A Novel Low-Cost Simulation Model for Point-of-Care Ultrasound Intussusception Practice.

Pediatric intussusception is a relatively common yet serious condition where prompt diagnosis is crucial. Point-of-care ultrasound (POCUS) has proven accurate for diagnosing this disease and can expedite both diagnosis and treatment. Previous research has shown that emergency physicians can diagnose intussusception with acceptable sensitivity and specificity but require prior training in recognizing the pathology. Despite the disease's relative frequency, any individual physician rarely encounters it, making a simulation model vital for learning this ultrasound modality. We created a model using low-cost, easily available components that can be used to train emergency physicians to diagnose intussusception on POCUS.

Development and Usability of an Inexpensive and Reusable Phantom for Ultrasound-Guided Needle Cannulation.

Introduction Ultrasound-guided peripheral venous catheter placement (UG-PVCP) is a key skill for establishing intravenous access, especially in patients with anatomical challenges. Ultrasound is highly operator-dependent, and it is essential to ensure a sufficient level of competence when educating healthcare professionals. Competence can be acquired through simulation-based training (SBT) using phantoms or simulators. We developed a phantom for SBT, and in this study, we explore the phantom's usability and technical fidelity. Methods Novices with no experience in UG-PVCP and experts who routinely performed the procedure were asked to perform three ultrasound-guided catheter placement attempts on the phantom. Afterward, they were asked to complete a usability questionnaire consisting of 14 questions exploring the usability and fidelity of the phantom. Results Fifty-seven participants were included in the study: 29 novices and 28 experts. When assessing positive questions about the frequency of use, ease of use, integration of functionality, quickness to learn, and confidence level, the study showed a median score of 4 to 5 out of 5 in the two groups. The median was 1 to 2 out of 5 for negative questions assessing cumbersomeness, unnecessary complexity, and model inconsistency. In an additional comment textbox, one participant mentioned that the cannulation did not feel realistic but that it was good for cannulation practice. Conclusions We believe the phantom is suitable for an educational curriculum since it shows a high level of usability, scoring high on positive questions while scoring low on negative questions, and having high functional fidelity.

Comparison of Force During the Endotracheal Intubation of Commercial Simulation Manikins.

Background  Medical simulation allows clinicians to safely practice the procedural skill of endotracheal intubation. Applied force to oropharyngeal structures increases the risk of patient harm, and video laryngoscopy (VL) requires less force to obtain a glottic view. It is unknown how much force is required to obtain a glottic view using commercially available simulation manikins and if variability exists. This study compares laryngoscopy force for a modified Cormack-Lehane (CL) grade I view in both normal and difficult airway scenarios between three commercially available simulation manikins. Methods Experienced clinicians (≥2 years experience) were recruited to participate from critical care, emergency medicine, and anesthesia specialties. A C-MAC size 3 VL blade was equipped with five force resistor reading (FSR) sensors (four concave surfaces, one convex), measuring resistance (Ohms) in response to applied pressure (1-100 Newtons). The study occurred in a university simulation lab. Using a randomized sequence, 49 physicians performed intubations on three manikins (Laerdal SimMan 3GPlus, Gaumard Hal S3201, CAE Apollo) in normal and difficult airway scenarios. The outcomes were sensor mean pressure, peak force, and CL grade. Summary statistics were calculated. Generalized estimating equations (GEEs) conducted for both scenarios assessed changes in pressure measured in three manikins while accounting for correlated responses of individuals assigned in random order. Paired t-test assessed for the in-manikin difference between scenarios. STATA/BE v17 (R) was used for analysis; results interpreted at type I error alpha is 0.05.  Results Participants included 49 experienced clinicians. Mean years' experience was 4(±6.6); median prior intubations were 80 (IQR 50-400). Mean individual sensor pressure varied within scenarios depending on manikin (p<0.001). Higher mean forces were used in difficult scenarios (603.4±128.9, 611.1±101.4, 467.5±72.4 FSR) than normal (462.5±121.9, 596.0±90.5, 290.6±63.2 FSR) for each manikin (p<0.001). All manikins required more peak force in the difficult scenario (p<0.03). The highest mean forces (Laerdal, CAE, difficult scenario) were associated with the higher frequency of grade 2A views (p<0.001). The Gaumard manikin was rated most realistic in terms of force required to intubate. Conclusion Commercially available high-fidelity manikins had significant variability in laryngoscopy force in both normal and difficult airway scenarios. In difficult airway scenarios, significant variability existed in CL grade between manikin brands. Experienced clinicians rated Gaumard Hal as the most realistic force applied during endotracheal intubation.

Using the Evidence-Development-Validation-Consensus (EDVC) Approach to Develop and Validate maxSIMdrone: A Training Program for Healthcare Professionals to Provide Cardiac Arrest Care Using Drones.

Introduction The challenges of delivering cardiac arrest (CA) courses in rural and remote (R&R) locations worldwide have been further exacerbated by the COVID-19 pandemic. However, it is important to note that this problem has always existed. The implementation of social distancing measures to combat the pandemic has had a significant impact on healthcare and medical education, particularly in relation to the training of students, laypeople (LP), and healthcare professionals (HCPs) in CA care. The combination of pandemic restrictions and pre-existing difficulties faced in R&R locations and large cities has disrupted the provision of comprehensive medical education. The suspension of basic life support and defibrillation (BLSD) courses during the pandemic may have negatively affected pre-hospital care for CA. However, it is essential to acknowledge that challenges in delivering these courses in R&R areas predate the pandemic. Materials and methods A 2021 epidemiological study in the Brazilian Amazon identified CA as the primary cause of death, followed by COVID-19. This highlights the importance of providing BLSD courses and training to emergency medical service (EMS) personnel in R&R locations. Even during a pandemic. Researchers from Ontario Tech University and Memorial University School of Medicine developed a drone with a simulation scenario to train HCPs in automated external defibrillators (AED) operation and guide LP in safe use through BLSD protocols. A literature review showed that different training methods yielded similar outcomes. Based on these findings, the evidence-development-validation-consensus (EDVC) hybrid approach was used to develop and validate an online training program using a learning management system (LMS) as a model. Results Teaching HCPs and LP in R&R locations, such as northern Canada and the Brazilian Amazon, presents challenges due to limited resources and internet access. One potential solution lies in the utilization of remote online LMS that facilitate the administration, documentation, tracking, reporting, automation, and delivery of educational courses and training programs. The literature review indicated that mixed training approaches, including face-to-face, online, and hybrid formats, produced similar outcomes in learning assessment, self-confidence, performance, skills, and knowledge acquisition. These findings support the viability of using LMS as a model to develop and validate a course where drones deliver AEDs and provide training to HCPs and LP in R&R locations. A comprehensive training program should encompass cognitive, affective, and psychomotor learning domains, addressing various skills and knowledge aspects. Conclusion This research study develops and validates LMS teaching methods to support a training program for HCPs and LP in using AEDs delivered by drones. The program combines design-based research and consensus development methods, such as design thinking and think-aloud observations. Drones are used to provide AEDs and develop simulation scenarios for training in R&R locations. The hybrid approach ensures a valid and evidence-based training program. The study presents the EDVC approach used to enhance the maxSIMdrone training program, enabling effective out-of-hospital CA care. The program incorporates participant feedback and improves knowledge and techniques in AED use. It has the potential to improve patient outcomes in resource-limited R&R locations.

Comparing Learning Outcomes in Cardiopulmonary Resuscitation (CPR) and/or Automated External Defibrillator (AED) Training for Laypeople in Face-to-Face, Online, and Mixed Training Methods: An Integrative Literature Review.

Cardiovascular diseases and cardiac arrest (CA) are the main causes of death worldwide. This review aims to identify publications on the learning outcomes for the use of an automated external defibrillator (AED) and/or cardiopulmonary resuscitation (CPR) to train laypeople (LP), the method of training used, the year of publication and their recommendations. We employed Miller's assessment pyramid to describe learning outcomes as knowledge, skills, and confidence. The methods of training are face-to-face, online, and mixed. The evidence found in this study will be used to support the development and validation of a simulation-based training program to teach LP to operate AEDs delivered by drones in rural and remote (R&R) locations. This article is an integrative literature review with a quantitative and qualitative research design and is composed of seven steps: research question, inclusion and exclusion criteria, search and selection of studies, the role of a second reviewer of the findings, data analysis, interpretation and discussion of the results, and finally knowledge synthesis. The results of this review demonstrate that there are no significant differences in the learning outcomes of the different training methods. Since these findings suggest good results in all methods, the development of a training program based on face-to-face, online, and mixed, especially for places with few resources such as R&R places, indicates all methods can be used as good practices to develop training programs.

A Porcine-Based Task Trainer for the Instruction of Seidel's Test and Ocular Foreign Body Removal.

Ophthalmologic emergencies account for tens of thousands of patients presenting to the emergency department (ED) each year. Studies continue to show that ophthalmology education in medical school is limited, and this leads to many resident physicians who lack confidence in their ophthalmological examination and procedural skills if opportunities to practice these skills are not deliberately sought out during their training. Medical simulation continues to be an excellent way for physicians to learn and master these anxiety-inducing procedures. We present a newly modified, innovative, and realistic porcine-based emergency ophthalmologic procedural task trainer with live television screen projection to further improve Emergency Medicine (EM) resident education on the performance of Seidel's test and ocular foreign body removal.

Evaluation of a Hands-On Wrist Fracture Simulator for Fracture Management Training in Emergency Medicine Residents.

Background Fractures are common in the emergency department, and fracture management training poses certain challenges. Recent emergency medicine (EM) residency graduates feel only somewhat prepared to manage fractures. In this study, our objectives were to determine the effect of introducing a wrist fracture simulator (Sawbones®) to traditional EM fracture management education and to assess resident attitudes, comfort with fracture management, and perceptions of the simulator. Methodology This six-month prospective study involved postgraduate year one residents at two academic EM programs. For convenience, each residency was considered as one test group. One residency group was deemed the traditional group (n = 10), while the other was the intervention simulator group (n = 16). Identical traditional lectures and buddy splinting workshops were provided. The simulator group received supplemental training with the Sawbones® simulator. Groups were filmed using this simulator for fracture management before the teaching sessions and at six months. Grading utilized a 27-point scale, with a subscale covering reduction. Data were collected regarding attitudes, comfort with fracture management, and perceptions of the simulator. Results In total, 26 residents participated in the study. There was no significant difference between groups at six months in overall fracture management scores (traditional group: 15.8 ± 3.1; simulator group: 15.4 ± 3.9; p = 0.92). On the subscale of fracture reduction skills, the simulator group showed significant improvement (p = 0.0078), while the traditional training group did not (p = 0.065). Both groups reported satisfaction with the simulator, improved comfort, and knowledge of fracture management. Conclusions Fracture management is an essential competency, and prior research has shown that most graduating EM residents do not feel comfortable with these skills. All participating residents in this study struggled with adequate fracture management, even after the teaching session. Our study suggests that there is a benefit to supplementing traditional training with a fracture simulator.

Cost-Effective Training Models in Point-of-Care Ultrasound for Medical Students in Emergency Medicine: An Evaluation of Current Resources.

Background Ultrasound is becoming more widely utilized in clinical practice; however, its effectiveness is limited by the operator's skills. Simulation models are attractive options for developing skills because they allow inexperienced users to practice without the risk of endangering patients. Objective The purpose of this study was to identify commercially available and homemade ultrasound models to describe them in terms of materials, cost, and whether they are high- or low-fidelity for medical student education. Methods This is an investigational study on cost-effective ultrasound training methods for medical students. Our study was performed using search engines in Google, Google Scholar, and PubMed to search for models for the following five modalities: foreign body identification, intravenous (IV) injection training, abdominal ultrasound, ocular ultrasound, and ultrasound-guided lumbar puncture training. Results Most homemade models for foreign body identification, IV injection training, and ocular ultrasound could be created for less than $20. IV injection training models were the cheapest commercially available models. There are multiple commercially available options for abdominal ultrasound models, but no options were found for homemade construction. The construction cost for lumbar puncture models was larger due to the need to purchase an anatomically accurate set of lumbar vertebrae. Conclusions This study provides initial guidance and suggestions for ultrasound training models that are currently available. Ultrasound models that can be cheaply made or purchased increase accessibility for medical students to gain early exposure in a cost-effective and safe manner.

Development of a Three-Dimensionally Printed Ultrasound-Guided Peripheral Intravenous Catheter Phantom.

Introduction Ultrasound-guided peripheral intravenous catheter (US-PIVC) placement is an effective technique to establish PIV access when the traditional approach fails. Many training programs utilize commercial or homemade phantoms for procedural training. However, commercial products tend to be expensive and lack realism, while homemade blocks tend to be single-use and degrade easily. Thanks to the increasing availability of three-dimensional (3D) printers in academic settings, we sought to design and develop a reusable 3D-printed US-PIVC phantom and to evaluate its utility in terms of time needed to achieve IV placement and perceived realism compared to a commercial model among a group of emergency medicine (EM) physicians. Methods The upper extremity vascular phantom was constructed using 3D printing and casting techniques. A convenience sampling of EM physicians was timed by placing a US-PIVC in the 3D-printed and commercial models. Participants were also surveyed to assess their impression of the realism of the models. The primary outcome was the time required for US-PIVC placement in the 3D-printed model compared to the commercial model. Secondary outcomes were the assessment of differences in perceived realism and total cost between the two models. Results Twenty-one EM physicians completed the study. There were no significant differences in the mean time (seconds) for US-PIVC placement in the 3D-printed model (31, SD: 21) compared to the commercial model (30, SD: 18), p=0.77. Mean realism score trended higher for the 3D-printed model (3.6, SD: 0.9) compared to the commercial model (3.1, SD: 1.0), p=0.10. The total cost for the 3D-printed model was $120, with the interchangeable replacement part costing $21, which was much cheaper compared to the commercial phantom, which cost $549. Conclusion We developed a 3D-printed reusable US-PIVC phantom, and it proved to be more economical without sacrificing the realism and time required for US-PIVC placement when compared to a commercial phantom.

Pericardiocentesis Simulation Model: Low Cost, Easy to Assemble, Effective Task Trainer.

Pericardial effusion is a potentially lethal condition. If it is discovered early, it can be treated by pericardiocentesis under controlled condition with imaging by experienced care providers. If it is diagnosed at a later stage with clinical compromise, then an emergent procedure might be necessary. Since it is encountered infrequently, many providers may have little or no experience in managing the condition and performing a life-saving pericardiocentesis. This is a technical report that describes the creation of a neonatal model for pericardiocentesis. This is a high-fidelity, low-cost model that is simple to create. Materials that are inexpensive and easy to obtain are utilized to make the model. Neonatal care providers, including residents, fellows, nurse practitioners, physician assistants, and attendings, can practice with this model. In some medical centers, an echocardiogram or bedside ultrasound is available to guide needle insertion; however, practicing the procedure on a model provides valuable experience. This model is designed to teach the performance of unguided pericardiocentesis without the use of simultaneous imaging. Included with this technical report are a supply list, a checklist, and a suggested scenario that can be used in association with this model. In this article, we have discussed our own experience and described lessons learned about training neonatal care providers in pericardiocentesis.

Development and Learner-Based Assessment of a Novel, Customized, 3D Printed Small Bowel Simulator for Hand-Sewn Anastomosis Training.

Hand-sewn bowel anastomosis (HSBA) is an essential skill for surgical residents to learn, as it is used in numerous surgical procedures. However, the opportunities to practice this skill before attempting it on patients are limited. Practice on simulators can help improve this technique, but there is a paucity of realistic, cost-efficient simulators for the acquisition of HSBA skills. This technical report describes the development of our simulator that consists of a small bowel manufactured from silicone and a 3D-printed clamp system to hold the bowel in place. Our simulator was co-designed by a clinical team of surgeons and then assessed for perceived acceptability and effectiveness by 16 junior residents in various surgical specialties at our faculty. A majority of the learners rated our simulator to be a good or very good learning tool for HSBA, although they suggested some minor improvements. Overall, our silicone small bowel model appears to be an effective and inexpensive way to acquire this surgical skill.

Novel Low-Cost Tracheo-Innominate Artery Fistula Bleed Simulator.

Tracheo-innominate artery fistulas are a rare complication of indwelling tracheotomies with a very high mortality rate. Due to the rare occurrence of this surgical emergency, most medical providers have little to no training or experience in recognizing, stabilizing, and repairing this life-threatening condition. Simulation of rare emergencies helps close knowledge gaps of medical providers at all levels. Although many providers may never experience these emergencies throughout their careers in clinical medicine, it is imperative that they distinguish and apply techniques for temporizing these life-threatening conditions in order to decrease patient mortality. This novel, low-cost, and easy-to-implement simulation is geared towards this goal and has been successfully tested in small group simulations at one academic center in San Antonio, Texas.

Simulated Umbilical Venous Catheter Placement Improves Resident Competence and Confidence.

Background Pediatric ACGME (Accreditation Council for Graduate Medical Education) requirements include demonstrated competence in umbilical line placement. Given a waning number of these procedures clinically available to residents, new methods of procedural teaching must be employed. We developed a simulation-based strategy, using adult-learning principles, to teach umbilical venous catheter (UVC) placement to pediatric residents. We also determined whether procedural teaching via simulation increased confidence and competence among pediatric residents in performing the procedure. Methods Out of 23 first-year pediatric residents, eight participated in the study. Participants completed a survey evaluating their self-perceived competence and confidence in umbilical line placement. Their simulated umbilical line placement was assessed using a standardized checklist. Residents were then trained on simulated line placement in small groups by neonatologists. Six months later, residents completed a post-training survey and were assessed while placing simulated lines. Statistical analysis was completed using a paired t-test for parametric data, Wilcoxon signed-rank sum test for non-parametric data, and McNemar's chi-squared test for categorical data. Spearman's correlation was used for ordinal variables and Pearson's correlation was used for continuous variables. Results Nine PGY-1 (post-graduate year-1) residents completed the pre-training survey and simulation, while eight residents completed the post-training survey and simulation. There was an increase in resident confidence in placing umbilical lines six months after completion of the training session (p = 0.015) even though there was no difference in the number of umbilical lines that residents had placed in the intervening time. The residents performed a greater number of steps correctly after the training compared to their performance before the training (p=0.001). There was a statistically significant positive correlation between resident confidence and the number of steps performed correctly (rs(14)= 0.649, p = 0.006). There was no correlation between confidence and the number of umbilical lines placed on live subjects. Conclusion A teaching strategy that allows pediatric residents to struggle to perform UVC placement in a simulated setting, before receiving expert instruction, is effective at increasing their confidence and competence, even in the absence of exposure to human subjects.

Creation and Evaluation of a Cesarean Section Simulator Training Program for Novice Obstetric Surgeons.

BACKGROUND: We evaluated a novel simulation-based cesarean section training program to teach critical techniques for cesarean section and hemorrhage management.  Methods: This was a prospective educational intervention. After Institutional Review Board approval, we recruited Obstetrics and Gynecology, Family Medicine, and General Surgery residents at three hospitals. All participants received didactic education. Participants were then randomized into two arms with one group to receive task-trainer based training and the other no training. Afterwards, all residents had their performance of a complete cesarean section and management of a post-partum hemorrhage evaluated on a high-fidelity simulator. Evaluators were blinded to randomization. EXPERIENCE: Thirty-three participants were recruited between July 2017 and January 2019. There were 19 trainees in the control group and 14 in the intervention group. The intervention group scored significantly higher on performance of the cesarean delivery (p-value 0.007), hemorrhage management (p-value 0.0002), and overall skill (p-value 0.008). There were no differences in the other categories. CONCLUSION: Participants trained with a combination of didactic education and task-trainers versus didactic education alone performed significantly better on all procedural aspects of a cesarean section and hemorrhage management on a high-fidelity simulator, demonstrating that simulation-based training allows trainees to gain procedural experience while decreasing patient risk.

A Novel Tube Thoracostomy Simulation Model for the Deployed or Resource-Limited Environment.

Tube thoracostomy placement is a critical, life-saving procedure often performed in the setting of trauma for the treatment of intrathoracic injury, such as hemothorax or pneumothorax. It also represents a high-acuity low-occurrence (HALO) event for many medical providers who may have limited opportunities for practice and mastery, particularly those in austere or resource-limited environments, such as in the deployed setting. Simulation offers opportunities for practicing the techniques required to properly perform and master the procedure. Finding affordable and accessible models for training, however, still represents a significant obstacle for many medical providers. We present a novel tube thoracostomy simulation model assembled from low cost and readily available materials.

Making the Cut: Implementing a Low Cost, Low Fidelity Simulation Model for Teaching Emergency Thoracotomy Procedure.

Emergent thoracotomy is a rare but high-stakes procedure for trauma patients. Emergency medicine residents are expected to perform this procedure after graduation, but few get the opportunity to perform it, leading to suboptimal performance and patient morbidity and mortality. Previous low-cost thoracotomy trainers revolve around modifying an existing costly thoracotomy task trainer or bear limited resemblance to actual landmarks and anatomy. This study attempts to bridge this gap by creating a low-cost model with supplies found at most home improvement/craft stores that is more anatomically accurate. We constructed a low fidelity model, which residents ultimately found to be helpful in mastering this rare procedure, and after the training session, they reported a greater level of comfort and familiarization with the procedure.

The Impact of Advanced Cardiac Life Support Simulation Training on Medical Student Self-reported Outcomes.

INTRODUCTION: Simulation has become a well-recognized and innovative tool in medical education. While there has been tremendous growth of simulation curricula at the level of graduate medical education, there have been few studies looking at simulation as a learning tool for undergraduate medical education. The goal of this study was to determine if high-fidelity simulation training impacts medical student perception of knowledge and confidence regarding comprehension and application of advanced cardiac life support (ACLS) algorithms. METHODS: This is a prospective observational survey study of third and fourth year medical students who participated in an ACLS simulation training during their emergency medicine rotation between January 2018 and October 2018. Cases covered several ACLS topics including unstable bradycardia, supraventricular tachycardia and ventricular tachycardia. After each session, students received a short survey to assess their simulation experience pertaining to knowledge and comfort levels with ACLS topics before and after the simulation experience. RESULTS: A total of 89 students were included in the study with 86.5% of those being fourth year students. There was a significant increase in both knowledge (pre-training 3.17 vs. 4.11 post-training, p<0.001) and comfort scores (pre-training 2.54 vs. 3.74 post-training, p<0.001) after the ACLS simulation training. Overall, 77.5% of students reported an increase in knowledge and 83.1% reported an increase in confidence after the training session.  Conclusions: The study revealed a statistically significant increase in both perceived knowledge and comfort and confidence of medical students after high-fidelity simulation using ACLS scenarios.