Construction and Evaluation of a Realistic Low-Cost Model for Training in Chest-Tube Insertion

INTRODUCTION

Emergency thoracostomy is applied in life-threatening situations. Simulation plays a pivotal role in training in invasive techniques used mainly in stressful situations. Currently available commercial simulation models for thoracostomy have various drawbacks.

METHODS

We designed a thoracostomy phantom from discarded hospital materials and pigskin with underlying flesh. The phantom can be used alone for developing technical skills or mounted on an actor in simulation scenarios. Medical students, intensive care unit (ICU) and emergency department teams, and thoracostomy experts evaluated its technical fidelity and usefulness for achieving learning objectives in workshops.

RESULTS

The materials used to construct the phantom cost €47. A total of 12 experts in chest-tube placement and 73 workshop participants (12 ICU physicians and nurses, 20 emergency physicians and nurses, and 41 fourth-year medical students) evaluated the model. All groups rated the model's usefulness and the sensation of perforating the pleura highly. Experts rated the air release after pleura perforation lower than other groups. Lung reexpansion was the lowest rated item in all groups. Ratings of the appearance and feel of the model correlated strongly among all groups and experts. The ICU professionals rated the resistance encountered in introducing the chest drain lower than the other groups.

CONCLUSIONS

This low-cost, reusable, transportable, and highly realistic model is an attractive alternative to commercial models for training in chest-tube insertion skills.

A novel simulation model for tube thoracostomy

Objective

Tube thoracostomy is a life-saving procedure that must be performed competently and expeditiously by emergency care providers. The primary objective of this project was to develop a simple, easily-reproducible, and realistic simulation model for tube thoracostomy placement by learners of emergency medicine.

Methods

This chest tube simulator utilizes two slabs of pork ribs with associated intercostal muscle and fascial planes to aid learners in identifying anatomic landmarks, palpating intercostal spaces, and performing blunt dissection in a manner that approximates human anatomy. Holes are cut on both sides of a 1.8-bushel capacity rectangular plastic clothing hamper, and rib slabs are secured to the hamper with zip ties or metal wire. A bed pillow with plastic cover is then placed inside of the plastic hamper to simulate lung tissue. The rib-hamper complex is then wrapped with cellophane or elastic compression bandages to further anchor the rib slabs and simulate skin and subcutaneous tissues.

Results

The initial cost of our thoracostomy model is approximately $50, much less than the $1,000-$3,000 cost for a commercial model. Although the hamper and pillow can be reused an indefinite number of times, the other components of our model must be replaced occasionally. Assuming a lifespan of 1,000 uses, our model costs approximately $1.78 per attempt, compared to $4.00 per attempt with the cheapest commercial mannequin system. In fact, assuming a longer useful lifespan for the mannequin does not substantially improve this comparison (e.g. $3.10 versus $1.77 per attempt for a 10,000 attempt lifespan for the commercial mannequin), largely due to the higher cost of commercial replacement skin pads when compared to the components consumed in our model with each attempt.

Conclusions

We describe a porcine thoracostomy model that simulates the look and feel of human ribs for purposes of tube thoracostomy training, although it could also be used for thoracentesis and thoracotomy simulation. This model is relatively cheap (costing around $50) and easy to produce within a few minutes utilizing commonly-available materials. Further study is needed to determine whether an inexpensive model like ours provides the same educational value as more expensive commercial mannequin models.

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.

Technology-enhanced trauma training in low-resource settings: A scoping review and feasibility analysis of educational technologies

BACKGROUND

Lack of training contributes to the burden of trauma-related mortality and morbidity in low- and lower-middle-income countries (LMICs). Educational technologies present a unique opportunity to enhance the quality of trauma training. Therefore, this study reviews current technologies used in trauma courses and evaluates their feasibility for LMICs.

METHODS

We conducted a scoping review evaluating the learning outcomes of technology-enhanced training in general trauma assessment, team skills or any procedures covered in the 2020 Advanced Trauma Life Support® program. Based on the Technology-Enhanced Learning criteria, we created and applied a feasibility analysis tool to evaluate the technologies for use in LMICs.

RESULTS

We screened 6471 articles and included 64. Thirty-four (45%) articles explored training in general trauma assessment, 28 (37%) in team skills, and 24 (32%) in procedures. The most common technologies were high-fidelity mannequins (60%), video-assisted debriefing (19%), and low-fidelity mannequins (13%). Despite their effectiveness, high-fidelity mannequins ranked poorly in production, maintenance, cost, and reusability categories, therefore being poorly suited for LMICs. Virtual simulation and digital courses had the best feasibility scores, but still represented a minority of articles in our review.

CONCLUSION

To our knowledge, this is the first study to perform a feasibility analysis of trauma training technologies in the LMIC context. We identified that the majority of trauma courses in the literature use technologies which are less suitable for LMICs. Given the urgent need for pediatric trauma training, educators must use technologies that optimize learning outcomes and remain feasible for low-resource settings.

LEVEL OF EVIDENCE

IV.

Simulator Fidelity Does Not Affect Training for Robot-Assisted Minimally Invasive Surgery

This study was undertaken to compare performance using a surgical robot after training with one of three simulators of varying fidelity. Methods: Eight novice operators and eight expert surgeons were randomly assigned to one of three simulators. Each participant performed two exercises using a simulator and then using a surgical robot. The primary outcome of this study is performance assessed by time and GEARS score. Results: Participants were randomly assigned to one of three simulators. Time to perform the suturing exercise (novices vs. experts) was significantly different for all 3 simulators. Using the da Vinci robot, peg transfer showed no significant difference between novices and experts and all participants combined (mean time novice 2.00, expert 2.21, p = 0.920). The suture exercise had significant differences in each group and all participants combined (novice 3.54, expert 1.90, p = 0.001). ANOVA showed p-Values for suturing (novice 0.523, expert 0.123) and peg transfer (novice 0.742, expert 0.131) are not significantly different. GEARS scores were different (p < 0.05) for novices and experts. Conclusion: Training with simulators of varying fidelity result in similar performance using the da Vinci robot. A dry box simulator may be as effective as a virtual reality simulator for training. Further studies are needed to validate these results.

Evolution of Medical Students' Perception of the Patient's Right to Privacy

During clinical rotations, medical students experience situations in which the patients' right to privacy may be violated. The aim of this study is to analyze medical students' perception of clinical situations that affect patients' right to privacy, and to look for the influential factors that may contribute to the infringement on their rights, such as the students' age, sex, academic year or parents' educational level. A cross-sectional study was conducted with a survey via "Google Drive". It consisted of 16 questions about personal information, 24 questions about their experience when rotating and 21 questions about their opinion concerning several situations related to the right to privacy. A total of 129 medical students from various Spanish medical schools participated. Only 31% of 3rd-6th year students declared having signed a confidentiality agreement when starting their clinical practice, and most students (52%) reported that doctors "sometimes", "rarely" or "never" introduce themselves and the students when entering the patients' rooms. Additionally, about 50% of all students reported that they would take a picture of a patient's hospitalization report without his/her (consent), which would be useful for an assignment. Important mistakes during medical students' rotations have been observed, as well as a general lack of knowledge regarding patient's right to privacy among Spanish medical students. Men and older students showed better knowledge of current legislation, as well as those whose parents were both university-educated and those in higher academic years.

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.

Trauma surgery simulation education in Japan: the Advanced Trauma Operative Management course

Simulation has become an important teaching tool, in part because of changes mandated by restrictions in resident work hours. Simulation models include life‐like mannequins, ex vivo tissue, cadavers, and live animal models. The Advanced Trauma Operative Management (ATOM) course teaches a standard approach for the treatment of traumatic injuries. The 1‐day course includes six lectures in the morning and a live animal surgery laboratory in the afternoon. The animal laboratory includes five standard injury scenarios. Advanced Trauma Operative Management was brought to Japan in 2008 and has carried out 60 courses, training more than 250 surgeons and 70 instructors at six training sites throughout Japan. There have been a number of innovations initiated by ATOM Japan including Nurse Participation Certificates and a course for Trauma Nurses that runs concurrently with the ATOM course. There are other trauma courses given throughout the world, which are scenario‐based and include concurrent nurse training. It is difficult to quantitatively assess the benefits of trauma training to patients. There are a number of documented cases in Japan of surgeons who have had good operative outcomes in the care of traumatically injured patients who attribute the successful management of these patients to participation in the ATOM course. Training in trauma surgery using simulation models and the ATOM course have had a positive impact on surgical training and patient care in Japan. These courses will continue to be modified and refined, resulting in better education and clinical outcomes. Education research is essential to determine the optimum use of the available models.

Swine used in the medical university: overview of 20 years of experience

Center for Development of Advanced Medical Technology (CDAMTec) in Jichi Medical University was established in 2009. It is the first educational research facility specialized for medical research and training using swine in Japan. Preclinical studies on large animals are essential prior to clinical trials to develop regenerative medical products and medical equipment. We have continued comprehensively considering using miniature swine for experiments to develop advanced medical technologies and train physicians with advanced clinical abilities, while paying attention to animal welfare. The center plays a pioneering role in this field by accumulating know-how such as (1) Construction and effective utilization of research facilities, (2) Procurement of quality animal resources, (3) Education and training of technical staff, (4) Establishment of support system for physicians and researchers. We now open up widely these expertise and foundation for medical research and training not only within our university but also outside the university, so as to move faster to practical use of advanced medical technology and contribute to human health and welfare.

Perceptions on the Impact of a Just-in-Time Room on Trainees and Supervising Physicians in a Pediatric Emergency Department

BACKGROUND

Just-in-time (JIT) training refers to education occurring immediately prior to clinical encounters. An in situ JIT room in a pediatric emergency department (ED) was created for procedural education.

OBJECTIVE

We examined trainee self-reported JIT room use, its impact on trainee self-perception of procedural competence/confidence, and the effect its usage has on the need for intervention by supervising physicians during procedures.

METHODS

Cross-sectional survey study of a convenience sample of residents rotating through the ED and supervising pediatric emergency medicine physicians. Outcomes included JIT room use, trainee procedural confidence, and frequency of supervisor intervention during procedures.

RESULTS

Thirty-one of 32 supervising physicians (97%) and 122 of 186 residents (66%) completed the survey, with 71% of trainees reporting improved confidence, and 68% reporting improved procedural skills (P < .05, +1.4-point average skills improvement on a 5-point Likert scale). Trainees perceived no difference among supervising physicians intervening in procedures with or without JIT room use (P = .30, paired difference -0.0 points). Nearly all supervisors reported improved trainee procedural confidence, and 77% reported improved trainee procedural skills after JIT room use (P < .05, paired difference +1.8 points); 58% of supervisors stated they intervene in procedures without trainee JIT room use, compared with 42% with JIT room use (P < .05, paired difference -0.4 points).

CONCLUSIONS

Use of the JIT room led to improved trainee confidence and supervisor reports of less procedural intervention. Although it carries financial and time costs, an in situ JIT room may be important for convenient JIT training.

Impact of simulation-based training in surgical chest tube insertion on a model of traumatic pneumothorax

Background

Chest tube insertion is required for most cases of traumatic pneumothorax. However, this procedure entails risks of potentially life-threatening complications. A "surgical" approach is widely recommended to minimize these risks. Simulation-based education has previously been used in surgical chest tube insertion, but not been subjected to rigorous evaluation.

Methods

The primary objective was to evaluate the success rate of surgical chest tube insertion in a task trainer (previously published). Secondary objectives were to assess performance with a performance assessment scale (previously designed), to measure the time of insertion, and to seek out a correlation between the learner's status, experience, and performance and success rate. Participants were surveyed for realism of the model and satisfaction; 65 participants (18 residents, 47 senior physicians) were randomized into SIM+ or SIM- groups. Both groups received didactic lessons. The SIM+ group was assigned deliberate practice on the model under supervision. Both groups were assessed on the model 1 month later.

Results

There was no difference between the SIM+ (n = 34) and SIM- (n = 31) groups regarding status (p = 0.44) or previous surgical insertion (p = 0.12). Success rate was 97 % (SIM+) and 58 % (SIM-), p = 0.0002. Performance score was 16.29 ± 1.82 (SIM+) and 11.39 ± 3.67 (SIM-), p = 3.13 × 10^-8. SIM+ presented shorter dissection time than SIM- (p = 0.047), but procedure time was similar (p = 0.71). Status or experience was not correlated with success rate, performance score, procedure time, or dissection time. SIM+ gained more self-confidence, judged the model more realistic, and were more satisfied than SIM-.

Conclusions

Simulation-based education significantly improved the success rate and performance of surgical chest tube insertion on a traumatic pneumothorax model.

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.

Objective Comparison of Animal Training Versus Artificial Simulation for Initial Cricothyroidotomy Training

This manuscript aims to determine if there is a difference in performance outcomes after initial training with either animals or simulators. Volunteers without prior experience performing emergency procedures were randomly assigned to receive training in cricothyroidotomy on either a pig model or on an artificial simulator. Volunteers were given identical lectures and trained to proficiency. Two weeks after training, trainees were tested using human cadavers as to their performance with time, incision size, incision start location, initial placement attempt, and final accuracy. Overall success rate of the animal-trained group was 64 per cent and in the artificial simulator group, 73 per cent ( P = 0.431). Median time to completion in the animal group and artificial simulator group was 143 s and 105 s ( P = 0.482), and incision lengths 4.0 cm and 3.2 cm ( P = 0.173), respectively. Accuracy of initially attempted incision placement and final cricothyroidotomy tube placement was also compared. Initially attempted site accuracy in the animal-trained group was 93 per cent and correct final position 79 per cent, and in the artificial group, 100 per cent ( P = 0.452) and 88 per cent ( P = 0.782), respectively. There was no statistically significant, objective difference in any metric between animal- and simulator-trained groups after cricothyroidotomy training. For initial training, there is no objective benefit of animal training.

Enhancing residents' neonatal resuscitation competency through unannounced simulation-based training

BACKGROUND

Almost half of pediatric third-year residents surveyed in 2000 had never led a resuscitation event. With increasing restrictions on residency work hours and a decline in patient volume in some hospitals, there is potential for fewer opportunities.

PURPOSE

Our primary purpose was to test the hypothesis that an unannounced mock resuscitation in a high-fidelity in-situ simulation training program would improve both residents' self-confidence and observed performance of adopted best practices in neonatal resuscitation.

METHODS

Each pediatric and medicine-pediatric resident in one pediatric residency program responded to an unannounced scenario that required resuscitation of the high fidelity infant simulator. Structured debriefing followed in the same setting, and a second cycle of scenario response and debriefing occurred before ending the 1-hour training experience. Measures included pre- and post-program confidence questionnaires and trained observer assessments of live and videotaped performances.

RESULTS

Statistically significant pre-post gains for self-confidence were observed for 8 of the 14 NRP critical behaviors (p=0.00-0.03) reflecting knowledge, technical, and non-technical (teamwork) skills. The pre-post gain in overall confidence score was statistically significant (p=0.00). With a maximum possible assessment score of 41, the average pre-post gain was 8.28 and statistically significant (p<0.001). Results of the video-based assessments revealed statistically significant performance gains (p<0.0001). Correlation between live and video-based assessments were strong for pre-post training scenario performances (pre: r=0.64, p<0.0001; post: r=0.75, p<0.0001).

CONCLUSIONS

Results revealed high receptivity to in-situ, simulation-based training and significant positive gains in confidence and observed competency-related abilities. Results support the potential for other applications in residency and continuing education.

The pig as a model for translational research: overview of porcine animal models at Jichi Medical University

To improve the welfare of experimental animals, investigators seek to respect the 3R principle (Replacement, Reduction, and Refinement). Even when large animal studies are essential before moving to clinical trials, it is important to look for ways to reduce the number of experimental animals used. At the Center for the Development of Advanced Medical Technology, we consider ‘medical’ pigs to be ideal preclinical model systems.

We have been using both wild-type and genetically modified pigs. We began using this approach about 10 years ago with a ‘total pig system’ to model human health and disease for the purposes of both medical skill education and the development of new devices and therapeutic strategies.

At our Center, medical students and residents use pigs to gain experience with surgical skills and train for emergency procedures after appropriate simulation training. Senior clinicians have also used these models to advance the development of innovative tools for endo- and laparoscopic procedures. The Center focuses on translational research for organ transplantation and stem cell therapy. Several pig models have been established for liver, intestine, kidney, pancreas, and lung transplantation. Mesenchymal stromal cells have been established in green fluorescent protein- and red fluorescent protein-transgenic pigs and tested to trans-differentiate organogenesis. A program to establish induced pluripotent stem cells in the pig is ongoing at our Center.

Here, we review our 10 years of activity in this field. Based on our experience in surgical education and research, experimental pigs are valuable models in translational research.

Ex-vivo porcine organs with a circulation pump are effective for teaching hemostatic skills

Surgical residents have insufficient opportunites to learn basic hemostatic skills from clinical experience alone. We designed an ex-vivo training system using porcine organs and a circulation pump to teach hemostatic skills. Residents were surveyed before and after the training and showed significant improvement in their self-confidence (1.83 ± 1.05 vs 3.33 ± 0.87, P < 0.01) on a 5 point Likert scale. This training may be effective to educate residents in basic hemostatic skills.

Randomized Objective Comparison of Live Tissue Training versus Simulators for Emergency Procedures

There is a lack of objective analysis comparing live tissue and simulator training. This article aims to objectively determine the difference in outcomes. Twenty-four Air Force volunteers without prior experience performing emergency procedures were randomly assigned to receive training in tube thoracostomy (chest tube) and cricothyroidotomy training on either a pig model (Sus scrofa domestica) or on the TraumaMan simulator. One week posttraining, students were tested on human cadavers with objective and subjective results recorded. Average completion time for tube thoracostomy in the animal model group was 2 minutes 4 seconds and 1 minute 51 seconds in the simulator group with a mean difference of 12 seconds ( P = 0.74). Average completion time for cricothyroidotomy in the animal model group was 2 minutes 35 seconds and 3 minutes 29 seconds in the simulator group with a mean difference of 53 seconds ( P = 0.32). Overall confidence was 9 per cent higher in the animal trained group ( P = 0.42). Success rate of cricothyroidotomy was 75 per cent in the animal model group and 58 per cent in the simulator-trained group ( P = 0.67). Success rate of chest tube placement was 92 per cent in the animal group and 83 per cent in the simulator group ( P = 1.00). There was no statistically significant difference in chest tube and cricothyroidotomy outcomes or confidence in the groups trained with live animal models or simulators at the 95 per cent confidence interval. Trends suggest a possible difference, but the number of cadavers required to reach greater than 95 per cent statistical confidence prohibited continuation of the study.