Development of a lumbar puncture virtual simulator for medical students training: A preliminary evaluation

BACKGROUND

Lumbar puncture is an essential medical procedure whose objective is to obtain cerebrospinal fluid. Lumbar puncture is considered a complex procedure, mainly for novice residents who suffer from stress and low confidence, which may result in harm to the patient.

METHODS

The LPVirSim, has been developed in four stages: i) requirements analysis through user-centred design; ii) prototyping of the virtual environment and the haptic component; iii) preliminary tests with Ph.D. students and physicians using two haptic devices (Omega.7 and Sigma.7); iv) a user study where physicians evaluated the usability and user experience.

RESULTS

The LPVirSim integrates non-technical skills and the possibility of representing different patients for training. Usability increased from 61.76 to 68.75 in the preliminary tests to 71.43 in the user study.

CONCLUSIONS

All the results showed good usability and demonstrated that the simulator arouses interest and realistically represents a Lumbar puncture, through the force and visual feedback.

Simulation-based summative assessment in healthcare: an overview of key principles for practice

BACKGROUND

Healthcare curricula need summative assessments relevant to and representative of clinical situations to best select and train learners. Simulation provides multiple benefits with a growing literature base proving its utility for training in a formative context. Advancing to the next step, "the use of simulation for summative assessment" requires rigorous and evidence-based development because any summative assessment is high stakes for participants, trainers, and programs. The first step of this process is to identify the baseline from which we can start.

METHODS

First, using a modified nominal group technique, a task force of 34 panelists defined topics to clarify the why, how, what, when, and who for using simulation-based summative assessment (SBSA). Second, each topic was explored by a group of panelists based on state-of-the-art literature reviews technique with a snowball method to identify further references. Our goal was to identify current knowledge and potential recommendations for future directions. Results were cross-checked among groups and reviewed by an independent expert committee.

RESULTS

Seven topics were selected by the task force: "What can be assessed in simulation?", "Assessment tools for SBSA", "Consequences of undergoing the SBSA process", "Scenarios for SBSA", "Debriefing, video, and research for SBSA", "Trainers for SBSA", and "Implementation of SBSA in healthcare". Together, these seven explorations provide an overview of what is known and can be done with relative certainty, and what is unknown and probably needs further investigation. Based on this work, we highlighted the trustworthiness of different summative assessment-related conclusions, the remaining important problems and questions, and their consequences for participants and institutions of how SBSA is conducted.

CONCLUSION

Our results identified among the seven topics one area with robust evidence in the literature ("What can be assessed in simulation?"), three areas with evidence that require guidance by expert opinion ("Assessment tools for SBSA", "Scenarios for SBSA", "Implementation of SBSA in healthcare"), and three areas with weak or emerging evidence ("Consequences of undergoing the SBSA process", "Debriefing for SBSA", "Trainers for SBSA"). Using SBSA holds much promise, with increasing demand for this application. Due to the important stakes involved, it must be rigorously conducted and supervised. Guidelines for good practice should be formalized to help with conduct and implementation. We believe this baseline can direct future investigation and the development of guidelines.

Impact of a simulation-based training on the experience of the beginning of residency

INTRODUCTION

We aimed to evaluate the impact of an immersive simulation session on the experience of the beginning of residency.

METHODS

The interventional group consisted of newly recruited residents in 2019, who participated in the workshop presenting four emergency scenarios frequently encountered during night shifts; the control group comprised residents who had begun their internship in 2018, without having participated in the simulation workshop. The level of psychological stress and self-confidence were self-estimated in the simulation group before and immediately after the workshop. During the second semester of residency, stress, self-efficacy and anxiety were evaluated in both groups with the Perceived Stress Scale (PSS), General Self-efficacy Scale (GSES), and Generalized Anxiety Disorder-7 (GAD-7) scale.

RESULTS

In the second semester 2020, the PSS, GSES and GAD-7 were 20.71±8.15 and 22.44±5.68 (P=0.40); 26.88±6.30 and 27.11±3.95 (P=0.87); 6.94±5.25 and 8.89±4.78 (P=0.22) for the simulation (n=17, 89.5% of participation) and control (n=9, 75%) groups, respectively. In the simulation group, the level of self-confidence had significantly improved from 1.82±0.95 before the session to 2.29±1.16 after the session (P=0.05). Interestingly, this improvement in self-confidence was significantly correlated with GAD-7 (P=0.014) and PSS (P=0.05), and tended to be correlated with GSES (P=0.09).

CONCLUSION

Our study showed a significant improvement in self-confidence between before and after the simulation session. Residents who experienced an improvement in self-confidence saw their stress and anxiety levels decrease during the second semester reevaluation, in favor of a prolonged benefit from the session.

Applying an immersive tutorial in virtual reality to learning a new technique

OBJECTIVE

The medical world is continuously evolving, with techniques being created or improved almost daily. Immersive virtual reality (VR) is a technology that could be harnessed to develop tools that meet the educational challenges of this changing environment. We previously described the immersive tutorial, a 3D video (filmed from the first-person point of view), displayed on a VR application. This tool offers access to supplementary educational data in addition to the video. Here we attempt to assess improvement in learning a technique using this new educational format.

MATERIAL AND METHODS

We selected a single neurosurgical technique for the study: external ventricular drainage. We wrote a technical note describing this procedure and produced the corresponding immersive tutorial. We conducted a prospective randomized comparative study with students. All participants read the technical note, and one group used the immersive tutorial as a teaching supplement. The students completed a multiple-choice questionnaire immediately after the training and again at six months.

RESULTS

One hundred seventy-six fourth-year medical students participated in the study; 173 were included in assessing the immediate learning outcomes and 72 were included at the six-month follow-up. The VR group demonstrated significantly better short-term results than the control group (P=0.01). The same trend was seen at six months.

CONCLUSION

To our knowledge, this study presents one of the largest cohorts for VR. The use of the immersive tutorial could enable a large number of healthcare professionals to be trained without the need for expensive equipment.

S’exercer à l’afflux massif de victimes hospitalières… Comment faire ?

La capacité à accueillir un afflux massif de victimes au sein d’un hôpital fait partie des obligations de tout établissement de santé (ES). Les modalités de cet accueil sont définies de façon réglementaire par le plan blanc d’établissement. Chaque ES doit s’entraîner. Les exercices sont un élément clé pour apprendre à mieux faire face à ces situations sanitaires exceptionnelles et inhabituelles. Ils permettent de tester les dispositifs et procédures en place, d’acquérir de l’expérience, de déterminer les points forts, les faiblesses et les axes d’amélioration. La conception d’un exercice nécessite avant tout la définition de ses grandes caractéristiques (contexte, type, objectifs), la détermination du cadre et du périmètre de l’exercice (convention d’exercice), la détermination des ressources humaines (animateurs, plastrons, évaluateurs, observateurs) et matérielles nécessaires. Il faudra aussi écrire le scénario (initial, cadence, évolutions prévues), organiser les conditions d’animation (dossier d’exercice) et d’observation, définir les modalités de briefing, de débriefing et les modalités d’évaluation (outils et critères). L’exercice devra mener à un retour d’expérience avec propositions de mesures correctrices si nécessaire. Il doit être piloté par un comité de pilotage multiprofessionnel sous l’égide du directeur d’établissement ou de son représentant. Il doit être conçu comme une étape dans un processus d’amélioration des pratiques professionnelles au profit des patients.

[Tourniquet use in civil and military medicines]

OBJECTIVES

The purpose of this literature review is, after a history and a point about current situation, to present the military use and precautions of use of tourniquet for civil and military medicine.

DATA SOURCES

A review of the Anglo-Saxon and French literature was performed in PUBMED database, from 1962 to 2012. The research was conducted using the following keywords: "tourniquet", "complications", "haemorrhage", "emergency", "military medicine", used alone or in combination.

DATA EXTRACTION

The extracted data concerned the history, the epidemiology, the interest of tourniquet during peacetime and wartime, adverse effects and the ratio benefit/risk.

DATA SYNTHESIS

The tourniquet is "a device which is tightened, in case of haemorrhage, around a limb in order to slow or stop the venous or arterial circulation before surgery…". This item is thus used in surgery to reduce intraoperative bleeding and in emergency medicine as a rescue technique for bleeding places non accessible to compression or to other technical hemostasis. It is also used for treating bleeding of mass casualties. However, its use is too poorly managed by health professionals and it remains risky. Recent armed conflicts have yet revived its day use.

CONCLUSION

The tourniquet has utility in times of war and in peacetime. In each case, indications and complications must be known.

[Review of medication errors: a case in an intensive care unit]

OBJECTIVE

The authors conducted for the first time a medication error review (REMED) following a medication error occurred in an intensive care unit. The aim of this study was to assess this first REMED.

STUDY DESIGN

Descriptive study.

METHODS

The analysis of the medication error, consisting in the administration of Clottafact(®) instead of Aclotine(®), was performed using the REMED method.

RESULTS

The medication error was characterized as "proved error" and "missed before administration". Four main causes were identified: poor quality of drug storage, homophony between Aclotine(®) and Clottafact(®), non-compliance with good practices, and need of hemofiltration for the patient. At least, this REMED analysis led to the establishment of four improvements measures.

CONCLUSION

The educational aspect of the REMED was clearly appreciated by all the different health care workers who participated to the analysis. Even if medication errors may occur at the different steps of the medication process, the REMED is a very good tool to improve the care quality and also to reduce the drug iatrogenic risk.

Auscultation in flight: comparison of conventional and electronic stethoscopes

OBJECTIVES

The ability to auscultate during air medical transport is compromised by high ambient-noise levels. The aim of this study was to assess the capabilities of a traditional and an electronic stethoscope (which is expected to amplify sounds and reduce ambient noise) to assess heart and breath sounds during medical transport in a Boeing C135.

METHODS

We tested one model of a traditional stethoscope (3MTM Littmann Cardiology IIITM) and one model of an electronic stethoscope (3MTM Littmann Stethoscope Model 3000). We studied heart and lung auscultation during real medical evacuations aboard a medically configured C135. For each device, the quality of auscultation was described using a visual rating scale (ranging from 0 to 100 mm, 0 corresponding to "I hear nothing," 100 to "I hear perfectly"). Comparisons were accomplished using a t-test for paired values.

RESULTS

A total of 36 comparative evaluations were performed. For cardiac auscultation, the value of the visual rating scale was 53 ± 24 and 85 ± 11 mm, respectively, for the traditional and electronic stethoscope (paired t-test: P = .0024). For lung sounds, quality of auscultation was estimated at 27 ± 17 mm for traditional stethoscope and 68 ± 13 for electronic stethoscope (paired t-test: P = .0003). The electronic stethoscope was considered to be better than the standard model for hearing heart and lung sounds.

CONCLUSION

Flight practitioners involved in air medical evacuation in the C135 aircraft are better able to practice auscultation with this electronic stethoscope than with a traditional one.

[Blast lung injuries]

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

[Use of rFVIIa (Novoseven) in the case of a patient with mitral valvular prothesis and anticoagulant accident]

We report the case of an haemorrhagic shock observed in a woman who received heparin for a cardiac valve in mitral position, efficiently treated with rFVIIa. The haemorrhagic complications under anticoagulation treatment remain rare, but can lead to real therapeutic dilemma. The use of rFVIIa has been evaluated in different clinical situations, including traumatic or post-operative haemorrhagic shock. The use of rFVIIa in the treatment of haemorrhagic complication under anticoagulation treatment is discussed.

[Carotido-cavernous fistula after traumatic brain injury: an unusual vascular complication]

The authors reported the case of a young man who suffered a cranial traumatism and showed neurological, ophthalmic and orbital signs with orbital bruit, cranial nerve palsy and chemosis while he was in the intensive care unit. Further examinations of imagery made it possible to highlight a high-flow carotid-cavernous fistula which was the origin of these symptoms and which was successfully treated by endovascular way. The aim of this article is to remind the reader of the characteristics of this pathology, in terms of epidemiology, physiopathology, clinical and paraclinical presentation, and therapeutic care.

Les complications cardiovasculaires aiguës de la cocaïne. À propos de deux observations

Concerning any socioprofessional category, some addictive drugs like cocaine are responsible for many complications. The authors relate two case reports of young patients who suffered from cardiovascular accidents due to this drug. The first one was diagnosed with an ischemic stroke caused by carotid artery dissection and a leg distal vascular obliteration, the second one with a myocardial infarction with transient left ventricular dysfunction. Through these two case reports, the authors take stock of the pathophysiological and therapeutic knowledge of cardiovascular accidents after cocaine intake.

[Severe hypofibrinegenemia after rattlesnake envenomation in France]

A 22-year-old man, who maintains illegally numerous exotic snakes at home (suburbs of Paris), was bitten by one of his Bresilian rattlesnakes, the lance-headed viper Bothrops moojeni, with grade III envenomation. The fibrinogen was less than 0,5 g/L, the prothombin time was 22%, the activated partial thromboplastin time was 94 seconds. The authors discuss the biological and clinical management of this defibrination, due to defibrinogenating proteases (thrombin-like enzymes), present in Bothrops moojeni venom. The patient received 7 vials of an antivenom directed to another crotal, Bothrops lanceolatus. Despite the importance of defibrinogenation, there was only a few clinical evidence of bleeding, according to the literature. The normalization of coagulation studies occured only after day 11. This case-report outlines the danger of the increase of exotic snakes maintained as pet in France and the difficulties to obtain specific antivenoms.

[The risk of thromboembolism in airline passengers]

Long carrier flights favor thromboembolism. The risk is well known to the general public but is probably really very low. The risk is however pertinent due to the volume of air travel in the world. Sitting in the same position for a long time induced venous stasis which is the principal factor favoring thrombosis in travelers, irrespective of the means of transportation. Long carrier flights also expose passengers to specific factors related to air travel: coagulation disorders and alterations of the endothelium related to hypobarism, hypoxia and low hygrometry in the cabin. Presence of pathogenic thrombophilia is not a constant factor. The prevention of venous thrombosis in air travelers calls upon simple measures: abundant hydration, avoiding use of alcohol and tobacco, walking and dorsal flexion of the feet. The only preventive option with proven efficacy is the use of elastic contention which reduces the risk of thromboembolic events. There is no consensus concerning the use of drugs proposed by certain authors; prudence should be the rule. All passengers should become aware of the risk of thromboembolism related to sitting in the same position for a long time.

L’embolie pulmonaire au secours de la tamponnade cardiaque

The association of cardiac tamponade and pulmonary embolism has not previously been described. We report the case of a patient, who presented with such an association, due to an underlying pulmonary carcinoma. When a major pericardial effusion is associated with pulmonary hypertension, some echocardiographic signs of tamponade may appear, such as a moderate right ventricular collapse, or the absence of a paradoxical septum. The presence of pulmonary hypertension in this context of tamponade may have paradoxically saved the life of this patient.

[Ambulatory treatment of burns in children]

A majority of burns in children may have an ambulatory management for which the paediatrician has an important role. He must assess the severity of the burn by quoting extent, depth and localization of the burn injuries and then send the most severe to a specialized burn centre. The circumstances and the social situation are important in the decision of either hospitalization or ambulatory care, remembering that the burn may correspond to child abuse. The treatment consists of initially refreshing the burn to limit the extension, then washing the lesions using topical antiseptic soap, finally applying standard silver sulfadiazine cream. Local care is accomplished daily the first few days, then every three days to follow the healing and to keep a watch on possible complications such as infections or failure to heal, which must be treated in burn units. Pain relief treatment is an important part of the management.

[Four hours for a record, or a severe fuminating cellulitis: can Saccharomyces cerevisiae be the causal agent?]

A 31-year-old woman presented with a subcutaneous cellulitis which occurred within four hours following a minor wound of a knee. This very short delay could be explained neither by the health state, nor the mechanism of injury, nor the bacteria usually responsible for such a cellulitis. Considering the clinical characteristics (high gas production) and the professional context (wine cellar employee), Saccharomyces cerevisiae, a yeast used for wine or bread production, may explain this complication.

-The value of MRI in cerebral fat embolism-

We report two clinical cases of cerebral fat embolism, thereby demonstrating the value of MRI.