A model to teach trauma care to medical students

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Training in polytrauma management in medical curricula: A scoping review

INTRODUCTION

Polytrauma (PT) is a leading cause of morbidity and mortality worldwide. However, it is unknown if PT teaching is taught or adequately included in undergraduate medical curricula. We conducted this scoping review to explore the literature on undergraduate PT training.

METHODS

Using Arksey and O'Malley's five stage framework, a scoping review was conducted. Nine medical and educational databases, including PubMed, MEDLINE, Scopus, CINAHL, PsycINFO, and EMBASE were searched using keywords identified by the authors. Eligible studies were limited to the English language, with no set limitations on the year of publication. Studies reporting on PT teaching in undergraduate medical curricula were included.

RESULTS

Nine studies were included. The articles were sub-categorised into three themes: current teaching of PT in medical curricula, trauma management courses and simulation-based trauma education. Four out of five studies on PT teaching in the curriculum were rated as inadequate by current or past students; on the other hand, three out of four trauma management/simulation courses were evaluated and all three were rated positively by students. Three trauma management courses compared students pre- and post-course scores on a written or practical test and reported significant improvement in post-course scores.

CONCLUSIONS

There is a relative paucity of literature on undergraduate PT training. There is a need for more research to explore how to deliver effective PT teaching to medical students.

Competency-based learning in traumatology

BACKGROUND

A multidisciplinary, competency-based trauma teaching program was introduced for final year medical students (n = 67) at Royal Prince Alfred Hospital (RPAH) in 1994 to complement the surgical clerkship.

METHODS

The method involved small groups rotating through a series of teaching stations each structured to address a predetermined competency. Four 3-hour sessions were held on the subject areas of resuscitation, plastic, orthopedic, and neurotrauma. Performance in the trauma section of a summative Objective Structured Clinical Examination (OSCE), 6 months after the teaching, was compared with that of a control group (n = 127) from other campuses where trauma was taught by a series of discipline-based lectures. Three trauma OSCE stations were designed to test psychomotor skills while five addressed aspects of the cognitive domain. Checklists were used to ensure standardization of scoring in a range of questions asked for skills tested at each station.

RESULTS

The marks of the RPAH students (mean 78% +/- SD 9%) were significantly higher (P < 0.0005) than the controls (mean 70% +/- SD 9%) in the 8 trauma questions. There was no significant difference (P = 0.8) in marks obtained by the study group (mean 61% +/- SD 8%) and controls (mean 63% +/- SD 7%) in 22 questions sampling a wide spectrum of nontrauma subject areas. The study group performed significantly better in one of the three skills stations and three of the five problem-solving stations when compared with the control group.

CONCLUSION

The innovation has the potential to fulfill a need for an integrated trauma program in the undergraduate core curriculum.

A chi-square automatic interaction detection (CHAID) analysis of factors determining trauma outcomes

OBJECTIVE

Analysis of variables predictive of trauma outcome by the CHAID (chi-square automatic interaction detection) statistical program.

DESIGN

Retrospective analysis of a prospectively maintained trauma database.

METHODS

The study group consisted of 607 primary ambulance retrievals to Royal Prince Alfred Hospital, Sydney, for the period of 6 fiscal years (1990-1996) with major injury (Injury Severity Score > 15).

MAIN RESULTS

The overall mortality fell from 26.6 to 16% (chi 2 test = 14.7, p = 0.01) during the study period. The emergency room Glasgow Coma Scale (GCS) score (preresuscitation) was the strongest predictor of death or survival. CHAID segmented the study group into three categories based on GCS scores (¿3¿, ¿4-12¿, and ¿13-15¿), each with significantly different outcome predictability. The mortality rate in those with a GCS score of 3 (n = 89) was 67%. Systolic blood pressure was the strongest predictor of outcome in this subset. The mortality in those with GCS score of 4-12 (n = 160) was 18%. Injury Severity Score was the strongest predictor in this subset. The mortality rate in those with GCS score of 13-15 was 5%. Age was the strongest predictor in this group.

CONCLUSION

The CHAID-generated flowchart has proved useful in this pilot study to analyze the interrelation between variables predictive of outcome in an Australian urban trauma population.

Competency-based learning in neonatology

An educational model integrating structured teaching with clinical experience, or clerkship, has been designed to enable students to learn the core knowledge, skills and attitudes necessary to care for the newborn. The programme is run for fifth year medical students as part of four, 9-week periods in Obstetrics and Gynaecology each year. A SCORPIO teaching session is held in week 1 to introduce students to the core competencies in the subject areas of newborn examination, breastfeeding, resuscitation, respiratory distress and anthropometry. Groups of four students rotate through each topic, which is conducted by a neonatologist or registrar in training. Eight problem-based learning sessions are held during weeks 2-9. Several students assess a clinical problem, identify learning issues and meet colleagues and a facilitator to share their learning experiences and resolve the problem. The clinical experience, or clerkship, is based in the neonatal nursery where 2-3 students spend a week consolidating their clinical and procedural skills. A study group was assessed at the end of the programme by an Objective Structured Clinical Examination (OSCE) and a Multiple Choice Questionnaire (MCQ). A control group did the same assessment in week 1. All students were asked to rate the educational value of the three learning methods on a 5-point Likert scale. The study group (n = 20) achieved a mean composite mark of 66% (SD 10%). This was significantly higher (P < 0.001) than that of the control group (n = 18), mean 45% (SD 7%). All students (100%) rated the educational value of SCORPIO as high or very high, and the comparative rating for problem-based learning and clerkship was 65%, respectively. The programme was enthusiastically received by the students and resulted in mastery of a range of core competencies necessary for care of the newborn.

Outcome of patients with neurotrauma: the effect of a regionalized trauma system

A system of regionalized trauma care was introduced to Sydney in early 1992. This study was carried out to assess the effect of regionalization on the outcome of patients suffering major head injury within the central Sydney area. A prospective before and after study extending over 3 years and centred on the time of designation of Royal Prince Alfred Hospital (RPAH) as a trauma centre, was the methodology used. The study group consisted of all patients admitted with head injury (Glasgow Coma Score < 9; admission systolic blood pressure > 90 mmHg; Injury Severity Score > 15) to RPAH from the central Sydney area. Outcome criteria include survival rates, transfer numbers, and time to definitive neurosurgical care. Fifty patients were entered during the first 18 months of the study, and 38 during the second 18 months. Fifteen in the first group required evacuation of intracranial mass lesions, as did nine in the second group. The overall mortality fell from 42 to 26% (P = 0.13). During the study period there were 77 primary retrievals and 20 required evacuation of mass lesions. The median time from injury to commencement of operation in these patients was 2 h 13 min (range 1 h 3 min-5 h 35 min). There were 11 transfers, four requiring craniotomy. The median time from injury to surgery was 7 h 24 min (range 3 h 2 min-10 h 25 min; P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Formative assessment: a student perspective

An educator's view would be that formative assessment has an important role in the learning process. This study was carried out to obtain a student perspective of the place of formative assessment in the curriculum. Final-year medical students at Royal Prince Alfred Hospital took part in four teaching sessions, each structured to integrate teaching with assessment. Three assessment methods were used; the group objective structured clinical examination (G-OSCE), structured short answer (SSA) questions and a pre/post-test multiple choice questionnaire (MCQ). Teaching sessions were conducted on the subject areas of traumatology, the 'acute abdomen', arterial disorders and cancer. Fifty-five students, representing 83% of those who took part in the programme, responded to a questionnaire where they were asked to rate (on a 5-point Likert scale) their response to general questions about formative assessment and 13 specific questions concerning the comparative value of the three assessment modalities. Eighty-nine per cent of respondents felt that formative assessment should be incorporated into the teaching process. The SSA assessment was regarded as the preferred modality to reinforce previous teaching and test problem-solving skills. The MCQ was the least favoured assessment method. The effect size variable between the total scores for the SSA and MCQ was 0.64. The variable between G-OSCE and SSA/MCQ was 0.26 and 0.33 respectively. Formative assessment is a potentially powerful method to direct learning behaviour. Students should have input into the methods used.

Value of the prospective 'before and after' study as a methodology to evaluate outcome in a trauma centre

A series of interventions (administrative, clinical and educational) was introduced to improve the quality of trauma care at Royal Prince Alfred Hospital, the designated trauma centre for the Central Sydney Area Health Service (CSAHS). A prospective, 'before and after' study was conducted to assess changes in outcome following the introduction of these measures. The trauma centre survival rate for patients admitted with serious injury (Injury Severity Scores > 15) increased significantly, from 72% in the nine months before trauma centre designation to 89% in the nine months after (P = 0.005). The peer review designated, potentially avoidable death rate did not change significantly over the two study periods, remaining in the 20-30% range. Similarly the unexpected death rate (TRISS) did not change significantly, remaining in the 20-45% range. A trend to a lower trauma centre mortality in those arriving with a systolic blood pressure < or = 90 mmHg was noted. Seven out of 14 patients 'at risk' from exsanguination died in the first 9 months compared with one out of seven in the second 9 months (P = 0.17). An unexpected finding was a change in the degree of injury severity and physiological status in patients arriving at the trauma centre. The Injury Severity Scores were significantly lower (P = 0.008) and the Revised Trauma Scores significantly higher (P = 0.0006) in the latter 9 months of the study. It was concluded that the improved trauma centre survival rate was a reflection of a reduced hospital mortality from haemorrhagic shock in conjunction with a lesser degree of injury severity in patients admitted from the CSAHS.