Simulating the IMA Recipient Site for DIEP Flap Surgery: A New Model for Dynamic Microsurgery Simulation with Real-Time Respiration and a Pilot Study.

BACKGROUND: Breast reconstruction (BR) using autologous free flaps has been shown to have numerous psychosocial and quality-of-life benefits. Unfortunately, the microsurgical learning curve is quite steep due to some unique operative challenges. Currently, there is no realistic simulation model that captures real-life respiratory excursion and the depth of internal mammary vessels within the compact recipient site. The purpose of this study was to delineate intraoperative measurements of depth and motion, describe the resulting simulation model, and conduct a pilot study evaluating the simulator as an educational resource. METHODS: This is a single-center, ethics-approved study. For the intraoperative measurements, all consecutive patients undergoing free flap BR using internal mammary vessels as recipients were recruited. Patient and intraoperative factors as well as intraoperative measurements were recorded. A dynamic model was developed based on intraoperative parameters. For the pilot study, plastic and reconstructive surgery trainees were recruited to complete a hand-sewn internal mammary artery (IMA) anastomosis using the new simulator and completed objective questionnaires pre- and postsimulation. Subjective feedback was recorded and themes determined. RESULTS: Fifteen operative sites were analyzed. Flap pocket was found to be between 4 and 5 cm in depth with vertical excursion of 3.7 ± 1.0mm and a respiratory rate of 9 to 14 breaths/minute. Previous radiation, rib space, body mass index (BMI), blood pressure, heart rate, tidal volume, and respiratory rate showed no correlation to vessel depth/excursion. Laterality, rib space, BMI, radiation, vitals, and tidal volume had no correlation with vessel movement. Twenty-two trainees were included in the pilot. An increase in confidence and mixed results for anxiety was reported. CONCLUSION: This study reports a novel microsurgical simulation model that provides a realistic deep inferior epigastric perforator free flap BR IMA anastomosis experience. It replicates movement of vessels in situ with real-time respiratory excursion and similar physical structures of the internal mammary system. This model shows promising results for increased use in microsurgical education.

Quantitative Assessment of Viral Dispersion Associated with Respiratory Support Devices in a Simulated Critical Care Environment.

Rationale: Patients with severe coronavirus disease (COVID-19) require supplemental oxygen and ventilatory support. It is unclear whether some respiratory support devices may increase the dispersion of infectious bioaerosols and thereby place healthcare workers at increased risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).Objectives: To quantitatively compare viral dispersion from invasive and noninvasive respiratory support modalities.Methods: This study used a simulated ICU room with a breathing-patient simulator exhaling nebulized bacteriophages from the lower respiratory tract with various respiratory support modalities: invasive ventilation (through an endotracheal tube with an inflated cuff connected to a mechanical ventilator), helmet ventilation with a positive end-expiratory pressure (PEEP) valve, noninvasive bilevel positive-pressure ventilation, nonrebreather face masks, high-flow nasal oxygen (HFNO), and nasal prongs.Measurements and Main Results: Invasive ventilation and helmet ventilation with a PEEP valve were associated with the lowest bacteriophage concentrations in the air, and HFNO and nasal prongs were associated with the highest concentrations. At the intubating position, bacteriophage concentrations associated with HFNO (2.66 × 104 plaque-forming units [PFU]/L of air sampled), nasal prongs (1.60 × 104 PFU/L of air sampled), nonrebreather face masks (7.87 × 102 PFU/L of air sampled), and bilevel positive airway pressure (1.91 × 102 PFU/L of air sampled) were significantly higher than those associated with invasive ventilation (P < 0.05 for each). The difference between bacteriophage concentrations associated with helmet ventilation with a PEEP valve (4.29 × 10-1 PFU/L of air sampled) and bacteriophage concentrations associated with invasive ventilation was not statistically significant.Conclusions: These findings highlight the potential differential risk of dispersing virus among respiratory support devices and the importance of appropriate infection prevention and control practices and personal protective equipment for healthcare workers when caring for patients with transmissible respiratory viral infections such as SARS-CoV-2.

A Quantitative Study of Particle Dispersion due to Respiratory Support Modalities in PC-12 Aircraft: Prehospital Patient Transport.

OBJECTIVE: It is unclear whether supplemental oxygen and noninvasive ventilation respiratory support devices increase the dispersion of potentially infectious bioaerosols in a pressurized air medical cabin. This study quantitatively compared particle dispersion from respiratory support modalities in an air medical cabin during flight. METHODS: Dispersion was measured in a fixed wing air ambulance during flight with a breathing medical mannequin simulator exhaling nebulized saline from the lower respiratory tract with the following respiratory support modalities: a nasal cannula with a surgical mask, high-flow nasal oxygen (HFNO) with a surgical mask, and noninvasive bilevel positive airway pressure (BiPAP) ventilation. RESULTS: Nasal cannula oxygen with a surgical mask was associated with the highest particle concentrations. In the absence of mask seal leaks, BiPAP was associated with 1 order of magnitude lower particle concentration compared with a nasal cannula with a surgical mask. Particle concentrations associated with HFNO with a surgical mask were lower than a nasal cannula with a surgical mask but higher than BiPAP. CONCLUSIONS: Particle dispersion associated with the use of BiPAP and HFNO with a surgical mask is lower than nasal cannula oxygen with a surgical mask. These findings may assist air medical organizations with operational decisions where little data exist about respiratory particle dispersion.

Developing and Evaluating Multimedia Patient Education Tools to Better Prepare Prostate-Cancer Patients for Radiotherapy Treatment (Randomized Study).

The purpose of this study is to determine the effectiveness of multimedia educational tools to improve CT planning preparation for intensity modulated radiotherapy (IMRT) for prostate cancer. Many patients are not prepared when given verbal preparation instructions to have a full bladder and empty rectum for their IMRT and require being rescanned, which results in additional costs for the patient and the hospital. A pamphlet and video outlining the proper preparation for prostate IMRT was created to decrease additional scans and the associated costs, while increasing patient satisfaction. A controlled, randomized experimental group study was conducted to examine the effectiveness of the multimedia tools (the video and the pamphlet), as compared to the pamphlet only, in preparing patients for their planning CT appointment. We found no statistical difference between the multimedia group and the pamphlet group in patients' preparedness for their appointments and the rescanning rate. However, patients in the multimedia group indicated that they felt more prepared about their treatment after watching the video and stated that they would recommend the video to other patients with prostate cancer. Furthermore, patients who had to wait longer for their planning CT appointment felt less prepared by the materials than those with a shorter wait time. We recommend reducing wait times between appointments as much as possible to increase patients' preparedness for the planning CT. We conclude that providing multimedia treatment information and minimizing wait times increases patients' feelings of preparedness leading to a more positive treatment experience and reducing costly rescans. TRIAL REGISTRATION: ClinicalTrials.gov NCT02410291.

Using a situational awareness global assessment technique for interprofessional obstetrical team training with high fidelity simulation.

Evidence suggests that breakdowns in communication and a lack of situation awareness contribute to poor performance of medical teams. In this pilot study, three interprofessional obstetrical teams determined the feasibility of using the situation awareness global assessment technique (SAGAT) during simulated critical event management of three obstetrical scenarios. After each scenario, teams were asked to complete questionnaires assessing their opinion of how their performance was affected by the introduction of questions during a SAGAT stop. Fifteen obstetrical professionals took part in the study and completed the three scenarios in teams consisting of five members. At nine questions per stop, more participants agreed or strongly agreed that there were too many questions per stop (57.1%) than when we asked six questions per stop (13%) and three questions per stop (0%). A number of interprofessional differences in response to this interprofessional experience were noted. A team SAGAT score was determined by calculating the proportion of correct responses for each individual. Higher scores were associated with better adherence to outcome times, although not statistically significant. A robust study design building on our pilot data is needed to probe the differing interprofessional perceptions of SAGAT and the potential association between its scores and clinical outcome times.

Cricothyroidotomy In Situ Simulation Curriculum (CRIC Study): Training Residents for Rare Procedures.

INTRODUCTION: Technical skill acquisition for rare procedures can be challenging given the few real-life training opportunities. In situ simulation (ISS), a training technique that takes place in the actual workplace, is a promising method to promote environmental fidelity for rare procedures. This study evaluated a simulation-based technical skill curriculum for cricothyroidotomy using deliberate practice, followed by an ISS evaluation session. METHODS: Twenty emergency medicine residents participated in a two-part curriculum to improve cricothryoidotomy performance. A pretest established participant baseline technical skill. The training session consisted of two parts, didactic teaching followed by deliberate practice using a task-training manikin. A posttest consisted of an unannounced, high-fidelity ISS, during an emergency department shift. The primary outcome was the mean performance time between the pretest and posttest sessions. Skill performance was also evaluated using a checklist scale and global rating scale. RESULTS: Cricothyroidotomy performance time improved significantly from pretest to posttest sessions (mean difference, 59 seconds; P < 0.0001). Both checklist and global rating scales improved significantly from the pretest to the posttest with a mean difference of 1.82 (P = 0.002) and 6.87 (P = 0.0025), respectively. Postcourse survey responses were favorable for both the overall curriculum experience and the unannounced ISS. CONCLUSIONS: This pilot study demonstrated that unannounced ISS is feasible and can be used to effectively measure cricothyroidotomy performance among EM residents. After a two-part training session consisting of didactic learning and deliberate practice, improved cricothyroidotomy skill performance was observed during an unannounced ISS in the emergency department. The integration of ISS in cricothyroidotomy training represents a promising approach; however, further study is needed to establish its role.

Peer coaching to teach faculty surgeons an advanced laparoscopic skill: A randomized controlled trial.

BACKGROUND: Preliminary evidence suggests that coaching is an effective adjunct in resident training. The learning needs of faculty, however, are different from those of trainees. Assessing the effectiveness of peer coaching at improving the technical proficiency of practicing surgeons is an area that remains largely unexplored. The purpose of this study was to assess the efficacy of a peer coaching program that teaches laparoscopic suturing to faculty surgeons. METHODS: Surgeons inexperienced in laparoscopic suturing were randomized to either conventional training or peer coaching. Both groups performed a pretest on a box trainer. The conventional training group then received a web link to a tutorial for teaching laparoscopic suturing and a box trainer for independent practice. In addition to the web link and the box trainer, the peer coaching group received 2 half hour peer coaching sessions. Both groups then performed a stitch on the box trainer that was video recorded. The primary outcome measure was technical performance, which was assessed by a global rating scale. RESULTS: Eighteen faculty were randomized (conventional training n = 9; peer coaching n = 9). Initially, there was no difference in technical skills between the groups (conventional training median score 10 [interquartile range 8.5-15]; peer coaching 13 [10.5-14]; P = .64). After the intervention, the peer coaching group had improved technical performance (conventional training 11 [8.5-12.5]; peer coaching 18 [17-19]; P < .01). Comparing the pre- and postintervention scores within both groups, there was an improvement in technical proficiency in the peer coaching group, yet none in the conventional training group (before conventional training 10 [8.5-15], after conventional training 11 [8.5-12.5]; P = .56; before peer coaching 13 [10.5-14], after peer coaching 18 [17-19]; P < .01). CONCLUSION: This trial demonstrates that a structured peer coaching program can facilitate faculty surgeons learning a novel procedure.