Which Model Is Better to Teach How to Perform Tube Thoracostomy: Synthetic, Cadaver, or Animal?

INTRODUCTION: The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models. METHODS: Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale. RESULTS: The theoretical post-test score was higher compared to the pretest score in all groups (P < 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training. CONCLUSIONS: The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.

Chest Tube Insertion Among Surgical and Nonsurgical Trainees: How Skilled Are Our Residents?

BACKGROUND: Competency-based medical education has renewed focus on the attainment and evaluation of resident skill. Proper evaluation is crucial to inform educational interventions and identify residents in need of increased training and supervision. Currently, there is a paucity of studies rigorously evaluating resident chest tube insertion skill. MATERIALS AND METHODS: Residents of all training levels before their intensive care unit rotation or currently rotating through the intensive care unit were invited to participate. Trainees inserted a thoracostomy tube on a high-fidelity simulator. Their performances were recorded and scored by blinded raters using the validated TUBE-iCOMPT rubric. Surgical and nonsurgical residents were compared. RESULTS: Forty-nine residents participated; 30 from nonsurgical and 19 from surgical training programs. Overall, trainees were most deficient in the "preprocedural checks" and "patient positioning and local anesthetic" domains. Surgical trainees demonstrated higher chest tube insertion skill than their nonsurgical peers (median total score 88 [interquartile range, 74-90] versus 75 [interquartile range, 66-85], respectively, P = 0.01), particularly in the "patient positioning" and "blunt dissection" domains (P = 0.01 and P = 0.03, respectively). These differences were no longer significant when controlled for experience and Advanced Trauma Life Support certification. CONCLUSIONS: Overall, surgical residents were more skilled than nonsurgical residents in tube thoracostomy placement. Relative skill deficits within the domains of chest tube insertion have also been identified among residents of different specialties. These areas can be targeted with educational interventions to improve resident performance, and ultimately, patient safety.

Evaluation of a Mobile Telesimulation Unit to Train Rural and Remote Practitioners on High-Acuity Low-Occurrence Procedures: Pilot Randomized Controlled Trial.

BACKGROUND: The provision of acute medical care in rural and remote areas presents unique challenges for practitioners. Therefore, a tailored approach to training providers would prove beneficial. Although simulation-based medical education (SBME) has been shown to be effective, access to such training can be difficult and costly in rural and remote areas. OBJECTIVE: The aim of this study was to evaluate the educational efficacy of simulation-based training of an acute care procedure delivered remotely, using a portable, self-contained unit outfitted with off-the-shelf and low-cost telecommunications equipment (mobile telesimulation unit, MTU), versus the traditional face-to-face approach. A conceptual framework based on a combination of Kirkpatrick's Learning Evaluation Model and Miller's Clinical Assessment Framework was used. METHODS: A written procedural skills test was used to assess Miller's learning level- knows-at 3 points in time: preinstruction, immediately postinstruction, and 1 week later. To assess procedural performance (shows how), participants were video recorded performing chest tube insertion before and after hands-on supervised training. A modified Objective Structured Assessment of Technical Skills (OSATS) checklist and a Global Rating Scale (GRS) of operative performance were used by a blinded rater to assess participants' performance. Kirkpatrick's reaction was measured through subject completion of a survey on satisfaction with the learning experiences and an evaluation of training. RESULTS: A total of 69 medical students participated in the study. Students were randomly assigned to 1 of the following 3 groups: comparison (25/69, 36%), intervention (23/69, 33%), or control (21/69, 31%). For knows, as expected, no significant differences were found between the groups on written knowledge (posttest, P=.13). For shows how, no significant differences were found between the comparison and intervention groups on the procedural skills learning outcomes immediately after the training (OSATS checklist and GRS, P=1.00). However, significant differences were found for the control versus comparison groups (OSATS checklist, P<.001; GRS, P=.02) and the control versus intervention groups (OSATS checklist, P<.001; GRS, P=.01) on the pre- and postprocedural performance. For reaction, there were no statistically significant differences between the intervention and comparison groups on the satisfaction with learning items (P=.65 and P=.79) or the evaluation of the training (P=.79, P=.45, and P=.31). CONCLUSIONS: Our results demonstrate that simulation-based training delivered remotely, applying our MTU concept, can be an effective way to teach procedural skills. Participants trained remotely in the MTU had comparable learning outcomes (shows how) to those trained face-to-face. Both groups received statistically significant higher procedural performance scores than those in the control group. Participants in both instruction groups were equally satisfied with their learning and training (reaction). We believe that mobile telesimulation could be an effective way of providing expert mentorship and overcoming a number of barriers to delivering SBME in rural and remote locations.

Transoceanic Telementoring of Tube Thoracostomy Insertion: A Randomized Controlled Trial of Telementored Versus Unmentored Insertion of Tube Thoracostomy by Military Medical Technicians.

Background:Tension pneumothorax is a frequent cause of potentially preventable death. Tube thoracostomy (TT) can obviate death but is invasive and fraught with complications even in experienced hands. We assessed the utility of a remote international virtual network (RIVN) of specialized mentors to remotely guide military medical technicians (medics) using wireless informatics.Methods:Medics were randomized to insert TT in training mannequins (TraumaMan; Abacus ALS, Meadowbrook, Australia) supervised by RIVN or not. The RIVN consisted of trauma surgeons in Canada and Australia and a senior medic in Ohio. Medics wore a helmet-mounted wireless camera with laser pointer to confirm anatomy and two-way voice communication using commercial software (Skype®). Performance was measured through objective task completion (pass/fail) regarding safety during the procedure, proper location, and secure anchoring of the tube, in addition to remote mentor opinion and subjective debrief.Results:Fourteen medics attempted TT, seven mentored and seven not. The RIVN was functional and surgeons on either side of the globe had real-time communication with the mentees. TT placement was considered safe, successful, and secure in 100% of mentored (n = 7) procedures, although two (29%) received corrective remote guidance. All (100%) of the unmentored attempted and adequately secured the TT and were safe. However, only 71% (n = 5) completed the task successfully (p = 0.46). Participating medics subjectively felt remote telementoring (RTM) increased self-confidence (strong agreement mean 5/5 ± 0); confidence to perform field TT (agreement (4/5 ± 1); and decreased anxiety (strong agreement 5/5 ± 1). Subjectively, the remote mentors felt in 100% of the mentored procedures that "yes" they were able to assist the medics (1.86 ± 0.38), and in 71% (n = 5) felt "yes" they made TT safer (2.29 ± 0.49).Conclusions:RTM descriptively increased the success of TT placement and allowed for real-time troubleshooting from thousands of kilometers with a redundant capability. RTM was subjectively associated with high levels of satisfaction and self-reported self-confidence. Continued controlled and critical evaluation and refinement of telemedical techniques should continue. Trial Registration: ID ISRCTN/77929274.

Development and validation of an objective assessment scale for chest tube insertion under 'direct' and 'indirect' rating.

BACKGROUND: There is an increasing need for objective and validated educational concepts. This holds especially true for surgical procedures like chest tube insertion (CTI). Thus, we developed an instrument for objectification of learning successes: the assessment scale based on Objective Structured Assessment of Technical Skill (OSATS) for chest tube insertion, which is evaluated in this study. Primary endpoint was the evaluation of intermethod reliability (IM). Secondary endpoints are 'indirect' interrater reliability (IR) and construct validity of the scale (CV). METHODS: Every participant (N = 59) performed a CTI on a porcine thorax. Participants received three ratings (one 'direct' on site, two 'indirect' via video rating). IM compares 'direct' with 'indirect' ratings. IR was assessed between 'indirect' ratings. CV was investigated by subgroup analysis based on prior experience in CTI for 'direct' and 'indirect' rating. RESULTS: We included 59 medical students to our study. IM showed moderate conformity ('direct' vs. 'indirect 1' ICC = 0.735, 95% CI: 0.554-0.843; 'direct' vs. 'indirect 2' ICC = 0.722, 95% CI 0.533-0.835) and good conformity between 'direct' vs. 'average indirect' rating (ICC = 0.764, 95% CI: 0.6-0.86). IR showed good conformity (ICC = 0.84, 95% CI: 0.707-0.91). CV was proven between subgroups in 'direct' (p = 0.037) and 'indirect' rating (p = 0.013). CONCLUSION: Results for IM suggest equivalence for 'direct' and 'indirect' ratings, while both IR and CV was demonstrated in both rating methods. Thus, the assessment scale seems a reliable method for rating trainees' performances 'directly' as well as 'indirectly'. It may help to objectify and facilitate the assessment of training of chest tube insertion.

Evaluation of effectiveness of a paediatric simulation course in procedural skills for paediatric residents - A pilot study.

OBJECTIVE: To explore the effects of simulation training on paediatric residents' confidence and skills in managing advanced skills in critical care. METHODS: The study was conducted at Alfaisal University, Riyadh, Saudi Arabia, from March to June 2016, and comprised junior residents in paediatrics. All paediatric residents (years 1 and 2) were recruited into two workshops, held one week apart. The first workshop covered lumbar puncture/ cerebrospinal fluid interpretation, oral intubation, bone marrow aspiration, and critical airway management. The second workshop covered chest tube insertion, pleural tap, insertion of central line, and arthrocentesis. The participants were surveyed using a 5-point Likert scale survey pre- and post-course, assessing their confidence. Their practical skills were assessed using a pre-objective structured clinical examination on the same day and post-course objective structured clinical examination a week later on selected skills. The outcome measures were: (1) pre-/post-course confidence rating, and (2) pre-/post-course objective structured clinical examination results. Data was analysed using SPSS 20. RESULTS: Of the 16 participants, 8(50%) were boys and 8(50%) girls. Besides, 13(81%) residents were in year-1 and 3(19%) in year-2. Median post-course confidence level ranks for all the skills were higher (p<0.05). There was no improvement in mean pre-objective structured clinical examination scores (2.31±2.66/ 7.46±3.02) and post- objective structured clinical examination scores (22.54±4.39/ 31.85±6.90) in Year 1 residents (p<0.001). CONCLUSIONS: Simulation course was significantly successful in improving residents' clinical skills and confidence in performing critical tasks.

Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action.

Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.

Development of a training model for small animal thoracocentesis and chest tube thoracostomy.

Training veterinary students to perform emergency procedures, such as thoracocentesis and chest tube thoracostomy, poses challenges in terms of providing adequate hands-on experience without compromising animal welfare. A small animal thoracocentesis and chest tube thoracostomy model has been developed, that allows repetitive practice in a safe, standardised environment. The model has been incorporated into a clinical skills laboratory, where students work through computerised case studies in small groups, performing thoracocentesis or chest tube thoracostomy where indicated during the case. Student feedback indicated a high degree of satisfaction with the model and the laboratory experience, high perceived value of the case studies in improving learning, and increased confidence to perform the procedures under supervision. This model can replace the use of live animals while students are practising these procedures, improving their technique, and learning the appropriate safeguards used to prevent injuries such as pulmonary trauma.

Construct validation of a small-animal thoracocentesis simulator.

Training students to perform emergency procedures is a critical but challenging component of veterinary education. Thoracocentesis is traditionally taught in the classroom, with students progressing to "see one, do one, teach one" during the clinical phase of their education. This method of teaching does not permit students to gain proficiency before performing thoracocentesis on a live animal in a high-stakes, high-stress environment and is dependent on the availability of animals requiring the procedure. A veterinary thoracocentesis simulator has been created to allow students an opportunity for repetitive practice in a low-stakes environment. This study evaluated the face, content, and construct validity of the thoracocentesis simulator. Face and content validation were confirmed by survey results, and construct validity was assessed through comparison of student and veterinarian performance on the simulator. Students' median checklist and global rating scores were significantly lower than those of the veterinarians, and students took significantly longer to perform the procedure, indicating that the simulator was able to differentiate the relative expertise of the user and establishing construct validity. This study supported the use of the thoracocentesis simulator for educators to demonstrate proper technique, for students to practice the steps needed to perform the procedure and experience an approximation of the tactile aspects of the task, and for formative assessment before performing the procedure on client-owned animals.

A Multidisciplinary Curriculum to Standardize Chest Procedures Training for Trainees in General Surgery, Emergency Medicine, and Critical Care.

Introduction: Critical care, emergency medicine, and surgical trainees frequently perform surgical and Seldinger-technique tube thoracostomy, thoracentesis, and thoracic ultrasound. However, approaches to teaching these skills are highly heterogeneous. Over 10 years, we have developed a standardized, multidisciplinary curriculum to teach these procedures. Methods: Emergency medicine residents, surgical residents, and critical care fellows, all in the first year of their respective programs, underwent training in surgical and Seldinger chest tube placement and securement, thoracentesis, and thoracic ultrasound. The curriculum included preworkshop instructional videos and 45-minute in-person practice stations (3.5 hours total). Sessions were co-led by faculty from emergency medicine, thoracic surgery, and pulmonary/critical care who performed real-time formative assessment with standardized procedural steps. Postcourse surveys assessed learners' confidence before versus after the workshop in each procedure, learners' evaluations of faculty by station and specialty, and the workshop overall. Results: One hundred twenty-three trainees completed course evaluations, demonstrating stable and positive responses from learners of different backgrounds taught by a multidisciplinary group of instructors, as well as statistically significant improvement in learner confidence in each procedure. Over time, we have made incremental changes to our curriculum based on feedback from instructors and learners. Discussion: We have developed a unique curriculum designed, revised, and taught by a multidisciplinary faculty over many years to teach a unified approach to the performance of common chest procedures to surgical, emergency medicine, and critical care trainees. Our curriculum can be readily adapted to the needs of institutions that desire a standardized, multidisciplinary approach to thoracic procedural education.

Accuracy of Needle Thoracostomy Site Selection among US Army Medics.

BACKGROUND: Tension pneumothorax is a prominent cause of potentially survivable death on the battlefield. Field management for suspected tension pneumothorax is immediate needle thoracostomy (NT). Recent data noted higher NT success rates and ease of insertion at the fifth intercostal space, anterior axillary line (5th ICS AAL), leading to an amendment of the Committee on Tactical Combat Casualty Care recommendations on managing suspected tension pneumothorax to include the 5th ICS AAL as a viable alternative site for NT placement. The objective of this study was to assess the overall accuracy, speed, and ease of NT site selection and compare these outcomes between the second intercostal space, midclavicular line (2nd ICS MCL) and 5th ICS AAL among a cohort of Army medics. METHODS: We designed a prospective, observational, comparative study and recruited a convenience sample of US Army medics from a single military installation to localize and mark the anatomic location where they would perform an NT at the 2nd ICS MCL and 5th ICS AAL on 6 live human models. The marked site was compared for accuracy to an optimal site predetermined by investigators. We assessed the primary outcome of accuracy via concordance with the predetermined NT site location at the 2nd ICS MCL and 5th ICS MCL. Secondarily, we compared time to final site marking and the influence of model body mass index (BMI) and gender on accuracy of selection between sites. RESULTS: A total of 15 participants performed 360 NT site selections. We found a significant difference between participants' ability to accurately target the 2nd ICS MCL compared to the 5th ICS AAL (42.2% versus 10% respectively, p is less than 0.001). The overall accuracy rate among all NT site selections was 26.1%. We also found a significant difference in time-to-site identification between the 2nd ICS MCL and 5th ICS AAL in favor of the 2nd ICS MCL (median [IQR] 9 [7.8] seconds versus 12 [12] seconds, p is less than 0.001). CONCLUSIONS: US Army medics may be more accurate and faster at identifying the 2nd ICS MCL when compared to the 5th ICS AAL. However, overall site selection accuracy is unacceptably low, highlighting an opportunity to enhance training for this procedure.

Use of mobile learning module improves skills in chest tube insertion.

BACKGROUND: Just-In-Time Learning is a concept increasingly applied to medical education, and its efficacy must be evaluated. MATERIALS AND METHODS: A 3-minute video on chest tube insertion was produced. Consenting participants were assigned to either the video group, which viewed the video on an Apple® iPod Touch immediately before chest tube insertion, or the control group, which received no instruction. Every participant filled out a questionnaire regarding prior chest tube experience. A trained clinician observed participants insert a chest tube on the TraumaMan® task simulator, and assessed performance using a 14-item skills checklist. RESULTS: Overall, 128 healthcare trainees participated, with 50% in the video group. Participants included residents (34.4%, n = 44), medical students (32.8%, n = 42), and U.S. Army Forward Surgical Team members (32.8%, n = 42). Sixty-nine percent of all participants responded that they had never placed a chest tube, but 7% had placed more than 20. Only 25% of the participants had previously used TraumaMan®. Subjects who viewed the video scored better on the skills checklist than the control group (11.09 ± 3.09 versus 7.17 ± 3.56, P < 0.001, Cohen's D = 1.16). Medical students (9.33 ± 2.65 versus 4.52 ± 3.64, P < 0.001), Forward Surgical Team members (10.07 ± 2.52 versus 8.57 ± 3.22, P < 0.001), anesthesia residents (8.25 ± 2.56 versus 5.9 ± 2.23, P = 0.017), and subjects who had placed fewer than 10 chest tubes (9.7 ± 3 versus 6.6 ± 3.9, P < 0.001) performed significantly better with the video. CONCLUSIONS: The procedural animation video is an effective medium for teaching procedural skills. Embedding the video on a mobile device, and allowing trainees to access it immediately before chest tube insertion, may enhance and standardize surgical education for civilians and military personnel.

Mannequin simulation improves the confidence of medical students performing tube thoracostomy: a prospective, controlled trial.

This study was undertaken to determine the educational benefits of mannequin simulation for performance of tube thoracostomy in a porcine model by medical students. Thirty medical students were randomized into two groups; the first performed tube thoracostomy on a mannequin simulator and then a porcine model; the second used only the porcine model. Performance measures included completion of subtasks, time to perform the procedure, a global score assigned by faculty raters, and a self-evaluation survey. Subtask completion rate was similar in both groups (P > 0.05). Mean time to perform the procedure was 9.8 minutes (+/- 0.9, simulator), and 9.3 minutes (+/- 1.0, nonsimulator, P > 0.05). Global scores were 12.3 (+/- 1.3, simulator) and 11.0 (+/- 1.4, non-simulator, P > 0.05). Self-evaluation of confidence (1 = "very", 7 = "not at all") showed the simulator group was significantly more confident (3.4 +/- 0.42) than the nonsimulator group (4.7 +/- 0.49, P < 0.05). All students met basic competencies to perform tube thoracostomy. The simulator group felt significantly more confident to subsequently perform the procedure on a patient, whereas performance was not statistically significantly different for the two groups. Further trials may be needed to delineate the optimal role for these simulators in teaching tube thoracostomy.

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 SurgeMan, 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.

Needle thoracostomy by non-medical law enforcement personnel: preliminary data on knowledge retention.

INTRODUCTION: Tension pneumothorax is the second leading cause of preventable combat death. Although relatively simple, the management of tension pneumothorax is considered an advanced life support skill set. The purpose of this study was to assess the ability of non-medical law enforcement personnel to learn this skill set and to determine long-term knowledge and skill retention. METHODS: After completing a pre-intervention questionnaire, a total of 22 tactical team operators completed a 90-minute-long training session in recognition and management of tension pneumothorax. Post-intervention testing was performed immediately post-training, and at one- and six-months post-training. RESULTS: Initial training resulted in a significant increase in knowledge (pre: 1.3 +/- 1.35, max score 7; post: 6.8 +/- 0.62, p < 0.0001). Knowledge retention persisted at one- and six-months post-training, without significant decrement. CONCLUSIONS: Non-medical law enforcement personnel are capable of learning needle decompression, and retain this knowledge without significant deterioration for at least six months.

A Peer-Reviewed Instructional Video is as Effective as a Standard Recorded Didactic Lecture in Medical Trainees Performing Chest Tube Insertion: A Randomized Control Trial.

OBJECTIVE: Online medical education resources are becoming an increasingly used modality and many studies have demonstrated their efficacy in procedural instruction. This study sought to determine whether a standardized online procedural video is as effective as a standard recorded didactic teaching session for chest tube insertion. DESIGN: A randomized control trial was conducted. Participants were taught how to insert a chest tube with either a recorded didactic teaching session, or a New England Journal of Medicine (NEJM) video. Participants filled out a questionnaire before and after performing the procedure on a cadaver, which was filmed and assessed by 2 blinded evaluators using a standardized tool. SETTING: Western University, London, Ontario. Level of clinical care: institutional. PARTICIPANTS: A total of 30 fourth-year medical students from 2 graduating classes at the Schulich School of Medicine & Dentistry were screened for eligibility. Two students did not complete the study and were excluded. There were 13 students in the NEJM group, and 15 students in the didactic group. RESULTS: The NEJM group׳s average score was 45.2% (±9.56) on the prequestionnaire, 67.7% (±12.9) for the procedure, and 60.1% (±7.65) on the postquestionnaire. The didactic group׳s average score was 42.8% (±10.9) on the prequestionnaire, 73.7% (±9.90) for the procedure, and 46.5% (±7.46) on the postquestionnaire. There was no difference between the groups on the prequestionnaire (Δ + 2.4%; 95% CI: -5.16 to 9.99), or the procedure (Δ -6.0%; 95% CI: -14.6 to 2.65). The NEJM group had better scores on the postquestionnaire (Δ + 11.15%; 95% CI: 3.74-18.6). CONCLUSIONS: The NEJM video was as effective as video-recorded didactic training for teaching the knowledge and technical skills essential for chest tube insertion. Participants expressed high satisfaction with this modality. It may prove to be a helpful adjunct to standard instruction on the topic.

Evaluation of Monaldi's approach with regard to needle decompression of the tension pneumothorax-A cadaver study.

BACKGROUND: Although needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi's approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels. METHODS: Six participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed. RESULTS: The needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06cm in right and from 3.00 to 5.00cm in left hemithoraces. The distance C-B lay between 1.03cm and 1.87cm (right side), and 0.84cm and 2.02cm (left side). CONCLUSION: In our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi's approach is a safe method for needle decompression of pneumothorax.

Teaching project: a low-cost swine model for chest tube insertion training.

OBJECTIVE: to describe and evaluate the acceptance of a low-cost chest tube insertion porcine model in a medical education project in the southwest of Paraná, Brazil. METHODS: we developed a low-cost and low technology porcine model for teaching chest tube insertion and used it in a teaching project. Medical trainees - students and residents - received theoretical instructions about the procedure and performed thoracic drainage in this porcine model. After performing the procedure, the participants filled a feedback questionnaire about the proposed experimental model. This study presents the model and analyzes the questionnaire responses. RESULTS: seventy-nine medical trainees used and evaluated the model. The anatomical correlation between the porcine model and human anatomy was considered high and averaged 8.1±1.0 among trainees. All study participants approved the low-cost porcine model for chest tube insertion. CONCLUSION: the presented low-cost porcine model for chest tube insertion training was feasible and had good acceptability among trainees. This model has potential use as a teaching tool in medical education.

A human cadaveric workshop: One solution to competence in the face of rarity.

Competent performance of cricothyroidotomy, lateral canthotomy and resuscitative thoracostomy is an expected standard for Australasian emergency physicians, but infrequent exposure to these procedures could impair physician confidence, reducing the likelihood of their execution in a critical timeframe. Training to perform these procedures is a recognised challenge for non-surgeons, and cadaver-based training is one method of addressing this need. We describe a 1 day cadaver-based workshop for emergency medicine doctors and briefly report on its impact on physician confidence. This workshop appeared effective in increasing the confidence of emergency medicine physicians to carry out rarely performed life and sight-saving procedures and also provides an opportunity for senior clinicians to increase compliance with continuing profession development schemes.