Comparison of manikin versus porcine models in cricothyrotomy procedure training

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel.

OBJECTIVES

To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams.

METHODS

Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired.

RESULTS

Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%).

CONCLUSIONS

An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Porcine model for tracheostomy training: evaluation of the content and construct validity

PURPOSE

Tracheostomy is a key procedure that residents in Oto-Rhino-Laryngology, Head and Neck surgery must master as a fundamental component of their training. Swine is a potential model for tracheostomy training as it mimics human anatomy and provides realistic haptic feedback. The purpose of this study is to evaluate its content and construct validity in surgical tracheostomy training.

METHODS

We carried out training sessions on dead swine with three groups of volunteers: young residents [postgraduate year (PGY)-1 to 3], experienced residents (PGY-4 to 6) and senior surgeons. Content validity was studied using questionnaires sent to senior surgeons. Construct validity was assessed by comparing the OSATS score on video analysis, between the three groups.

RESULTS

19 individuals participated in the training sessions. OSATS score were statistically different between groups (p < 0.05) with a mean score of 19 for young residents, 24.7 for experienced residents and 31.3 for senior surgeon, with a good inter-rater reliability (Pearson coefficient > 0.9). Experienced surgeons agreed that the model was a useful training tool, strongly agreed that it improved performance, and that it would be used to train their students.

CONCLUSIONS

The dead pig is a suitable model to train for human tracheotomy, with good content and construction validity.

Establishment and application of cricothyrotomy in vivo

BACKGROUND

Cricothyrotomy is a procedure performed to establish an airway in critical airway events. It is performed only rarely and anesthesiologists are often unprepared when called upon to perform it. This study aimed to simulate cricothyrotomy using pig larynx and trachea models to help anesthesiologists master cricothyrotomy and improve the ability to establish cricothyrotomy quickly.

METHODS

The porcine larynx and trachea were dissected and covered with pigskin to simulate the structure of the anterior neck of a human patient. An animal model of cricothyrotomy was established. Forty anesthesiologists were randomly divided into four groups. Each physician performed three rounds of cricothyrotomy, and recorded the time to accomplish each successful operation. After training the cricothyrotomy procedure, a questionnaire survey was conducted for the participating residents using a Likert scale. The participants were asked to score the utility of the training course on a scale of 1 ((minimum) to 5 ((maximum).

RESULTS

Through repeated practice, compared with the time spent in the first round of the operation (67 ± 29 s), the time spent in the second round of the operation (47 ± 21 s) and the time spent in the third round of the operation (36 ± 11 s) were significantly shortened (P < 0.05). Results of the survey after training were quite satisfied, reflecting increased the ability of proficiency in locating the cricothyroid membrane and performing a surgical cricothyrotomy.

CONCLUSION

The porcine larynx and trachea model is an excellent animal model for simulating and practicing cricothyrotomy, helping anesthesiologists to master cricothyrotomy and to perform it proficiently when required.

Evaluation of the Educational Value of Low-Cost Training Model for Emergency Cricothyrotomy

BACKGROUND

In this study, we aimed to evaluate the educational value and students' satisfaction with the hand-made low-cost cricothyrotomy simulation model.

MATERIALS AND METHODS

A low-cost and hand-made model and a high-fidelity model were used to assess the students. The students' knowledge and satisfaction were evaluated using a 10-item checklist and a satisfaction questionnaire, respectively. Medical interns in the present study participated in a two-hour briefing and debriefing session held in the Clinical Skills Training Center by an emergency attending doctor.

RESULTS

Based on the results of data analysis, no significant differences were found between the two groups in terms of gender, age, the month of internship, and last semester's grade (P = .628, .356, .847, and .421, respectively). We also found no significant differences between our groups in terms of the median score of each item in the assessment checklist (P = .838, .736, .805, .172, .439, .823, .243, .950, .812, and .756, respectively). The study groups had no significant difference in the median total scores of the checklist as well (P = .504). Regarding the students' satisfaction, our results showed that interns evaluated their experience of the model as positive (median scores of 4 and 5 out of 5). They also gave the hand-made model a median score of 7 in comparison with the high-fidelity model and 8 out of 10 for its usability.

CONCLUSION

The study results showed that a low-cost model could be as effective as an expensive high-fidelity model for teaching the necessary knowledge of cricothyrotomy techniques to medical trainees.

Comparing the Scalpel-Bougie-Tube Emergency Front-of-Neck Airway (eFONA) Technique on Conventional Manikins and Ovine Larynges: Evaluating Cost, Realism, and Performance in Anaesthetic Trainees

Background Emergency front-of-neck airway (eFONA) is a crucial life-saving procedure in "cannot intubate, cannot oxygenate" (CICO) situations. It is essential to teach and maintain eFONA skills for healthcare providers, especially anesthesiologists. This study aims to assess the effectiveness of cost-effective ovine larynx models compared to conventional manikins in teaching eFONA using the scalpel-bougie-tube technique to a group of anaesthesia novices and newly appointed anaesthetic Fellows. Methods and study design The study was conducted at Walsall Manor Hospital, a district general hospital in the Midlands, UK. Participants underwent a pre-survey to assess familiarity with FONA and the ability to perform a laryngeal handshake. After a lecture and demonstration, participants performed two consecutive emergency cricothyrotomies on both ovine models and conventional manikins, followed by a post-survey to assess their confidence in performing eFONA and rate their experience using sheep larynges. Results The training session significantly improved the participants' ability to perform a laryngeal handshake and their confidence in performing eFONA. The majority of participants rated the ovine model higher in terms of realism, difficulty with penetration, difficulty in recognising landmarks, and difficulty in performing the procedure. Additionally, the ovine model was more cost-effective compared to conventional manikins. Conclusion Ovine models provide a more realistic and cost-effective alternative to conventional manikins for teaching eFONA using the scalpel-bougie-tube technique. The use of these models in routine airway teaching enhances the practical skill set of anaesthesia novices and newly appointed anaesthetists, better preparing them for CICO situations. However, further training with objective assessment methods and larger samples is needed to corroborate these findings.

Technology-enhanced simulation in emergency medicine: Updated systematic review and meta-analysis 1991-2021

Background

Over the past decade, the use of technology-enhanced simulation in emergency medicine (EM) education has grown, yet we still lack a clear understanding of its effectiveness. This systematic review aims to identify and synthesize studies evaluating the comparative effectiveness of technology-enhanced simulation in EM.

Methods

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, Web of Science, and Scopus to identify EM simulation research that compares technology-enhanced simulation with other instructional modalities. Two reviewers screened articles for inclusion and abstracted information on learners, clinical topics, instructional design features, outcomes, cost, and study quality. Standardized mean difference (SMD) effect sizes were pooled using random effects.

Results

We identified 60 studies, enrolling at least 5279 learners. Of these, 23 compared technology-enhanced simulation with another instructional modality (e.g., living humans, lecture, small group), and 37 compared two forms of technology-enhanced simulation. Compared to lecture or small groups, we found simulation to have nonsignificant differences for time skills (SMD 0.33, 95% confidence interval [CI] -0.23 to 0.89, n = 3), but a large, significant effect for non-time skills (SMD 0.82, 95% CI 0.18 to 1.46, n = 8). Comparison of alternative types of technology-enhanced simulation found favorable associations with skills acquisition, of moderate magnitude, for computer-assisted guidance (compared to no computer-assisted guidance), for time skills (SMD 0.50, 95% CI -1.66 to 2.65, n = 2) and non-time skills (SMD 0.57, 95% CI 0.33 to 0.80, n = 6), and for more task repetitions (time skills SMD 1.01, 95% CI 0.16 to 1.86, n = 2) and active participation (compared to observation) for time skills (SMD 0.85, 95% CI 0.25 to 1.45, n = 2) and non-time skills (SMD 0.33 95% CI 0.08 to 0.58, n = 3).

Conclusions

Technology-enhanced simulation is effective for EM learners for skills acquisition. Features such as computer-assisted guidance, repetition, and active learning are associated with greater effectiveness.

Efficacy of a single-day task trainer-based extracorporeal membrane oxygenation training course

Background

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology used to treat respiratory and heart failure. The coronavirus pandemic has resulted in significantly more ECMO patients worldwide. However, the number of hospitals with ECMO capabilities and ECMO-trained staff are limited. Training of personnel in ECMO could supplement this demand.

Objective

To evaluate our previously developed ECMO course using a task trainer-based training, as opposed to an existing live tissue-training model, and determine if such a program was adequate and could be expanded to other facilities.

Methods

Seventeen teams, each consisting of a physician and nurse, underwent a 5 hour accelerated ECMO course in which they watched prerecorded ECMO training lectures, primed circuit, cannulated, initiated ECMO, and corrected common complications. Training success was evaluated via knowledge and confidence assessments and observation of each team attempting to initiate ECMO while troubleshooting complications on a Yorkshire swine.

Results

Seventeen teams successfully completed the course. Sixteen teams (94%, 95% CI = 71%-100%) successfully placed the swine on veno-arterial ECMO. Of those 16 teams, 15 successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments and confidence levels of physicians and nurses increased by 24.3% from pretest (mean of 65.3%, SD 14.4%) to posttest (mean of 89.6%, SD 10.3%), p < 0.0001.

Conclusions

An abbreviated one day lecture and hands-on task trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live tissue training program.

Scoring metrics for assessing skills in arthroscopic rotator cuff repair: performance comparison study of novice and expert surgeons

PURPOSE

We aim to develop quantitative performance metrics and a deep learning model to objectively assess surgery skills between the novice and the expert surgeons for arthroscopic rotator cuff surgery. These proposed metrics can be used to give the surgeon an objective and a quantitative self-assessment platform.

METHODS

Ten shoulder arthroscopic rotator cuff surgeries were performed by two novices, and fourteen were performed by two expert surgeons. These surgeries were statistically analyzed. Two existing evaluation systems: Basic Arthroscopic Knee Skill Scoring System (BAKSSS) and the Arthroscopic Surgical Skill Evaluation Tool (ASSET), were used to validate our proposed metrics. In addition, a deep learning-based model called Automated Arthroscopic Video Evaluation Tool (AAVET) was developed toward automating quantitative assessments.

RESULTS

The results revealed that novice surgeons used surgical tools approximately 10% less effectively and identified and stopped bleeding less swiftly. Our results showed a notable difference in the performance score between the experts and novices, and our metrics successfully identified these at the task level. Moreover, the F1-scores of each class are found as 78%, 87%, and 77% for classifying cases with no-tool, electrocautery, and shaver tool, respectively.

CONCLUSION

We have constructed quantitative metrics that identified differences in the performances of expert and novice surgeons. Our ultimate goal is to validate metrics further and incorporate these into our virtual rotator cuff surgery simulator (ViRCAST), which has been under development. The initial results from AAVET show that the capability of the toolbox can be extended to create a fully automated performance evaluation platform.

Evaluation of a Novel Three-Dimensional Emergency Cricothyrotomy Task Trainer

Background

Emergency cricothyrotomy is a critical, yet infrequently performed and time-sensitive procedure that requires practice in order to be reliably completed in emergent airway situations. Many physicians never have the opportunity to practice this rarely performed but highly impactful procedure during their training due to a lack of an affordable, high-fidelity training model. In this study, the educational impact and realism of a new synthetic cricothyrotomy training model (high-fidelity emergency cricothyrotomy, HiFEC) were compared with those of a standard porcine explant model.

Methodology

A total of thirty-one attending physicians from four medical specialties were recruited on a volunteer basis to participate in a cricothyrotomy simulation workshop. Participants were randomly assigned to complete the initial workshop using one of the two models but had the opportunity to practice on both trainers. Pre- and post-workshop comfort level as well as the realism of the models were surveyed using questionnaires and evaluated using a five-point Likert scale.

Results

Improvements in self-reported comfort levels were seen in both the porcine group (p = 0.0014) and HiFEC group (p = 0.0036) as well as overall (p < 0.001). The realism rating of both training models was similar with a median score of 4 on a five-point Likert scale. When comparing the cost of conducting our workshop using these models, the synthetic model saved over $650.

Conclusions

Given the similar realism of the models and the improvement in participant comfort level, the synthetic HiFEC trainer is an effective and more affordable alternative training model for emergency cricothyrotomies.

High Risk, Low Volume: Evaluation of a Reusable Cricothyrotomy Model in a Paramedic Difficult Airway Training Course

OBJECTIVE

Cricothyrotomy is rarely performed by prehospital providers. Developing this low-frequency, high-acuity skill and maintaining competence is difficult; thus, using a realistic training model is paramount to successful training. The aim of this study was to evaluate a 3-dimensional-printed bleeding cricothyrotomy trainer in increasing paramedic comfort level and procedural competence as defined by completing the procedure unassisted without error.

METHODS

Model implementation took place during mandatory biannual difficult airway training courses for all paramedics employed by a hospital-based ambulance agency. Participating paramedics performed 3 surgical cricothyrotomies using the bleeding trainer and subsequently completed an anonymous written survey that evaluated the comfort level of providers in performing a surgical cricothyrotomy both before and after training using a 10-point visual analog scale.

RESULTS

Forty-four paramedics participated in the difficult airway training course. All (44/44) completed the postsurvey. Participants noted that their procedural skill comfort level improved after the training took place (average improvement of 3 ± 1.93). Participants also indicated that the high-fidelity trainer played a significant role in their increased comfort after skills training.

CONCLUSION

The bleeding cricothyrotomy model evaluated provides a high-fidelity, cost-effective means of teaching and maintaining a rare, lifesaving skill that is rarely performed in the field.

Effectiveness of Surgical Airway Training Laboratory and Assessment of Skill and Knowledge Fade in Surgical Airway Establishment Among Prehospital Providers

OBJECTIVE

This study aimed to evaluate the effectiveness of surgical airway education composed of training using cadavers. The secondary aim was to evaluate the presence and degree of knowledge and skill fade 3 months after training.

METHODS

Thirteen participants were recruited from a helicopter emergency medical services program. Participants were assessed at multiple points during training using a multiple-choice examination and a timed evaluation of the ability to establish a surgical airway.

RESULTS

Training was effective at increasing knowledge and skill, with a mean increase in multiple-choice examination scores of 14.6 percentage points after training (P < .01) and a mean decrease in time to airway establishment of 26 seconds (P < .01). The training was not associated with the ability to establish a surgical airway in less than 40 seconds, with only 46% of participants able to do so. There was no evidence of knowledge or skill fade at 3 months after training.

CONCLUSION

Surgical airway training that includes both didactic and clinical learning using human cadavers is effective at increasing both knowledge and skill. Additional training is needed to establish competency in consistently performing surgical airways in less than 40 seconds. No knowledge or skill fade was present at 3 months after training.

Simulating Surgical Skills in Animals: Systematic Review, Costs & Acceptance Analyses

Background: Modern surgery demands high-quality and reproducibility. Due to new working directives, resident duty hours have been restricted and evidence exists that pure on-the-job training provides insufficient exposure. We hypothesize that supplemental simulations in animal models provide a realistic training to augment clinical experiences. This study reviews surgical training models, their costs and survey results illustrating academic acceptance.

Methods: Animal models were identified by literature research. Costs were analyzed from multiple German and Austrian training programs. A survey on their acceptance was conducted among faculty and medical students.

Results: 915 articles were analyzed, thereof 91 studies described in-vivo animal training models, predominantly for laparoscopy (30%) and microsurgery (24%). Cost-analysis revealed single-training costs between 307€ and 5,861€ depending on model and discipline. Survey results illustrated that 69% of the participants had no experience, but 66% would attend training under experienced supervision. Perceived public acceptance was rated intermediate by medical staff and students (4.26; 1–low, 10 high).

Conclusion: Training in animals is well-established and was rated worth attending in a majority of a representative cohort to acquire key surgical skills, in light of reduced clinical exposure. Animal models may therefore supplement the training of tomorrow's surgeons to overcome limited hands-on experience until virtual simulations can provide such educational tools.

Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures

The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among Surge-Man, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.

Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model

In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartile-range) times to successful airway device placement were 108 (30–256) and 90 (63–188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma.

Multidisciplinary Simulation Training Improves Surgical Resident Comfort With Airway Management

BACKGROUND

Airway management is an essential element of surgical training, but with fewer procedures performed during residency, simulation is crucial to fill educational gaps. We evaluated the effect of a multidisciplinary airway simulation on the comfort of general surgery residents in managing airways.

MATERIALS AND METHODS

All residents PGY 2-5 at a large academic general surgery residency program participated in a multidisciplinary airway management simulation. Precourse surveys evaluated self-perception of skills in three areas of airway management: surgical airway, basic ventilator strategies, and endotracheal intubation. Simulation consisted of didactic and procedural components and used high- and low-fidelity models including silicon airways, ventilators, porcine trachea, and airway adjuncts. Instruction was provided by anesthesia and otolaryngology faculty. Postcourse assessment was performed with a four-level Likert questionnaire. Results were analyzed using paired t-tests.

RESULTS

Of the 19 residents surveyed, 37% of residents had 1-5 h and 32% had 5-10 h of prior airway instruction. Significant increases in mean comfort were observed across all three studied areas. Residents reported increased comfort performing a surgical airway (1.16 versus 1.95), P < 0.0001, and troubleshooting ventilator issues (1.59 versus 2.16), P < 0.0001. Comfort regarding overall airway management including endotracheal intubation demonstrated similar improvement (1.84 versus 2.32), P = 0.02. Subgroup analysis by PGY level showed the greatest impact on comfort level in junior residents.

CONCLUSIONS

Multidisciplinary airway simulation can be effectively implemented in a general surgery training program and positively affect trainee comfort with these techniques, particularly among junior residents.

Comparison of Manikin Versus Porcine Trachea Models When Teaching Emergent Cricothyroidotomy Among Emergency Medicine Residents

OBJECTIVES

Emergent cricothyroidotomy (EC) is a rarely used yet lifesaving procedure that is important for an emergency physician to master throughout his or her training. We evaluated the difference in utilization of a manikin or porcine model among emergency medicine (EM) residents when teaching EC. We also evaluated the difference in the models using two different commonly utilized and taught techniques: "scalpel-finger-bougie" (SFB) technique and the Melker technique (MT).

METHODS

This was a prospective crossover design. Instructions about the procedure were provided; study participants were randomly assigned to one of two groups and performed cricothyrotomy on both manikin and porcine simulators using both the Melker and the SFB techniques. Each group was started with the technique on the second simulator opposite what they started with on the first simulator. After the procedures, study participants completed a questionnaire that used the same format for both groups. All survey questions required a 7-point Likert scale response. Confidence, difficulty, reality of the anatomy, and landmarks were compared.

RESULTS

Fifteen EM residents participated in the study. Compared to the porcine-first group, the manikin-first group rated the anatomy more realistic (question 5) after their first attempt (6.29 vs. 5.87) than their second attempt (using the porcine model; 4.29 vs. 5.62; main effect for attempts [first vs. second] p = 0.027; interaction p = 0.074). Interestingly, the porcine model-first group rated the landmarks (question 6) significantly easier to find in both attempts (6.87 vs. 5.86 on the first attempt and 6.50 vs. 5.57 on the second attempt; p = 0.012). Twelve participants (80%) chose SFB as their preferred technique to use in real-life scenario.

CONCLUSION

The Manikin model tends to be more realistic in cricothyrotomy simulation than the porcine model. The influence of fresh pig skin overlying the porcine model may require further research. Landmark identification during the procedure was easier on both models when participants start with the porcine model. Participants prefer the SFB over MT if faced with a real-life scenario.

Necessity to depict difficult neck anatomy for training of cricothyroidotomy: A pilot study evaluating two surgical devices on a new hybrid training model

BACKGROUND

Everyone dealing with airway emergencies must be able to accomplish cricothyroidotomy, which cannot be trained in real patients. Training models are necessary.

OBJECTIVE

To evaluate the suitability of a hybrid training model combining synthetic and porcine parts to depict variable neck anatomy.

DESIGN

Model-based comparative trial.

SETTING

Armed Forces Hospital Ulm, Germany, August 2018.

INTERVENTION

On four anatomical neck variations (long slim/long obese/short slim/short obese) we performed two surgical approaches to cricothyroidotomy (SurgiCric II vs. ControlCric).

PARTICIPANTS

Forty-eight volunteers divided into two groups based on their personal skill level: beginners group and proficient performers group.

MAIN OUTCOME MEASURES

Time to completion was recorded for each procedure. Once the operator had indicated completion, the correct anatomical tube placement was confirmed by dissection and structures were inspected for complications. Primary outcomes were successful tracheal placement of an airway tube and time needed to achieve a patent airway. Secondary outcome was assessment of complications.

RESULTS

Overall, 384 procedures were performed. Median time to completion was 74 s. In total, 284 procedures (74%) resulted in successful ventilation. Time to completion was longer in short obese than in long slim and the risk of unsuccessful procedures was increased in short obese compared with long slim. Even if ControlCric resulted in faster completion of the procedure, its use was less successful and had an increased risk of complications compared with SurgiCric II. Proficient performers group performed faster but had an increased risk of injuring the tracheal wall compared with beginners group.

CONCLUSION

Participants had difficulties in performing cricothyroidotomy in obese models, but various and difficult anatomical situations must be expected in airway management and therefore must be taught. A new hybrid model combining porcine and synthetic materials offers the necessary conditions for the next step in training of surgical airway procedures.

TRIAL REGISTRATION

The study was performed without human tissue or living animals, and was therefore exempted from ethical review by the University of Ulm Ethical Committee, Germany (Chairperson Prof Dr C. Lenk) on 9 August 2018. Hence a protocol number was not attributed.

The effectiveness of educational methods for cricothyroid membrane identification by dental students: A prospective study using neck photographs and tracheotomy trainers

The purpose of this study was to evaluate the accurate identification of the cricothyroid membrane (CTM) by fifth grade dental students, before undergoing the relevant anesthesiology practicum. Moreover, we aimed to determine the educational effectiveness of the cricothyrotomy practicum in anesthesiology. Before the lecture and without prior notification, 119 students were provided with a photograph of a man's neck and instructed to attach a blue sticker to the cricothyrotomy puncture site and to a palpable tracheotomy trainer, after applying sufficient palpation. After this, students attended a 60-min lecture on the emergency airway management method. Two and 16 days after the lecture and practicum, students were presented with a new neck photograph and the tracheotomy trainer and asked again to place stickers (red stickers: at 2 days; green stickers: at 16 days) on the cricothyrotomy penetration site. The data were analyzed with an image processing software, by superimposing the 119 stickers on the neck photographs and tracheotomy trainers, to visually examine the accuracy of CTM identification. The rate of correct sticker placement in the neck photographs was 41.2% before the lecture, 80.7% 2 days after the lecture, and 77.3% 16 days after the lecture (before vs. 2 and 16 days after, p value < 0.01). For the tracheotomy trainer, the rate was 36.1% before the lecture, 97.5% 2 days after the lecture, and 94.1% 16 days after the lecture (before vs. 2 and 16 days after, p value < 0.01). Furthermore, the proportion of students with mistakes above and below the CTM was higher than that of students with mistakes to the right or left. In conclusion, the rate of accurate CTM identification among dental students was low before they underwent the relevant practicum, but most students were able to identify the CTM accurately after the lecture and practicum in a small class.

A high-fidelity simulator for needle cricothyroidotomy training is not associated with increased proficiency compared with conventional simulators: A randomized controlled study

BACKGROUND

A high-fidelity task simulator for cricothyroidotomy was created using data from a 3-dimensional (3D) computed tomography scan using a 3D printer. We hypothesized that this high-fidelity cricothyroidotomy simulator results in increased proficiency for needle cricothyroidotomy compared with conventional simulators.

METHODS

Cricothyroidotomy-naive residents were recruited and randomly assigned to 2 groups, including simulation training with a conventional simulator (Group C) and with a high-fidelity simulator (Group 3D). After simulation training, participants performed cricothyroidotomy using an ex vivo porcine larynx fitted with an endoscope to record the procedure. The primary outcomes were success rate and procedure time. The secondary outcome was a subjective measure of the similarity of the simulator to the porcine larynx.

RESULTS

Fifty-two residents participated in the study (Group C: n = 27, Group 3D: n = 25). There was no significant difference in the success rate or procedure time between the 2 groups (success rate: P = .24, procedure time: P = .34). There was no significant difference in the similarity of the simulators to the porcine larynx (P = .81).

CONCLUSION

We developed a high-fidelity simulator for cricothyroidotomy from 3D computed tomography data using a 3D printer. This anatomically high-fidelity simulator did not have any advantages compared with conventional dry simulators.

Evaluation of an Innovative Bleeding Cricothyrotomy Model

Objectives

Emergency medicine (EM) residents are required to perform a cricothyrotomy during training as per the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Cricothyrotomy is a rare procedure, comprising 0.45% of emergency department airway management procedures. Procedural competence in utilizing a realistic trainer is of utmost importance. We have developed a cricothyrotomy trainer using a fused deposition modeling (FDM) three-dimensional (3D) printer and innovative bleeding tissue to enhance fidelity. We aim to evaluate the trainer’s realism.

Methods

Implementation occurred during a difficult airway educational lab for EM residents in April 2018. Participants completed anonymous written surveys after performing a cricothyrotomy on the trainer. The survey evaluated the realism of the trainer and compared it to other available models by utilizing five-point visual analog scales (VAS). The participants rated their comfort level in performing the procedure pre- and post-educational lab on a five-point VAS. Demographic data included postgraduate year, prior clinical cricothyrotomy experience as a primary operator versus as an assistant, and previous trainer experience. The survey included open-response suggestions for trainer improvement. 

Results

Forty-three EM residents completed the survey (82.7%, 43/52). The mean realism rating of the trainer was 3.81 (95% CI = 3.54-4.1). The participants reported previous training on cadaver (62.8%, 27/43), porcine (46.5%, 20/43), and manikin (67.4%, 29/43) models prior to using this trainer. The bleeding cricothyrotomy trainer was rated higher than other models (4.45, 95% CI = 4.28-4.63). Participants noted improved comfort with performing the cricothyrotomy after the educational lab (average improvement of 1.23±0.75). Participants specifically commented on the realism of the bleeding and skin texture; however, they also recommended a reduction in the size of the cricothyroid membrane space. 

Conclusion

The innovative bleeding cricothyrotomy trainer has greater fidelity and reported superiority when compared to other commonly used nonbleeding models. This trainer provides a more advanced platform to teach an infrequent yet critical procedural skill to emergency medicine residents.

Percutaneous dilatational tracheostomy using the ETView Tracheoscopic Ventilation Tube®: a teaching course in a pig model

OBJECTIVE

We planned a training course for trainees of different specialties with the aim of teaching the skills of a new procedure for performing percutaneous dilatational tracheostomy (PDT) with an ETView tracheoscopic ventilation tube instead of standard bronchoscopy in an ex vivo pig model.

METHODS

The endotracheal tube, with a camera-embedded tip, was used as an alternative to standard bronchoscopy for visualization of patient airways. The procedure was performed on a home-made animal model. The participants were asked to perform PDT in three different sessions to improve their dexterity. The primary endpoint was the reduction of complications seen during the different sessions of the training course. The secondary endpoint was the satisfaction of the participants as assessed by an anonymous survey.

RESULTS

Thirty-seven residents in anesthesiology and 7 in thoracic surgery in the first 2 years of their training and without any confidence with percutaneous tracheostomy participated in the study. Tracheal cuff lesions and impalement of the tracheal tube were the most observed complications, and were concentrated in the early sessions. A significant reduction in complications and operative time was seen during the ongoing sessions of the course. No lesions of the posterior tracheal wall and only a ring fracture occurred during the last session of the course. All participants were satisfied with the course.

CONCLUSIONS

Our course seems to confer the technical skills to perform percutaneous tracheostomy to trainees and instill confidence with the procedure. However, the experience acquired on a training course should be evaluated in clinical practice.

A porcine model for teaching surgical cricothyridootomy

OBJECTIVE

To evaluate the acceptability of an educational project using A porcine model of airway for teaching surgical cricothyroidotomy to medical students and medical residents at a university hospital in southern Brazil.

METHODS

we developed a teaching project using a porcine model for training in surgical cricothyroidotomy. Medical students and residents received lectures about this surgical technique and then held practical training with the model. After the procedure, all participants filled out a form about the importance of training in airway handling and the model used.

RESULTS

There were 63 participants. The overall quality of the porcine model was estimated at 8.8, while the anatomical correlation between the model and the human anatomy received a mean score of 8.5. The model was unanimously approved and considered useful in teaching the procedure.

CONCLUSION

the training of surgical cricothyroidotomy with a porcine model showed good acceptance among medical students and residents of this institution.

3D force/torque characterization of emergency cricothyroidotomy procedure using an instrumented scalpel

Emergency Cricothyroidotomy (CCT) is a surgical procedure performed to secure a patient's airway. This high-stakes, but seldom-performed procedure is an ideal candidate for a virtual reality simulator to enhance physician training. For the first time, this study characterizes the force/torque characteristics of the cricothyroidotomy procedure, to guide development of a virtual reality CCT simulator for use in medical training. We analyze the upper force and torque thresholds experienced at the human-scalpel interface. We then group individual surgical cuts based on style of cut and cut medium and perform a regression analysis to create two models that allow us to predict the style of cut performed and the cut medium.

"I got it on Ebay!": cost-effective approach to surgical skills laboratories

BACKGROUND

Surgical education is witnessing a surge in the use of simulation. However, implementation of simulation is often cost-prohibitive. Online shopping offers a low budget alternative. The aim of this study was to implement cost-effective skills laboratories and analyze online versus manufacturers' prices to evaluate for savings.

MATERIALS AND METHODS

Four skills laboratories were designed for the surgery clerkship from July 2014 to June 2015. Skills laboratories were implemented using hand-built simulation and instruments purchased online. Trademarked simulation was priced online and instruments priced from a manufacturer. Costs were compiled, and a descriptive cost analysis of online and manufacturers' prices was performed. Learners rated their level of satisfaction for all educational activities, and levels of satisfaction were compared.

RESULTS

A total of 119 third-year medical students participated. Supply lists and costs were compiled for each laboratory. A descriptive cost analysis of online and manufacturers' prices showed online prices were substantially lower than manufacturers, with a per laboratory savings of: $1779.26 (suturing), $1752.52 (chest tube), $2448.52 (anastomosis), and $1891.64 (laparoscopic), resulting in a year 1 savings of $47,285. Mean student satisfaction scores for the skills laboratories were 4.32, with statistical significance compared to live lectures at 2.96 (P < 0.05) and small group activities at 3.67 (P < 0.05).

CONCLUSIONS

A cost-effective approach for implementation of skills laboratories showed substantial savings. By using hand-built simulation boxes and online resources to purchase surgical equipment, surgical educators overcome financial obstacles limiting the use of simulation and provide learning opportunities that medical students perceive as beneficial.

Out-of-Hospital Surgical Airway Management: Does Scope of Practice Equal Actual Practice?

INTRODUCTION

Pennsylvania, among other states, includes surgical airway management, or cricothyrotomy, within the paramedic scope of practice. However, there is scant literature that evaluates paramedic perception of clinical competency in cricothyrotomy. The goal of this project is to assess clinical exposure, education and self-perceived competency of ground paramedics in cricothyrotomy.

METHODS

Eighty-six paramedics employed by four ground emergency medical services agencies completed a 22-question written survey that assessed surgical airway attempts, training, skills verification, and perceptions about procedural competency. Descriptive statistics were used to evaluate responses.

RESULTS

Only 20% (17/86, 95% CI [11-28%]) of paramedics had attempted cricothyrotomy, most (13/17 or 76%, 95% CI [53-90%]) of whom had greater than 10 years experience. Most subjects (63/86 or 73%, 95% CI [64-82%]) did not reply that they are well-trained to perform cricothyrotomy and less than half (34/86 or 40%, 95% CI [30-50%]) felt they could correctly perform cricothyrotomy on their first attempt. Among subjects with five or more years of experience, 39/70 (56%, 95% CI [44-68%]) reported 0-1 hours per year of practical cricothyrotomy training within the last five years. Half of the subjects who were able to recall (40/80, 50% 95% CI [39-61%]) reported having proficiency verification for cricothyrotomy within the past five years.

CONCLUSION

Paramedics surveyed indicated that cricothyrotomy is rarely performed, even among those with years of experience. Many paramedics felt that their training in this area is inadequate and did not feel confident to perform the procedure. Further study to determine whether to modify paramedic scope of practice and/or to develop improved educational and testing methods is warranted.

Teaching project: a low-cost swine model for chest tube insertion training

Objective: to describe and evaluate the acceptance of a low-cost chest tube insertion porcine model in a medical education project in the southwest of Paraná, Brazil. Methods: we developed a low-cost and low technology porcine model for teaching chest tube insertion and used it in a teaching project. Medical trainees - students and residents - received theoretical instructions about the procedure and performed thoracic drainage in this porcine model. After performing the procedure, the participants filled a feedback questionnaire about the proposed experimental model. This study presents the model and analyzes the questionnaire responses. Results: seventy-nine medical trainees used and evaluated the model. The anatomical correlation between the porcine model and human anatomy was considered high and averaged 8.1±1.0 among trainees. All study participants approved the low-cost porcine model for chest tube insertion. Conclusion: the presented low-cost porcine model for chest tube insertion training was feasible and had good acceptability among trainees. This model has potential use as a teaching tool in medical education.

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

BACKGROUND

Trauma procedural and management skills are often learned on live tissue. However, there is increasing pressure to use simulators because their fidelity improves and as ethical concerns increase. We randomized military medical technicians (medics) to training on either simulators or live tissue to learn combat casualty care skills to determine if the choice of modality was associated with differences in skill uptake.

METHODS

Twenty medics were randomized to trauma training using either simulators or live tissue. Medics were trained to perform five combat casualty care tasks (surgical airway, needle decompression, tourniquet application, wound packing, and intraosseous line insertion). We measured skill uptake using a structured assessment tool. The medics also completed exit questionnaires and interviews to determine which modality they preferred.

RESULTS

We found no difference between groups trained with live tissue versus simulators in how they completed each combat casualty care skill. However, we did find that the modality of assessment affected the assessment score. Finally, we found that medics preferred trauma training on live tissue because of the fidelity of tissue handling in live tissue models. However, they also felt that training on simulators also provided additional training value.

CONCLUSION

We found no difference in performance between medics trained on simulators versus live tissue models. Even so, medics preferred live tissue training over simulation. However, more studies are required, and future studies need to address the measurement bias of measuring outcomes in the same model on which the study participants are trained.

LEVEL OF EVIDENCE

Therapeutic/care management study, level II.

A hierarchical task analysis of cricothyroidotomy procedure for a virtual airway skills trainer simulator

BACKGROUND

Despite the critical importance of cricothyroidotomy (CCT) for patient in extremis, clinical experience with CCT is infrequent, and current training tools are inadequate. The long-term goal is to develop a virtual airway skills trainer that requires a thorough task analysis to determine the critical procedural steps, learning metrics, and parameters for assessment.

METHODS

Hierarchical task analysis is performed to describe major tasks and subtasks for CCT. A rubric for performance scoring for each task was derived, and possible operative errors were identified.

RESULTS

Time series analyses for 7 CCT videos were performed with 3 different observers. According to Pearson's correlation tests, 3 of the 7 major tasks had a strong correlation between their task times and performance scores.

CONCLUSIONS

The task analysis forms the core of a proposed virtual CCT simulator, and highlights links between performance time and accuracy when teaching individual surgical steps of the procedure.

Evaluation of a novel Surgicric® cricothyroidotomy device for emergency tracheal access in a porcine model

A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric(®) , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use. The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.

Every surgical resident should know how to perform a cricothyrotomy: an inexpensive cricothyrotomy task trainer for teaching and assessing surgical trainees

OBJECTIVE

Emergency cricothyrotomy is a rare but potentially lifesaving procedure. Training opportunities for surgical residents to learn this skill are limited, and many graduating residents have never performed one during their training. We aimed to develop and validate a novel and inexpensive cricothyrotomy task trainer that can be constructed from household items.

DESIGN

A model was constructed using a toilet paper roll (trachea and larynx), Styrofoam (soft tissue), cardboard (thyroid cartilage), zip tie (cricoid), and fabric (skin). Participants were asked to complete a simulated cricothyrotomy procedure using the model. They were then evaluated using a 10-point checklist (5 points total) devised by 6 general surgeons. Participants were also asked to complete an anonymous survey rating the educational value and the degree of enjoyment regarding the model.

SETTING

A tertiary care teaching hospital.

PARTICIPANTS

A total of 54 students and general surgery residents (11 medical students, 32 interns, and 11 postgraduate year 3 residents).

RESULTS

All 54 participants completed the training and assessment. The scores ranged from 0 to 5. The mean (range) scores were 1.8 (1-4) for medical students, 3.5 (1-5) for junior residents, and 4.9 (4-5) for senior-level residents. Medical students were significantly outperformed by junior- and senior-level residents (p < 0.001). Trainees felt that the model was educational (4.5) and enjoyable (4.0).

CONCLUSIONS

A low-fidelity, low-cost cricothyrotomy simulator distinguished the performance of emergency cricothyrotomy between medical students and junior- and senior-level general surgery residents. This task trainer may be ideally suited to providing basic skills to all physicians in training, especially in settings with limited resources and clinical opportunities.

A home-made animal model in comparison with a standard manikin for teaching percutaneous dilatational tracheostomy

OBJECTIVES

As airway management specialists, thoracic surgeons should be familiar with percutaneous dilatational tracheostomy. To optimize the learning curve, we propose a home-made pig model obtained from a slaughterhouse for training residents in the technical aspects of performing percutaneous dilatational tracheostomy. The satisfaction of the residents' training experience using this model was compared with that using a standard manikin model.

METHODS

Fifty residents participated in the present study. At the end of the session, each participant completed a questionnaire assessing the pig model and the manikin by assigning a score (ranging from 1 to 4) to five specific characteristics including (i) reality of skin turgor; (ii) landmark recognition; (iii) feasibility of the procedure; (iv) reality of the model and (v) preference of each model. The differences between models were statistically analysed.

RESULTS

Forty-five participants completed the study. The pig model, compared with the manikin model, presented a higher value regarding the reality of skin turgor (1.7 ± 0.5 vs 0.4 ± 0.8; respectively, P < 0.0001); landmark recognition (3.8 ± 0.5 vs 2.0 ± 0.5; respectively; P < 0.0001) and reality of the model (3.0 ± 0.8 vs 1.3 ± 1.0; respectively; P < 0.0001). No difference was found regarding the feasibility of the procedure (3.7 ± 0.6 vs 3.5 ± 0.5; respectively, P = 0.1). The pig model was preferred to the manikin (3.2 ± 0.7 vs 1.6 ± 1.0; respectively, P < 0.0001).

CONCLUSIONS

Our pig model allowed residents to develop the skills required for successful percutaneous dilatational tracheostomy. In particular, they developed confidence with certain manoeuvres such as needle and guide-wire placement, dilatation of the trachea and insertion of a cannula, before attempting the procedure on a live patient.

What's your best time? Chronometry in the learning of medical procedures

OBJECTIVES

Most medical procedures have a time element. It is uncommon, however, to explicitly use chronometry, the measurement of time, in the learning of these procedures. This study considered whether instructional designs that include chronometry could improve deliberate practice and be used in meaningful formative assessments.

METHODS

A selective review of the medical education literature was undertaken to identify how chronometry was used in a broad sampling of medical education research in the learning of medical procedures. We identified prior publications in which time measurement was used either directly as a pedagogic intervention or as an assessment method in a medical school programme.

RESULTS

Our review suggests a number of desirable features of chronometry. For the individual learner, procedural time measurements can demonstrate both improving ability and increasing consistency. Chronometry can enhance instructional designs involving deliberate practice by facilitating overlearning (i.e. learning that goes beyond minimum competence), increasing the challenge level and enhancing self-regulation of learning (e.g. self-competition). Breaking down chronometric data into meaningful interval or split times might further inform instructional designs.

CONCLUSIONS

Chronometry has the potential to contribute to instructional designs and assessment methods in medical procedures training. However, more research is needed to elucidate its full potential and describe possible negative consequences of this widely available but underutilised educational tool.

Do we need animal hands-on courses for transplantation surgery?

BACKGROUND

Transplantation surgery requires many years of training. This study evaluates and presents the results of our recent four-yr animal hands-on courses of transplantation surgery on participants' training.

METHODS

Since 2008, five two-d hands-on courses of transplantation surgery were performed on swine models at our department. Sixty-one participants were asked to answer three questionnaires (pre-course, immediate post-course, subsequent post-course). The questions pertained to their past education, expectations, and evaluation of our courses, as well as our course's effectiveness in advancing their surgical abilities. The results were analyzed, compared and are presented herein.

RESULTS

On average, 1.8 multiorgan procurements, 2.3 kidney, 1.5 liver, and 0.7 pancreas transplantations were performed by each participant. 41.7% of participants considered their previous practical training only satisfactory; 85% hoped for more opportunities to practice surgery; 73.3% evaluated our courses as very good; and 95.8% believed that our courses had fulfilled their expectations. 66% found the effectiveness of our course in advancing their surgical abilities very good; 30% good, and 4% satisfactory.

CONCLUSION

Animal hands-on courses of transplantation surgery are one of the best options to learn and practice different operations and techniques in a near to clinical simulated model. Regular participation in such courses with a focus on practical issues can provide optimal opportunities for trainees with the advantage of direct mentoring and feedback.

A comparison of two open surgical cricothyroidotomy techniques by military medics using a cadaver model

STUDY OBJECTIVE

The CricKey is a novel surgical cricothyroidotomy device combining the functions of a tracheal hook, stylet, dilator, and bougie incorporated with a Melker airway cannula. This study compares surgical cricothyroidotomy with standard open surgical versus CricKey technique.

METHODS

This was a prospective crossover study using human cadaveric models. Participants included US Army combat medics credentialed at the emergency medical technician-basic level. After a brief anatomy review and demonstration, participants performed in random order standard open surgical cricothyroidotomy and CricKey surgical cricothyroidotomy. The primary outcome was first-pass success, and the secondary outcome measure was procedural time.

RESULTS

First-attempt success was 100% (15/15) for CricKey surgical cricothyroidotomy and 66% (10/15) for open surgical cricothyroidotomy (odds ratio 16.0; 95% confidence interval 0.8 to 326). Surgical cricothyroidotomy insertion was faster for CricKey than open technique (34 versus 65 seconds; median time difference 28 seconds; 95% confidence interval 16 to 48 seconds).

CONCLUSION

Compared with the standard open surgical cricothyroidotomy technique, military medics demonstrated faster insertion with the CricKey. First-pass success was not significantly different between the techniques.

Comparison of a percutaneous device and the bougie-assisted surgical technique for emergency cricothyrotomy: an experimental study on a porcine model performed by air ambulance anaesthesiologists

Background

A large number of techniques and devices for cricothyroidotomy have been developed. In this study, the Portex™ Cricothyroidotomy Kit (PCK, Smiths Medical Ltd, Hythe, UK) was compared with the bougie assisted emergency surgical cricothyrotomy technique (BACT).

Methods

Twenty air ambulance anaesthesiologists performed emergency cricothyrotomy on a cadaveric porcine airway model using both PCK and BACT. Baseline performance and performance after the intensive training package were recorded. Success rate, time to secured airway and tracheal damage were the primary endpoints, and confidence rating was a secondary endpoint.

Results

During baseline testing, success rates for PCK and BACT were 60% and 95%, respectively. Tracheal injury rate with PCK was 60% while no such injury was found in BACT. A lecture was given and skills were trained until the participants were able to perform five consecutive successful procedures with both techniques. In the post-training test, all participants were successful with either technique. The mean time to successful insertion was reduced by 15.7 seconds (from 36.3 seconds to 20.6 seconds, p< 0.001) for PCK and by 7.8 seconds (from 44.9 seconds to 37.1 seconds, p=0.021) for BACT. In the post-training scenario, securing the airway with PCK was significantly faster than with BACT (p<0.001). Post-training tracheal laceration occurred in six (30%) of the PCK procedures and in none of the BACT procedures (p=0.028).

The self-evaluated confidence level was measured both pre- and post-training using a confidence scale with 10 indicating maximum amount of confidence. The median values increased from 4 to 8 for PCK and from 6.5 to 9.5 for BACT. All participants reported that BACT was their preferred technique.

Conclusions

Testing the base-line PCK skills of prehospital anaesthesiologists revealed low confidence, sub-optimal performance and a very high failure rate. The BACT technique demonstrated a significantly higher success rate and no tracheal damage. In spite of PCK being a significantly faster technique in the post-training test, the anaesthesiologists still reported a higher confidence in BACT. Limitations of the cadaveric porcine airway may have influenced this study because the airway did not challenge the clinicians with realistic tissue bleeding.

Technology-enhanced simulation in emergency medicine: a systematic review and meta-analysis

OBJECTIVES

Technology-enhanced simulation is used frequently in emergency medicine (EM) training programs. Evidence for its effectiveness, however, remains unclear. The objective of this study was to evaluate the effectiveness of technology-enhanced simulation for training in EM and identify instructional design features associated with improved outcomes by conducting a systematic review.

METHODS

The authors systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Original research articles in any language were selected if they compared simulation to no intervention or another educational activity for the purposes of training EM health professionals (including student and practicing physicians, midlevel providers, nurses, and prehospital providers). Reviewers evaluated study quality and abstracted information on learners, instructional design (curricular integration, feedback, repetitive practice, mastery learning), and outcomes.

RESULTS

From a collection of 10,903 articles, 85 eligible studies enrolling 6,099 EM learners were identified. Of these, 56 studies compared simulation to no intervention, 12 compared simulation with another form of instruction, and 19 compared two forms of simulation. Effect sizes were pooled using a random-effects model. Heterogeneity among these studies was large (I(2) ≥ 50%). Among studies comparing simulation to no intervention, pooled effect sizes were large (range = 1.13 to 1.48) for knowledge, time, and skills and small to moderate for behaviors with patients (0.62) and patient effects (0.43; all p < 0.02 except patient effects p = 0.12). Among comparisons between simulation and other forms of instruction, the pooled effect sizes were small (≤ 0.33) for knowledge, time, and process skills (all p > 0.1). Qualitative comparisons of different simulation curricula are limited, although feedback, mastery learning, and higher fidelity were associated with improved learning outcomes.

CONCLUSIONS

Technology-enhanced simulation for EM learners is associated with moderate or large favorable effects in comparison with no intervention and generally small and nonsignificant benefits in comparison with other instruction. Future research should investigate the features that lead to effective simulation-based instructional design.

Emergency cricothyroidotomy: a randomized crossover trial comparing percutaneous techniques: classic needle first versus "incision first"

OBJECTIVES

Emergency cricothyroidotomy is potentially lifesaving in patients with airway compromise who cannot be intubated or ventilated by conventional means. The literature remains divided on the best insertion technique, namely, the open/surgical and percutaneous methods. The two are not mutually exclusive, and the study hypothesis was that an "incision-first" modification (IF) may improve the traditional needle-first (NF) percutaneous approach. This study assessed the IF technique compared to the NF method.

METHODS

A randomized controlled crossover design with concealed allocation was completed for 180 simulated tracheal models. Attending and resident emergency physicians were enrolled. The primary outcome was time to successful cannulation; secondary outcomes included needle insertion(s), incision, and dilatation attempts. Finally, proportions of intratracheal insertion on the first attempt and subjective ease of insertion were compared.

RESULTS

  The IF technique was significantly faster than the standard NF technique (median = 53 seconds, interquartile range [IQR] = 45.0 to 86.4 seconds vs. median = 90 seconds, IQR = 55.2 to 108.6 seconds; p < 0.001). The median number of needle insertions was significantly higher for the NF technique (p = 0.018); there was no significant difference in dilation or incision attempts. Intratracheal insertion on the first attempt was documented in 90 and 93% of the NF and IF techniques, respectively (p = 0.317). All the study participants found the IF hybrid approach easier.

CONCLUSIONS

The IF modification allows faster access, fewer complications, and more favorable clinician endorsement than the classic NF percutaneous technique in a validated model of cricothyroidotomy. We suggest therefore that the IF technique be considered as an improved method for insertion of an emergency cricothyroidotomy.

Cost: the missing outcome in simulation-based medical education research: a systematic review

BACKGROUND

The costs involved with technology-enhanced simulation remain unknown. Appraising the value of simulation-based medical education (SBME) requires complete accounting and reporting of cost. We sought to summarize the quantity and quality of studies that contain an economic analysis of SBME for the training of health professions learners.

METHODS

We performed a systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Articles reporting original research in any language evaluating the cost of simulation, in comparison with nonstimulation instruction or another simulation intervention, for training practicing and student physicians, nurses, and other health professionals were selected. Reviewers working in duplicate evaluated study quality and abstracted information on learners, instructional design, cost elements, and outcomes.

RESULTS

From a pool of 10,903 articles we identified 967 comparative studies. Of these, 59 studies (6.1%) reported any cost elements and 15 (1.6%) provided information on cost compared with another instructional approach. We identified 11 cost components reported, most often the cost of the simulator (n = 42 studies; 71%) and training materials (n = 21; 36%). Ten potential cost components were never reported. The median number of cost components reported per study was 2 (range, 1-9). Only 12 studies (20%) reported cost in the Results section; most reported it in the Discussion (n = 34; 58%).

CONCLUSION

Cost reporting in SBME research is infrequent and incomplete. We propose a comprehensive model for accounting and reporting costs in SBME.

Emergency cricothyroidotomy performed by inexperienced clinicians--surgical technique versus indicator-guided puncture technique

Background

To improve the ease and safety of cricothyroidotomy especially in the hand of the inexperienced, new instruments have been developed. In this study, we compared a new indicator-guided puncture technique (PCK) with standard surgical technique (ST) regarding success rate, performance time and complications.

Methods

Cricothyroidotomy in 30 human cadavers performed by 30 first year anaesthesia residents. The set chosen for use was randomised: PCK-technique (n=15) and ST (n=15). Success rates, insertion times and complications were compared. Traumatic lesions were anatomically confirmed after dissection.

Results

The ST-group had a higher success rate (100% vs 67%; p=0.04). There was no difference in time taken to complete the procedure (PCK 82 s. vs ST 95 s.; p=0.89). There was a higher complication rate in the PCK-group (67% vs 13%; p=0.04). Most frequent complication in the PCK-group was injury to the posterior tracheal wall (n=8), penetration to the oesophageal lumen (n=4) and injury to the thyroid and/or cricoid cartilage (n=5). In the ST-group in only 2 cases minor complications were observed (small vessel injury).

Conclusions

In this human cadaver study the PCK technique produced more major complications and more failures than the ST. In the hand of the inexperienced operator the standard surgical approach seems to be a safe procedure, which can successfully be performed within an adequate time. The PCK technique cannot be recommended for inexperienced operators.

Preliminary Development and Engineering Evaluation of a Novel Cricothyrotomy Device

Cricothyrotomy is one of the procedures used to ventilate patients with upper airway blockage. This paper examines the most regularly used and preferred cricothyrotomy devices on the market, suggests critical design specifications for improving cricothyrotomy devices, introduces a new cricothyrotomy device, and performs an engineering evaluation of the device’s critical components. Through a review of literature, manufacturer products, and patents, four principal cricothyrotomy devices currently in clinical use were identified. From the review, the Cook™ Melker device is the preferred method of clinicians but the device has acknowledged problems. A new emergency needle cricothyrotomy device (ENCD) was developed to address all design specifications identified in literature. Engineering, theoretical, and experimental assessments were performed. In situ evaluations of a prototype of the new device using porcine specimens to assess insertion, extraction, and cyclic force capabilities were performed. The device was very successful in its evaluation. Further discussion focuses on these aspects and a comparison of the new device with established devices. The proposed emergency needle cricothyrotomy device performed very well. Further work will be pursued in the future with in-vitro and in-vivo with canine models demonstrates the capabilities of the ENCD.