Comparison of AirAngel® vs. Storz® videolaryngoscope and Macintosh® laryngoscope for endotracheal intubation training: prospective randomized crossover study.

BACKGROUND: For both normal and difficult airway management, VL is thought to be more effective. However, VL seems far from being offered as a standard option in both healthcare delivery and educational activities in low-income countries, considering its high costs. Therefore, three-dimensional(3D)printed VLs may be considered an alternative to conventional VLs in low-income countries and other places with limited resources. Our objective was to compare the efficacy of AirAngel 3D-printed VL (3D-PVL) with those of commercially available Storz® VL (SVL) and conventional Macintosh® laryngoscope (MCL) in normal and difficult airway scenarios in the hands of inexperienced users. METHODS: This is a prospective randomized crossover manikin study that included 126 senior medical students with no experience in intubation. The effectiveness of all three laryngoscopy devices in the hands of inexperienced users was evaluated in terms of intubation time, glottic visualization, ease of use, endotracheal tube placement, and intubation success rate. Between 2020 and 2022, 126 last year medical students participated in the study. RESULTS: MCL resulted in significantly longer intubation times than 3D-PVL and SVL in the difficult airway scenario, with no significant difference between 3DPVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction MCL: 28.54 s; SVL: 26.68 s; 3DPVL: 26.64 s). Both SVL and 3D-PVL resulted in significantly better Cormack - Lehane grades in both normal and difficult airway scenarios, and thus provided better glottic viewing than MCL, with no significant difference between 3D-PVL and SVL (Wilcoxon test, p < 0.016; Bonferroni correction, MCL: 1.73; SVL: 1.29; 3DPVL: 1.25). The SVL was the easiest device to use for normal airway scenarios (1: very easy, 5: very difficult), while the MCL was the most difficult (MCL: 2.64; 3DPVL: 1.98; SVL: 1.49). Conversely, no significant difference was found between 3DPVL and other devices in terms of ease of use in difficult airway scenarios and in terms of accurate placement of the endotracheal tube and successful intubation attempts. CONCLUSION: 3D-PVL is a good educational and possible clinical alternative to conventional VL, particularly in places with limited resources, due to its low cost.

Comparing Learning Outcomes of Machine-Guided Virtual Reality-Based Training With Educator-Guided Training in a Metaverse Environment: Randomized Controlled Trial.

BACKGROUND: Virtual reality (VR) modules are commonly used for health care training, such as adult advanced cardiac life support (ACLS), due to immersion and engagement. The metaverse differs from current VR serious gaming by enabling shared social connections, while current VR modules focus on computer-based content without social interaction. Educators in the metaverse can foster communication and collaboration during training sessions. OBJECTIVE: This study aimed to compare learning outcomes of VR-based, machine-guided training with educator-guided, VR-based training in the metaverse environment. METHODS: A total of 62 volunteered students from Acibadem Mehmet Ali Aydinlar University Vocational School for Anesthesiology were randomly divided into 2 groups of 31 participants each: one group received VR-based training with machine guidance (MG), and the other received VR-based training with educator guidance (EG) in the metaverse. The members of both groups undertook VR-based basic training for ACLS. Afterward, the MG group was trained with a VR-based advanced training module, which provides training with full MG, whereas the EG group attended the VR-based, educator-guided training in the metaverse. The primary outcome of the study was determined by the exam score of the VR-based training module. Descriptive statistics defined continuous variables such as VR exam scores and time spent on machine- or educator-guided training. The correlation between training time and VR exam scores was assessed with the Spearman rank correlation, and nonnormally distributed variables were compared using the Mann-Whitney U test. Statistical significance was set at P<.05, with analyses executed by MedCalc Statistical Software (version 12.7.7). RESULTS: Comparing the VR test scores between the MG and EG groups revealed no statistically significant difference. The VR test scores for the EG group had a median of 86 (range 11-100). In contrast, the MG group scores had a median of 66 (range 13-100; P=.08). Regarding the correlation between the duration of machine-guided or educator-guided training and VR-based exam scores, for the MG group, =0.569 and P=.005 were obtained. For the EG group, this correlation was found to be =0.298 and P=.10. While this correlation is statistically significant for the MG group, it is not significant for the EG group. The post hoc power analysis (80%), considering the correlation between the time spent on training and exam scores, supported this finding. CONCLUSIONS: The results of this study suggest that a well-designed, VR-based serious gaming module with MG could provide comparable learning outcomes to VR training in the metaverse with EG for adult ACLS training. Future research with a larger sample size could explore whether social interaction with educators in a metaverse environment offers added benefits for learners. TRIAL REGISTRATION: ClinicalTrials.gov NCT06288087; https://clinicaltrials.gov/study/NCT06288087.

Comparing the Outcomes of Virtual Reality-Based Serious Gaming and Lecture-Based Training for Advanced Life Support Training: Randomized Controlled Trial.

BACKGROUND: Simulation-based Advanced Cardiac Life Support (ACLS) or Advanced Life Support (ALS) training for health care professionals is important worldwide for saving lives. Virtual reality (VR)-based serious gaming can be an alternative modality to be used as a part of simulation-based ALS training. OBJECTIVE: The aim of this study is to investigate whether a VR-based ALS serious game module can replace classroom-based ALS lectures, the latter being part of existing conventional ALS training protocols in addition to skills training. METHODS: Participants were students from Acibadem Mehmet Ali Aydinlar University's Vocational School for Anesthesiology (N=29) randomly divided into 2 groups with 15 (conventional training group) and 14 (VR-based training group) participants each. Participants in the conventional training group had to complete the pretest consisting of multiple-choice questions at the beginning of the study. Afterward, they took part in an interactive classroom-based ALS lecture. The next step involved skills training with task trainers to teach them compression skills. Following this, the conventional training group was divided into Code Blue teams, each consisting of 5 participants for the simulation session. Two independent instructors evaluated video recordings in terms of technical and nontechnical skills. The score acquired from the manikin-based simulation session was considered the main performance indicator in this study to measure the learning outcome. A similar workflow was used for the VR-based training group, but this group was trained with the VR-based ALS serious game module instead of the theoretical lecture. The final stage of the study involved completing the posttest consisting of multiple-choice questions. A preference survey was conducted among the study participants. Mann-Whitney U and Wilcoxon signed-rank tests were used to analyze the 2 groups' performances in this study. RESULTS: The improvement in posttest results compared with pretest results was significant in the conventional training group (P=.002). Hands-on technical scores of the conventional training group were higher than those of the VR-based training group during manikin-based simulation, but total scores, including those for technical and crisis resource management skills, acquired from the manikin-based simulation session did not reveal any significant difference between the 2 groups. The results of the VR preference survey revealed that the majority of the participants prefer VR-based serious game-based training instead of classroom lectures. CONCLUSIONS: Although hands-on technical scores of the conventional training group during the manikin-based simulation session were higher than those of the VR-based training group, both groups' total performance scores, including those for technical and crisis resource management skills, did not differ significantly. The preference survey reveals that the majority of the participants would prefer a VR-based ALS serious gaming module instead of lecture-based training. Further studies are required to reveal the learning outcome of VR-based ALS serious gaming. TRIAL REGISTRATION: ClinicalTrials.gov NCT05798910; https://clinicaltrials.gov/study/NCT05798910.

The emotions experienced by family medicine residents and interns during their clinical trainings: a qualitative study.

BACKGROUND: The family medicine residents and final year medical students are challenged with increased workload and they experience various emotions during their clinical trainings. They are confronted with uncertainties in their role descriptions and they witness illness, suffering and deaths as part of their everyday duties which may lead to burnout. Only several studies have focused on these experiences to find out what the family medicine residents and medical students were literally feeling. AIM: The aim of this study was to explore the family medicine residents' and final year medical students' emotions during their clinical trainings. METHOD: This qualitative study was performed with 15 family medicine residents and 24 final-year medical students using a convenience sample from two medical faculties to explore and analyze their emotions. Data were gathered by means of focus group interviews, including six interviews conducted and recorded through online meetings. Data were analyzed for themes using a thematic analysis approach. Since the interviews reached saturation in terms of content, the interviews were terminated at the end of sixth focus group meetings. Each interview took an average of 45-60 min. RESULTS: Three main themes emerged from the data regarding residents' and interns' emotions. These were the "clinical climate's role", "emotions during patient encounters" and "coping strategies with negative emotions". The most commonly encountered emotions were tension and anxiety followed by frustration and uncertainty. CONCLUSIONS: The family medicine residents and final-year medical students are challenged with emotions during their clinical trainings. Therefore, medical educators have to be aware of the need to support them in reflecting their emotions by prioritizing residents'and interns' well-being.

Teaching and Assessment of Medical Students During Complex Multifactorial Team-Based Tasks: The "Virtual on Call" Case Study.

Abstract: Although considerable efforts have been made to incorporate simulation-based learning (SBL) in undergraduate medical education, to date, most of the medical school curricula still focus on pure knowledge or individual assessment of objective structured clinical examination skills (OSCE). To this end, we designed a case study named "iG4 (integrated generation 4) virtual on-call (iVOC)". We aimed to simulate an on-call shift in a high-fidelity virtual hospital setting in order to assess delegates' team-based performance on tasks related to patient handovers (prioritisation, team allocation). Methods: A total of 41 clinical year medical students were split into 3 cohorts, each of which included 3 groups of 4 or 5 people. The groups consisted of a structured mix of educational and cultural backgrounds of students to achieve homogeneity. Each performing group received the handover for 5 patients in the virtual hospital and had to identify and deal with the acutely unwell ones within 15 minutes. We used TEAMTM tool to assess team-based performances. Results: The mean handover performance was 5.44/10 ± 2.24 which was the lowest across any performance marker. The overall global performance across any team was 6.64/10 ± 2.11. The first rotating team's global performance for each cycle was 6.44/10 ± 2.01, for the second 7.89/10 ± 2.09 and for the third 6.78/10 ± 1.64 (p = 0.099 between groups). Conclusion: This is one of the first reported, high-fidelity, globally reproducible SBL settings to assess the capacity of students to work as part of a multinational team, highlighting several aspects that need to be addressed during undergraduate studies. Medical schools should consider similar efforts with the aim to incorporate assessment frameworks for individual performances of students as part of a team, which can be a stepping-stone for enhancing safety in clinical practice.

Studying Brain Activation during Skill Acquisition via Robot-Assisted Surgery Training.

Robot-assisted surgery systems are a recent breakthrough in minimally invasive surgeries, offering numerous benefits to both patients and surgeons including, but not limited to, greater visualization of the operation site, greater precision during operation and shorter hospitalization times. Training on robot-assisted surgery (RAS) systems begins with the use of high-fidelity simulators. Hence, the increasing demand of employing RAS systems has led to a rise in using RAS simulators to train medical doctors. The aim of this study was to investigate the brain activity changes elicited during the skill acquisition of resident surgeons by measuring hemodynamic changes from the prefrontal cortex area via a neuroimaging sensor, namely, functional near-infrared spectroscopy (fNIRS). Twenty-four participants, who are resident medical doctors affiliated with different surgery departments, underwent an RAS simulator training during this study and completed the sponge suturing tasks at three different difficulty levels in two consecutive sessions/blocks. The results reveal that cortical oxygenation changes in the prefrontal cortex were significantly lower during the second training session (Block 2) compared to the initial training session (Block 1) (p < 0.05).

Team performance training for medical students: Low vs high fidelity simulation.

OBJECTIVES: The aim of this study is to evaluate a simulation-based team performance course for medical students and compare its low- and high-fidelity components. STUDY DESIGN: This is a prospective crossover observational study. Groups participated in one low- and one high-fidelity session twice. Low-fidelity scenarios included management of an emergency case on a simulated-patient, whereas high-fidelity scenarios constituted of multiple-trauma cases where simulated-patients wore a hyper-realistic suit. Team performance was assessed objectively, using the TEAM™ tool, and subjectively using questionnaires. Questionnaires were also used to assess presence levels, stress levels and evaluate the course. RESULTS: Participants' team performance was higher in the low-fidelity intervention as assessed by the TEAM™ tool. An overall mean increase in self-assessed confidence towards non-technical skills attitudes was noted after the course, however there was no difference in self-assessed performance between the two interventions. Both reported mean stress and presence levels were higher for the high-fidelity module. Evaluation scores for all individual items of the questionnaire were ≥4.60 in both NTS modules. Students have assessed the high-fidelity module higher (4.88 out of 5, SD = 0.29) compared to low-fidelity module (4.74 out of 5, SD = 0.67). CONCLUSIONS: Both the low- and high-fidelity interventions demonstrated an improvement in team performance of the attending medical students. The high-fidelity intervention was more realistic, yet more stressful. Furthermore, it proved to be superior in harvesting leadership, teamwork and task management skills. Both modules were evaluated highly by the students, however, future research should address retention of the taught skills and adaptability of such interventions.

Performance Monitoring via Functional Near Infrared Spectroscopy for Virtual Reality Based Basic Life Support Training.

The use of serious game tools in training of medical professions is steadily growing. However, there is a lack of reliable performance assessment methods to evaluate learner's outcome. The aim of this study is to determine whether functional near infrared spectroscopy (fNIRS) can be used as an additional tool for assessing the learning outcome of virtual reality (VR) based learning modules. The hypothesis is that together with an improvement in learning outcome there would be a decrease in the participants' cerebral oxygenation levels measured from the prefrontal cortex (PFC) region and an increase of participants' serious gaming results. To test this hypothesis, the subjects were recruited and divided into four groups with different combinations of prior virtual reality experience and prior Basic Life Support (BLS) knowledge levels. A VR based serious gaming module for teaching BLS and 16-Channel fNIRS system were used to collect data from the participants. Results of the participants' scores acquired from the serious gaming module were compared with fNIRS measures on the initial and final training sessions. Kruskal Wallis test was run to determine any significant statistical difference between the groups and Mann-Whitney U test was utilized to obtain pairwise comparisons. BLS training scores of the participants acquired from VR based serious game's the learning management system and fNIRS measurements revealed decrease in use of resources from the PFC, but increase in behavioral performance. Importantly, brain-based measures can provide an additional quantitative metric for trainee's expertise development and can assist the medical simulation instructors.

Does management of cardiac arrest scenarios differ between residents of different disciplines? A comparison with simulation.

BACKGROUND: Training multidisciplinary teams using simulation allows for communication, development and maintenance of teamwork. In this study we compared the behavior of residents from emergency and anesthesiology departments on treatment of cardiac arrest. METHODS: 42 anesthesiology and 29 emergency residents are included in the study. Two scenarios were designed for diagnosis and treatment of asystole and ventricular fibrillation. First scenario was a case with ventricular fibrillation (VF) and the second was an asystole case. ACLS protocols were used for assessment. Age, years of training, and years in practice were compared for each group. RESULTS: Anesthesiology residents attempted to secure the airway immediately after checking the carotid pulse and began the cardiac compressions. After intubation, the vast majority (88%) of participants monitorized the patient. Only 11.9% of the residents started compressions and were reminded to monitorize the patient. Emergency residents immediately started CPR with compressions and ventilation by mask. 79.3% of them decided to intubate after a few compressions but 20.7% of them didn't attempt it. 50% of the residents monitorized the simulator whereas the other half was reminded to. There was no significant difference between the groups in terms of ventricular fibrillation and asystole management, but the age of the doctors was a decisive factor affecting the success in the VF simulation. CONCLUSIONS: This study demonstrates the use of simulation to identify the deficiencies in basic knowledge and the skills of emergency and anesthesiology residents. It highlights the need to emphasize criteria that should be used in resuscitation.

Job burnout in 159 anesthesiology trainees.

BACKGROUND: Anesthesiology may be stressful and most anesthesiologists develop mechanisms for coping. However, inexperienced trainee anesthesiologists seem to be vulnerable. We studied stress perception and job burnout in trainee anesthesiologists. METHODS: Responses to perceived stress scale (PSS) and Maslach Burnout Inventory (MBI) were evaluated in 159 trainee anesthesiologists. RESULTS: In our results, when perceived stress was increased, emotional exhaustion and depersonalization increased but personal accomplishment decreased, as expected. Perceived stress was very high in the early years of training. There was a negative correlation between age and emotional exhaustion and depersonalization, but positive correlation with personal accomplishment. Female anesthesiologists had higher personal accomplishment, but lower depersonalization points than male anesthesiologists in our study. There was no statistical association between marital status, PSS, and MBI; ≥2 children group had a significant high personal accomplishment but low depersonalization and emotional exhaustion scores. Line regression analysis showed a statistically significant relationship between PSS and emotional exhaustion and between age and depersonalization. CONCLUSIONS: Social factors such as gender and number of children affect the work life of our trainees.