Towards understanding the suture/ligature skills during the training process using WKS-2RII

Object

Nowadays, most of the surgical training programs follow a duration-based format that focuses on improving technical skills of trainees for a fixed amount of time before declaring their proficiency. More recently, different approaches have been proposed for the skills assessment; such as the objective structured clinical examination (OSCE). The OSCE consists of different stations in which trainees are required to perform practical exams while their performance is evaluated by examiners. However, their performance cannot be easily assessed by the simple observation of the task. As a result, no standard evaluation criteria can be conceived.

Methods

Thanks to the recent advances in Robot Technology (RT); more efficient training systems can be conceived. In particular, authors believe in the importance of developing automated training devices designed to provide training progress quantitative information of trainees. For this reason, at Waseda University, since 2004, we have proposed as a long-term research goal, the development of a Patient Robot which nearly reproduces the human body anatomy and physiology by embedding sensors and actuators into a human model. Due to the complexity of patient robot development, as a first approach, we have proposed the development of a Suture/Ligature Training System. In this paper, the details of Waseda-Kyotokagaku Suture No. 2 Refined II (WKS-2RII) are presented. The WKS-2RII has been designed to reproduce the task conditions of the suture and ligature as well as to provide quantitative information of artificial skin movement, and the physical properties of the suture. From such collected data, we have proposed an Evaluation Function that integrates all the proposed evaluation parameters.

Results

In order to verify the effectiveness of the WKS-2RII, a set of experiments were proposed to analyze the performance of subjects while performing the task with the WKS-2RII. The experiments were designed to determine if the proposed system may provide more detailed information of the task in a quantitative way. From the experimental results, we have confirmed that the WKS-2RII is capable of providing quantitative assessment of the task. In contrast to the conventional training methods (i.e., OSCE, etc.), the WKS-2RII can provide more detailed information of the task performance, so that the proposed system can detect the differences among different level of expertise (five surgeons, five medical students and five unskilled persons) as well as detect improvements of trainees by plotting the learning curve.

Conclusions

In this paper, we have presented the improvements on the WKS-2RII and a unique evaluation function has been proposed. Regarding the weighting coefficients, the discriminant analysis method was used to determine the optimal values of the weighting coefficients.     

Prehospital endotracheal intubation in patients with severe traumatic brain injury: Guidelines versus reality

The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS) ≤ 8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation.We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS ≤ 8 who were referred to a level 1 trauma centre in Amsterdam (n = 127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital.Patients were mostly male, aged 45 ± 21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate.We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.     

Testing airway management skills: interactive video courseware vs ACLS instructor

Lectures and demonstrations have been the teaching and testing strategies most often employed by the American Heart Association in Advanced Cardiac Life Support (ACLS) training. I compared the abilities of interactive videodisc (IVD) courseware and ACLS instructors to evaluate airway management skills. METHODS & MATERIALS: Twenty-two subjects were simultaneously tested during 30 attempts at endotracheal (ET) intubation and 34 attempts at esophageal obturator airway or esophageal gastric tube airway (EOA/EGTA) insertion. The instructors were blind to the visual and auditory messages produced. RESULTS: The IVD program and the ACLS instructors showed high agreement in their evaluation of student performance for time of intubation (95.5% ET; 100% EOA/EGTA), proper tube placement (91% ET; 93% EOA/EGTA), appropriate tube assessment (95.5% ET; 100% EOA/EGTA), and correct EOA/EGTA cuff inflation (100%). Lower levels of agreement were noted with ET and EOA/EGTA appropriate head positioning, and the evaluation of tooth pressure with ET intubation (60.5%, 76.5%, and 66.0%, respectively). The IVD system was unable to detect certain procedural errors associated with appropriate intubation procedure--syringe attachment, syringe removal after cuff inflation, and control of tube after intubation. The low agreement for tooth pressure suggests that the sensor-equipped manikin may better evaluate tooth pressure than does the observer. CONCLUSIONS: Although the IVD system shows promise as an adjunct method for instruction and testing, it cannot be considered suitable for 'stand-alone' instruction. Further research is needed to explore costs, skills retention, and possible impact of the medium for training hospital and prehospital-care personnel.     

Effective performance of a new post-operative cardiac resuscitation simulation training scheme in the Paediatric Intensive Care Unit

Objective  This feasibility study aimed to describe and evaluate the effectiveness of a novel chest re-opening paediatric resuscitation scenario training scheme. Methods  A novel scheme offering training on specialist skills required for post-operative cardiac patients such as chest re-opening and cardiac pacing via simulation was described. A prospective audit of the first 23 consecutive training sessions was conducted to assess the scheme’s effectiveness. Parameters assessed included timing of chest re-opening or cardiac pacing orders, and any delays in carrying out these orders. Results  The median time required for the medical team leader to order chest re-opening was 4 min. New medical leaders took significantly longer to order chest re-opening than experienced medical team leaders (P = 0.02, Mann–Whitney U test). The performance of the team-in-training deteriorated with the introduction of new members but was correctable with serial training. Conclusions  Effective simulation training integrating chest re-opening and cardiac pacing into standard paediatric resuscitation guidelines may be achieved without high fidelity simulation equipment.     

Comparison of Endotracheal Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway Patency in a Moving Ambulance

BackgroundEarly and successful management of the airway in the prehospital and hospital settings is critical in life-threatening situations.ObjectiveWe aimed to perform endotracheal intubation (ETI) by direct laryngoscopy (DL) and video laryngoscopy (VL) on airway manikins on a moving track and to compare the properties of intubation attempts.MethodsOverall, 79 participants with no previous VL experience were given 4 h of ETI training with DL and VL using a standard airway manikin. ETI skill was tested inside a moving ambulance. The number of attempts until successful ETI, ETI attempt times, time needed to see the vocal cords, and the degree of convenience of both ETI methods were recorded.ResultsOverall, 22 of 79 individuals were men; mean age was 30.3 ± 4.5 years. No difference was found in the comparison of the two methods (p = 0.708). Time needed to see the vocal cords for those who were successful in their first attempt were between 1 and 8 s in both methods. In the VL method, time needed to see the vocal cords (p = 0.001) and the intubation time (p < 0.001) in the first attempt were shorter than in the DL method. The VL method was easier (p < 0.001). The success rate was 97.5% in DL and 93.7% in VL.ConclusionsThe VL method is rapid and easier to see the vocal cords and perform successful ETI. Therefore, it might be preferred in out-of-hospital ETI applications.     

An assessment of paramedic performance during invasive airway management

Objective. To assess the performance of paramedics, in a newly-initiated prehospital program, during invasive airway management. Methods. An audit of paramedic call reports for a 12-month period from January to December 1997 was performed. Call reports that documented invasive airway management were retrieved and relevant data were extracted using a preformulated data-entry form. Results. Paramedics attempted tracheal intubation in 453 patients and were successful in 408 (90.1%); 331 of the patients were in cardiopulmonary arrest with vital signs absent (VSA), 101 had medical emergencies, and 21 had trauma-related problems. In the VSA cohort, the tracheas of 96% of the patients were intubated successfully; 80.1% on the first attempt, 10.6% on the second, 4.5% on the third, and 0.9% after more than three attempts. In the medical cohort, the tracheas of 74.3% of the patients were intubated; 60.4% on the first attempt, 11.9% on the second, and 2.9% on the third. In the trauma cohort, 71.4% of the intubations were successful; 66.6% on the first attempt, 26.6% on the second, and 6.6% on the third. There was a difference (p < 0.001) in the incidence of successful intubations comparing the VSA cohort with the medical/trauma cohorts. There was also a difference (p < 0.001) between the success rate for nasal intubations (43 of 68, 63% of patients successfully intubated) and that for oral intubation (365 of 385, 94% of patients). Conclusion. This study demonstrated a difference in the paramedics' success rates for tracheal intubation in VSA patients compared with those with preserved airway reflexes and a lower success rate for nasal vs oral tracheal intubation. These differences may be due to inadequate training, technical difficulties experienced in the field, or lack of sufficient exposure to medical/trauma scenarios to gain management experience. Future training to address these issues, both in the initial training phase and in the continuing education program, may be beneficial in improving performance. PREHOSPITAL EMERGENCY CARE 2000;4:164-167     

Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D,Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial

BackgroundThe use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario.ObjectiveWe compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin.MethodsThirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation.ResultsAll participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42 s, 56 s, and 56 s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29 s and 40 s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation.ConclusionsIn an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.     

A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success

Introduction: Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance.

Objectives: The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success.

Methods: The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation.

Results: A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311).

Conclusions: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.     

A method of assessing the efficacy of memory rehabilitation techniques using a "real-world" memory task: learning a computer language

A software program developed to assess the effectiveness of memory rehabilitation techniques is described. This project addresses current weaknesses in the research literature on memory rehabilitation: 1) remediation strategies are evaluated in terms of performance on a practical, real-world memory task, rather than a laboratory learning task; 2) the program allows maximum flexibility in assessing a wide variety of remediation strategies and training schedules; and, 3) the software, which provides sensitive outcome measures and detailed feedback about performance, is adaptable to the needs of patients with widely varying degrees of memory impairment. The results of a demonstration project are included to illustrate the use of this technology in determining the usefulness of different mnemonic strategies for patients with specific patterns of memory deficit. The importance of assessing maintenance of rehabilitation training over time is stressed.     

The analysis of self and tutor assessment in the skill of basic life support (BLS) and endotracheal intubation: focused on the discrepancy in assessment

Introduction

This paper reports the results of a study of fourth year medical students that assessed whether assessments of basic life support (BLS) and intubation performance differ when assessed by the students themselves or by tutors. This information should be helpful for designing the contents of a complementary education core.

Methods

Tutor assessments and student-assessments were conducted using a checklist and a fivepoint rating scale, and then compared. For the two skill performance tests, Resusci^® Anne SkillGuide™ and Laerdal^® Airway Management Trainer (Laerdal, Norway) devices were used. The check-lists used to evaluate students were based on International Liasion Committee on Resuscitation (ILCOR) guidelines and Korean Emergency Airway Management Society (KEAMS) tutor guidelines.

Results

A total of 83 medical students participated in the study, intra-class correlation coefficient between tutor and student assessment were 0.542 (95% CI 0.371-0.678) in BLS and 0.693 (0.538-0.802). There were also no significant differences between self-assessments and tutor assessments based on the five-point. In BLS skill session, we found out that “maintenance of airway” and “palpating a carotid pulse” were the mostly missed parts. In the intubation skill, omitting the parts of ‘securing the airway’ while preparing for intubation, proper positioning of blade tip in the valleculae, and appropriate insertion of endotracheal tube were demonstrated.

Conclusion

We observed correlations between student self-assessments and tutor assessments for both BLS and intubation. Analyzing the discrepancies between self-assessment and tutor assessment will be helpful in focusing training on the steps that were omitted by students or during which students demonstrated incompetence.     

Role of rapid sequence induction for intubation in the prehospital setting: helpful or harmful?

Use of rapid sequence induction for intubation was introduced to the prehospital environment in the hope of enhancing patient outcome by improving early definitive airway management. Varying success has been achieved in both air and ground transport emergency medical services systems, but concern persists about the potential to cause patients harm. Individual emergency medical services systems must determine the need for rapid sequence induction for intubation and their ability to implement a rapid sequence induction for intubation protocol effectively with minimal adverse events. Therefore, the value of rapid sequence induction for intubation is dependent on each emergency medical services system design in their ability to establish personnel requirements and ongoing training, expertise in airway management skills, medical direction and supervision, and a quality assurance program. If these principles are strictly adhered to, rapid sequence induction for intubation may be safely used as an advanced airway management technique in the prehospital setting.     

Simulation training program for midwives to manage postpartum hemorrhage: A randomized controlled trial

PurposeTo explore the effectiveness of a simulation training program for midwives in performance and knowledge for the management of postpartum hemorrhage (PPH).MethodsThe study design was a randomized controlled trial. Midwives working at one obstetrics ward in an urban area were randomly assigned to simulation training program or no training. This “simulation program” included pre study e-learning and simulation. Inclusion criteria were midwives who: 1) had two or three years of clinical experience, 2) worked in an obstetrics ward, and 3) had experience with birth assistance. There was one exclusion criterion namely prior experience of simulation training for PPH. Change in performance was evaluated using a PPH scenario performance test at one month after the simulation training. Change in knowledge was evaluated by a 25-item multiple-choice questionnaire completed shortly before the training and one month after the training. The ethical review committee of St Luke's International University granted approval (No. 14-096).ResultsEighty-one midwives were randomly assigned to either the intervention group (n = 40) or the control group (n = 41). Performance in the simulation training group was significantly better in comparison to the no training group; mean performance score was 23.85(SD 2.71) in the training group versus 18.00(SD 3.01) in the no training group (MD 5.85 95% CI 4.85–7.12, t = 9.17, p < 0.001). Knowledge was significantly increased in the simulation training group; amount of knowledge score was 3.65(SD 3.40) in the training group versus − 0.02(SD 3.02) in the no training group (MD 3.67 95% CI 2.25–5.10, t = 5.14, p < 0.001).ConclusionBoth performance and knowledge about the management of PPH were significantly improved after simulation training. However, assessments of long-term effects on performance, and knowledge and the clinical outcomes in managing of obstetric complications are necessary to adequately evaluate the effectiveness of simulation training.     

Utility of the Pentax-AWS without interruption of chest compression: Comparison of the Macintosh laryngoscope with the Pentax-AWS in manikin model

Background

Emergency airway management in suboptimal conditions can result in difficulties in tracheal intubation. The video laryngoscope (Pentax-AWS^®) has potential advantages during difficult tracheal intubations. According to the 2005 guidelines for cardiopulmonary resuscitation (CPR), all rescuers should minimize interruption of chest compressions. Our hypothesis is that tracheal intubation using the Pentax-AWS^® is possible without interruption of chest compressions. We tested this using tracheal intubation performed by less experienced medical personnel in a manikin model.

Methods

Thirty-two less experienced (<10 tracheal intubations) medical interns performed intubation using the Pentax-AWS^® and the Macintosh laryngoscope in an ALS simulator (Laerdal, Stavanger, Norway) in each of three scenarios. The three scenarios were: (1) normal airway without chest compression, (2) normal airway with continuous chest compression, and (3) difficult airway with continuous chest compression. The success rate, time required to complete tracheal intubation and to visualize vocal cords, POGO (percentage of glottic opening) score, dental compression and the ease of intubation were recorded.

Results

All participants performed successful intubation with the Pentax-AWS^® in the three scenarios. In the two continuous chest compression scenarios (scenarios 2 and 3), the success rate was significantly higher with the Pentax-AWS^® than with the Macintosh laryngoscope.

Conclusions

The Pentax-AWS^® was an effective tool for endotracheal intubation during chest compression performed by less experienced medical personnel in a manikin model simulating cardiac arrest, both under conditions of normal and difficult airways.     

Students insert the laryngeal tube quicker and more often successful than the esophageal–tracheal combitube in a manikin

BackgroundEndotracheal intubation remains the standard of airway management. Because intubation skills are difficult to acquire, for medical students teaching of easier to learn techniques should be considered.MethodsWe retrospectively analyzed data that were collected in a University teaching facility. 264 medical students were taught how to use laryngeal tube (LT) and Esophageal Tracheal Combitube^® (ETC) in a manikin. The students underwent one of two different types of extraglottic airway management training consisting of either long lecture (30 min) and intensive training (2 h) (group IT, n = 48), or brief (10 min) lecture and 20 min of training (group BT, n = 216). Both groups underwent a test 6 weeks after training, group IT had an additional test 24 h after training.ResultsAfter 24 h students in group IT were faster using the LT than the ETC (31.7 s ± 2.1 vs. 51.9 s ± 5.8, p < 0.001). Up to 6 weeks after training students were able to place the LT significantly faster than the ETC in both groups (26.5 s ± 2.1 vs. 53.9 s ± 5.8 group IT and 43.4 s ± 1.6 vs. 103.8 s ± 4.4 group BT, p < 0.001). At 24 h and 6 weeks following intensive training, there was no statistical difference in the time required for insertion of either device.ConclusionFollowing different training scenarios in a manikin, students were able to place the LT much faster than the ETC. Even brief training was sufficient to generate short insertion times for the LT.     

Quantifying kinematics of purposeful movements to real, imagined, or absent functional objects: Implications for modelling trajectories for robot-assisted ADL tasks**

Background  

Robotic therapy is at the forefront of stroke rehabilitation. The Activities of Daily Living Exercise Robot (ADLER) was developed to improve carryover of gains after training by combining the benefits of Activities of Daily Living (ADL) training (motivation and functional task practice with real objects), with the benefits of robot mediated therapy (repeatability and reliability). In combining these two therapy techniques, we seek to develop a new model for trajectory generation that will support functional movements to real objects during robot training. We studied natural movements to real objects and report on how initial reaching movements are affected by real objects and how these movements deviate from the straight line paths predicted by the minimum jerk model, typically used to generate trajectories in robot training environments. We highlight key issues that to be considered in modelling natural trajectories.     

国产明视插管软镜与纤维支气管镜经鼻困难气管插管的比较*

目的比较国产明视插管软镜(VIS)与纤维支气管镜(FOB)引导经鼻困难气管插管的临床应用效果。方法择期选择困难气道患者60例,Mallampati评分为Ⅲ或Ⅳ级,美国麻醉师协会评级(ASA)Ⅰ或Ⅱ级,年龄22~68岁,体重53~82 kg,随机分为VIS组(V组)和FOB组(F组),每组30例。分别采用VIS和FOB引导经鼻气管插管。观察记录两组气管插管时间、气管插管成功率及气管插管相关并发症发生情况,记录麻醉诱导前(T_0)、麻醉诱导后(T_1)、声门暴露时(T_2)、气管导管进入声门即刻(T_3)的平均动脉压(MAP)、心率(HR)和脉搏血氧饱和度(SpO_2)。结果与T_0时比较,T_1时两组MAP明显下降、HR明显减慢(均P0.05);与T_1时比较,T_3时两组MAP明显升高、HR明显增快(均P0.05),两组间比较差异无统计学意义(P0.05);气管插管期间两组SpO_2均无明显降低。V组和F组气管插管时间分别为(76.0±18.0)和(80.0±20.0)s、一次气管插管成功率分别为96.7%和93.3%,两组间比较差异均无统计学意义(均P0.05);气管插管并发症发生率两组间比较差异无统计学意义(P0.05)。结论与FOB相比较,国产VIS引导经鼻困难气管插管同样安全可靠、快速有效、插管成功率高,气管插管并发症少。     

A is for airway: alternative airway devices

There are many alternative airway devices available on today's market. The type of device that your department uses will depend on your medical control, as well as local protocols and regulations. These devices all require practice, refresher training and on-going skill maintenance. Endotracheal intubation remains the gold standard for airway control; however, proper usage of an alternative airway device can allow patients to be ventilated and oxygenated, even if they cannot be immediately intubated.