animal alternatives, LTT is still widely used due to its presumed educational benefits. In this paper, the question of whether LTT can still be justified, is discussed. We developed a normative framework based on the premise that LTT can only be ethically justified when it yields indispensable benefits, and when these benefits outweigh those of alternative training methods. A close examination of the evidence base for the presumed advantages of LTT showed that it is not superior to simulation-based methods in terms of educational benefit. Since credible alternatives that do not cause harm to animals are available, we conclude that LTT on animal models is ethically unjustified.

Training and Assessing Critical Airway, Breathing, and Hemorrhage Control Procedures for Trauma Care: Live Tissue Versus Synthetic Models

INTRODUCTION

Optimal teaching and assessment methods and models for emergency airway, breathing, and hemorrhage interventions are not currently known. The University of Minnesota Combat Casualty Training consortium (UMN CCTC) was formed to explore the strengths and weaknesses of synthetic training models (STMs) versus live tissue (LT) models. In this study, we compare the effectiveness of best in class STMs versus an anesthetized caprine (goat) model for training and assessing seven procedures: junctional hemorrhage control, tourniquet (TQ) placement, chest seal, needle thoracostomy (NCD), nasopharyngeal airway (NPA), tube thoracostomy, and cricothyrotomy (Cric).

METHODS

Army combat medics were randomized to one of four groups: 1) LT trained-LT tested (LT-LT), 2) LT trained-STM tested (LT-STM), 3) STM trained-LT tested (STM-LT), and 4) STM trained-STM tested (STM-STM). Participants trained in small groups for 3 to 4 hours and were evaluated individually. LT-LT was the "control" to which other groups were compared, as this is the current military predeployment standard. The mean procedural scores (PSs) were compared using a pairwise t-test with a Dunnett's correction. Logistic regression was used to compare critical fails (CFs) and skipped tasks.

RESULTS

There were 559 subjects included. Junctional hemorrhage control revealed no difference in CFs, but LT-tested subjects (LT-LT and STM-LT) skipped this task more than STM-tested subjects (LT-STM and STM-STM; p < 0.05), and STM-STM had higher PSs than LT-LT (p < 0.001). For TQ, both STM-tested groups (LT-STM and STM-STM) had more CFs than LT-LT (p < 0.001) and LT-STM had lower PSs than LT-LT (p < 0.05). No differences were seen for chest seal. For NCD, LT-STM had more CFs than LT-LT (p = 0.001) and lower PSs (p = 0.001). There was no difference in CFs for NPA, but all groups had worse PSs versus LT-LT (p < 0.05). For Cric, we were underpowered; STM-LT trended toward more CFs (p = 0.08), and STM-STM had higher PSs than LT-LT (p < 0.01). Tube thoracostomy revealed that STM-LT had higher CFs than LT-LT (p < 0.05), but LT-STM had lower PSs (p < 0.05). An interaction effect (making the subjects who trained and tested on different models more likely to CF) was only found for TQ, chest seal, and Cric; however, of these three procedures, only TQ demonstrated any significant difference in CF rates.

CONCLUSION

Training on STM or LT did not demonstrate a difference in subsequent performance for five of seven procedures (junctional hemorrhage, TQ, chest seal, NPA, and NCD). Until STMs are developed with improved anthropomorphic and tissue fidelity, there may still be a role for LT for training tube thoracostomy and potentially Cric. For assessment, our STM appears more challenging for TQ and potentially for NCD than LT. For junctional hemorrhage, the increased "skips" with LT may be explained by the differences in anatomic fidelity. While these results begin to uncover the effects of training and assessing these procedures on various models, further study is needed to ascertain how well performance on an STM or LT model translates to the human model.