Teaching basic fiberoptic intubation skills in a simulator: initial learning and skills decay

Current Clinical and Educational Uses of Immersive Reality in Anesthesia: Narrative Review

BACKGROUND

The concept of immersive reality (IR), an umbrella term that encompasses virtual reality, augmented reality, and mixed reality, has been established within the health care realm as a potentially valuable tool with numerous applications in both medical education and patient care.

OBJECTIVE

This review aimed to introduce anesthesiologists to the emerging and rapidly evolving literature on IR, its use in anesthesia education, and its transferability into the clinical context.

METHODS

A review of the relevant literature was conducted using the PubMed database from inception to July 5, 2023. Additional references were identified from the reference lists of selected papers.

RESULTS

A total of 51 papers related to the use of IR in anesthesia medical education (including both technical and nontechnical skills) and 63 papers related to applications in clinical practice (eg, preprocedure planning, patient education, and pain management) were included. We present evidence supporting the use of IR in the training and clinical practice of modern anesthesiologists.

CONCLUSIONS

IR is useful for a variety of applications in anesthesia medical education and has potential advantages over existing simulation approaches. Similarly, IR has demonstrated potential improvements in patient care across several clinical contexts relevant to practicing anesthesiologists. However, many applications remain in the early stages of development, and robust trials are urgently needed to confirm clinical or educational effectiveness and to assess mechanisms, educational validity, and cost-effectiveness.

[Features of general anesthesia during dental interventions in children with dystrophic epidermolysis bullosa]

OBJECTIVE

To summarize and present the experience of general anesthesia with nasotracheal intubation for children suffering from dystrophic epidermolysis bullosa (DBE) during dental interventions on an outpatient basis.

MATERIALS AND METHODS

In 2023, 18 children with DBE received dental treatment under general anesthesia, two patients underwent general anesthesia twice a month with a break due to the large volume of intervention.

RESULTS

The paper highlights the main features of preoperative examination of this category of patients, preparation for monitoring, induction of anesthesia, and ensuring patency of the upper respiratory tract. The practical recommendations and techniques mentioned in the article allow the anesthesiologist to minimize the risks of damage to the skin and mucous membrane of the mouth and pharynx. The duration of anesthesia ranged from 50 to 225 minutes, the average duration of anesthesia was 135 minutes. The observation time in the wake-up ward ranged from 105 to 360 minutes, the average time of postoperative observation was 177 minutes. There were no perioperative hemodynamic and respiratory disorders.

CONCLUSION

With proper preparation of the anesthesiological team, strict observance of the rules for working with children suffering from DBE, general combined anesthesia with nasotracheal intubation ensure a high safety profile for these patients and create comfortable conditions for high-quality dental work.

Handoff Education Interventions: A Scoping Review Focused on Sustaining Improvements

Handoffs involve the transfer of patient information and responsibility for care between health care professionals. The purpose of the current scoping review was (1) to describe handoff studies with education as part of the intervention and (2) to explore the role of handoff educational interventions in sustaining handoff improvements. This scoping review utilized previously published systematic reviews and a structured, systematic search of 5 databases (January 2006-June 2020). Articles were identified, and data were extracted by pairs of trained, independent reviewers. The search identified 74 relevant articles, most published after 2015 (70%) and conducted in the United States (76%). Almost all of the studies (99%) utilized instruction, 66% utilized skills practice, 89% utilized a memory aid, and 43% utilized reinforcement. However, few studies reported using education theory or followed accepted tenets of curriculum development. There has been a substantial increase over time in reporting actual handoff behavior change (17%-68%) and a smaller but important increase in reporting patient outcomes (11%-18%). Thirty-five percent of studies (26/74) had follow-up for 6 months or more. Twelve studies met the criteria for sustained change, which were follow-up for 6 months or more and achieving statistically significant improvements in either handoff skills/processes or patient outcomes at the conclusion of the study. All 12 studies with sustained change used multi-modal educational interventions, and reinforcement was more likely to be used in these studies than all others (75%, 9/12) versus (37%, 23/62), P = 0.015. Future handoff intervention efforts that include education should use education theory to guide development and include needs assessment and goals and measurable objectives. Educational interventions should be multi-modal and include reinforcement. Future research studies should measure actual handoff behavior change (skills/process) and patient outcomes, include follow-up for more than 6 months, and use education reporting guidelines.

Retention of En Route Cricothyroidotomy Skills in Novice Providers Following a Simulation-Based Mastery Learning Curriculum

INTRODUCTION

Surgical cricothyroidotomy (SC) is a vital skill that combat first responders must master as airway obstruction is the third most preventable cause of death on the battlefield. Degradation of skills over time is a known problem, and there is inadequate knowledge regarding the rate of SC skill retention. Our prior study showed that simulation-based mastery learning was effective in training 89 novices how to reliably perform an en route SC to mastery performance standards. This study aims to assess the durability of this skill by bringing participants back in 3 separate cohorts at 6, 12, or 24 months following the initial training to perform SC in the same test environment.

MATERIALS AND METHODS

This was a randomized prospective trial. Random cohorts of equal subjects who previously underwent SC simulation-based mastery learning training were selected to return at 6, 12, and 24 months to retest in the same en route medical evacuation (MEDEVAC) helicopter scenario. A total of 22, 14, and 10 subjects returned at 6, 12, and 24 months, respectively, due to Coronavirus-19 impacts and travel limitations. Participants in the 24-month cohort received a refresher training prior to retesting. All attempts were recorded and blindly graded using the same 10 item standardized SC checklist used in initial training. Our previous work found that mastery criteria for performing a SC were ≤40 seconds and completion of 9/10 items on the checklist. Outcome measures in this study were time to complete the procedure and percent of subjects who completed at least 9/10 items on the SC checklist.

RESULTS

There was an increase in time required to complete the procedure compared to initial training in all three retesting cohorts (initial: median 27.50, interquartile range 25.38-31.07 seconds; 6 months: median 36.33, interquartile range 31.59-55.22 seconds; 12 months: median 49.50, interquartile range 41.75-60.75 seconds; 24 months: median 38.79, interquartile range 30.20-53.08 seconds; P < .0001, P < .0001, P = .0039). There was a decline in median value checklist scores compared to initial training in the 6- and 12-month retesting cohorts (initial: median 10.00/10, interquartile range 9.50-10.00; 6 months: median 8.00/10, interquartile range 6.75-9.00; 12 months: median 8.00/10, interquartile range 6.75-9.25; P < .0001, P < .001). There was no difference in median checklist scores between the initial and 24-month retesting scenario (initial: median 10.00/10, interquartile range 9.50-10.00; 24 months: 10.00/10, interquartile range 9.00-10.00; P= .125). There was a decrease in retention of skills as only 31.82% of subjects at 6 months and 14.29% at 12 months met the defined passing criteria of time to completion of ≤40 seconds and checklist score of ≥9/10. A brief refresher course several months prior to the 24-month cohort retesting greatly increased the retention of SC procedural skills, with 60% of subjects meeting the time and checklist criteria.

CONCLUSIONS

This study showed that the skill required to perform a SC after initial mastery training does decay significantly. A brief refresher course can help increase retention of skills. Based on our findings SC skills should be refreshed at a minimum of every 6 months to assure optimal proficiency.

Does an instructional video as a stand-alone tool promote the acquisition of practical clinical skills? A randomised simulation research trial of skills acquisition and short-term retention

BACKGROUND

The effectiveness of instructional videos as a stand-alone tool for the acquisition of practical skills is yet unknown because instructional videos are usually didactically embedded. Therefore, we evaluated the acquisition of the skill of a humeral intraosseous access via video in comparison to that of a self-study with an additional retention test.

METHODS

After ethical approval, we conducted two consecutive studies. Both were designed as randomised controlled two-armed trials with last-year medical students as independent samples at our institutional simulation centre of a tertiary university hospital centre. In Study 1, we randomly assigned 78 participants to two groups: Vid-Self participants watched an instructional video as an intervention, followed by a test, and after seven days did a self-study as a control, followed by a test. Self-Vid ran through the trial in reverse order. In Study 2, we investigated the influence of the sequence of the two teaching methods on learning success in a new sample of 60 participants: Vid-Self watched an instructional video and directly afterward did the self-study followed by a test, whereas Self-Vid ran through that trial in reverse order. In Studies 1 and 2, the primary outcome was the score (worst score = 0, best score = 20) of the test after intervention and control. The secondary outcome in Study 1 was the change in score after seven days.

RESULTS

Study 1: The Vid-Self (Participants n = 42) was superior to the Self-Vid (n = 36) (mean score 14.8 vs. 7.7, p < 0.001). After seven days, Self-vid outperformed Vid-Self (mean score 15.9 vs. 12.5, p < 0.001). Study 2: The Vid-Self (n = 30) and Self-Vid (n = 30) scores did not significantly differ (mean 16.5 vs. mean 16.5, p = 0.97).

CONCLUSION

An instructional video as a stand-alone tool effectively promotes the acquisition of practical skills. The best results are yielded by a combination of an instructional video and self-study right after each other, irrespective of sequence.

TRIAL REGISTRATIONS

ClinicalTrials.gov: NCT05066204 (13/04/2021) (Study 1) and NCT04842357 (04/10/2021) (Study 2).

Evaluation of a 12-hole clock model for improving bronchoscopic skills in simulated normal and difficult airways among anesthesia residents: A randomized controlled study

BACKGROUND

Simulation-based training is used to improve fiberoptic bronchoscopic skills for novices. We developed a nonanatomical task trainer (named 12-hole clock model) that focused on training manipulation of bronchoscopes. The aim of this study was to evaluate the training effect of this model on bronchoscopic skills and learning interests in simulated normal and difficult airways among anesthesia residents.

METHODS

Forty-three anesthesia residents without experience in bronchoscopic intubation were randomly divided into control (n = 22) and intervention groups (n = 21). All participants received standard multimedia learning and a baseline test using a normal airway manikin. Then, the control and intervention groups engaged in 60 minutes of training via a traditional airway manikin or the clock model, respectively. After training, the participants completed bronchoscopic performance assessments in simulated normal and difficult airways, as well as an electronic questionnaire related to the course.

RESULTS

During training, the total hands-on time of bronchoscopic practice recorded by trainees' themselves was longer in the intervention group than in the control group (1568 ± 478 seconds vs 497 ± 172 s, P < .0001). Posttraining, the time required to visualize the carina in simulated normal airways was longer in the intervention group than in the control group (22.0 [18.0, 29.0] vs 14.0 [10.8, 18.3], P < .0001), while it was shorter for simulated difficult airways (24.0 [16.0, 32.0] s vs 27.0 [21.0, 35.5] s, P = .0425). The survey results indicated that confidence in bronchoscopic intubation increased in both groups, without significant differences in satisfaction, acceptance, or perceived difficulty between the groups. However, the interest ratings were higher in the intervention group than in the control group.

CONCLUSIONS

The 12-hole clock model is a simple and feasible method for improving bronchoscopic skills and promoting interest among trainees.

TRIAL REGISTRATION

NCT05327842 at Clinicaltrials.gov.

Simulation-based bronchoscopy training: Randomized trial comparing worked example to video introduction

INTRODUCTION

Learning the complex skill of bronchoscopy involves the integration of cognitive domains and motor skills. The development of simulators has opened up new possibilities in bronchoscopy training. This study aimed at evaluating how effective the modeling example methodology is in training this skill and assessed its effect on cognitive load in learning.

METHODS

Forty-seven medical students participating in a simulator-based bronchoscopy training program were randomly allocated to a control group, receiving a video lesson, and the modeling example group. They were evaluated by the simulator's metrics at different time points: pre-, posttest, and 15 days and 12 months after training. Cognitive load was assessed with the modified Paas scale.

RESULTS

Simulation-based training was effective for both groups, based on simulator metrics (p < .05). The modeling example group outperformed the control group in all measures at posttest and after 15 days (p < .001). After 12 months, there was a decline in skill in both groups, but the modeling example group performed better (p < .001). Simulation-based training reduced cognitive load, more strongly so in the modeling example group (p < .001).

CONCLUSION

The modeling example group showed substantial benefits over the control group, both in reducing the cognitive load in learning and in retaining knowledge and skill after 15 days and 12 months.

Is there a benefit for anesthesiologists of adding difficult airway scenarios for learning fiberoptic intubation skills using virtual reality training? A randomized controlled study

Fiberoptic intubation for a difficult airway requires significant experience. Traditionally only normal airways were available for high fidelity bronchoscopy simulators. It is not clear if training on difficult airways offers an advantage over training on normal airways. This study investigates the added value of difficult airway scenarios during virtual reality fiberoptic intubation training. A prospective multicentric randomized study was conducted 2019 to 2020, among 86 inexperienced anesthesia residents, fellows and staff. Two groups were compared: Group N (control, n = 43) first trained on a normal airway and Group D (n = 43) first trained on a normal, followed by three difficult airways. All were then tested by comparing their ORSIM® scores on 5 scenarios (1 normal and 4 difficult airways). The final evaluation ORSIM® score for the normal airway testing scenario was significantly higher for group N than group D: median score 76% (IQR 56.5-90) versus 58% (IQR 51.5-69, p = 0.0039), but there was no difference in ORSIM® scores for the difficult intubation testing scenarios. A single exposure to each of 3 different difficult airway scenarios did not lead to better fiberoptic intubation skills on previously unseen difficult airways, when compared to multiple exposures to a normal airway scenario. This finding may be due to the learning curve of approximately 5-10 exposures to a specific airway scenario required to reach proficiency.

Confidence in airway management proficiency: a mixed methods study of intensive care specialists in Australia and New Zealand

Objective: To explore self-confidence, and the respective facilitators and barriers, among intensive care specialists in Australia and New Zealand in relation to airway management. Design: A mixed methods study. Setting: 11 intensive care units across Australia and New Zealand. Participants: 48 intensive care specialists. Intervention: A structured online interview and the presentation of three discrete airway management clinical scenarios - routine endotracheal intubation, awake fibreoptic intubation (AFOI), and emergency front of neck access (FONA). Main outcome measures: Graded Likert scale responses regarding confidence in airway management were analysed, and perceptions of facilitators and barriers to confidence in each select scenario were obtained as free text. A deductive thematic analysis was done iteratively on free text entry and allowed for the development of a coding framework. NVivo software used the coding framework to run coding queries and cross-tabulations for comparison of relationships between themes and participant demographic characteristics. Results: Participants reported differing levels of confidence. Clinical experience, an anaesthetic qualification and training (including simulation) were the major facilitators to influencing confidence. Participants were more confident performing routine intubation than AFOI or FONA. Equipment, checklists or protocols, and availability of video-laryngoscopy were also identified as facilitators to confidence by most participants. Work relationships, teams and other staff availability were identified as further facilitators to confidence; lack of these factors were less commonly identified as barriers. Conclusions: Confidence in airway management among intensive care specialists in Australia and New Zealand varies, both between specialists and depending on clinical context. Multiple facilitators to improving this exist, including additional mandatory training.

Practice what you teach: An approach to integrate airway education for experienced anesthesia clinicians

BACKGROUND

The COVID-19 pandemic has disrupted clinician education. To address this challenge, our divisional difficult airway program (AirEquip) designed and implemented small-group educational workshops for experienced clinicians. Our primary aim was to test the feasibility and acceptability of a small-group, flexible-curriculum skills workshop conducted during the clinical workday. Secondary objectives were to evaluate whether our workshop increased confidence in performing relevant skills and to assess the work-effort required for the new program.

METHODS

We implemented a 1:1 and 2:1 (participant to facilitator ratio) airway skills workshop for experienced clinicians during the workday. A member of the AirEquip team temporarily relieved the attendee of clinical duties to facilitate participation. Attendance was encouraged but not required. Feasibility was assessed by clinician attendance, and acceptability was assessed using three Likert scale questions and derived from free-response feedback. Participants completed pre and postworkshop surveys to assess familiarity and comfort with various aspects of airway management. A work-effort analysis was conducted and compared to the effort to run a previously held larger-format difficult airway conference.

RESULTS

Fifteen workshops were conducted over 7 weeks; members of AirEquip were able to temporarily assume participants' clinical duties. Forty-seven attending anesthesiologists and 17 CRNAs attended the workshops, compared with six attending anesthesiologists and five CRNAs who attended the most recent larger-format conference. There was no change in confidence after workshop participation, but participants overwhelmingly expressed enthusiasm and satisfaction with the workshops. The number of facilitator person-hours required to operate the workshops (105 h) was similar to that required to run a single all-day larger-format conference (104.5 h).

CONCLUSION

It is feasible and acceptable to incorporate expert-led skills training into the clinical workday. Alongside conferences and large-format instruction, this modality enhances the way we are able to share knowledge with our colleagues. This concept can likely be applied to other skills in various clinical settings.

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion: a survey of internal medicine trainees in Scotland

BACKGROUND

Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience.

METHODS

Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student's unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance.

RESULTS

Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P =  < 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience.

CONCLUSIONS

SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.

Bronchoscopy simulation training in the post-pandemic world

Bronchoscopy is an important procedure to examine the airways. It is traditionally taught by having trainees perform it in humans. This carries risks, albeit rarely, and causes stress to trainees. The objective of this study was to review bronchoscopy simulators, as well as their use in and impact on medical education, presenting perspectives on the use of simulators in the post-pandemic world. This review was based on articles published in English in 2000-2021 and retrieved from any of the following databases: MEDLINE (PubMed), Embase, SciELO, and Google Scholar. Bronchoscopy simulators have improved markedly over time, allowing the teaching/learning process to take place in a risk-free environment. Bronchoscopy simulation training is an interesting option for the evaluation of the airways, especially in the coming years, with the COVID-19 pandemic highlighting the need for continuing medical education.

A surgical needs assessment for airway rapid responses: A retrospective observational study

BACKGROUND

Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition.

METHODS

A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event.

RESULTS

A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis.

CONCLUSION

Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures.

LEVEL OF EVIDENCE

Epidemiologic/prognostic, level III.

Managing the difficult airway: A survey of doctors with different seniority in China

ABSTRACT

Although equipment and human resources are vital elements of difficult airway management (DAM). But the approach and practice of DAM are more important. So, we conducted the present survey to address anesthesiologists of different working years in this knowledge gap.This nationwide cross-sectional study was conducted from October 27, 2016 to November 27, 2016. The survey was completed online in New Youth Anesthesia Forum including DAM assessment, anticipated and unanticipated DAM, difficult airway algorithm, use of the front of neck access (FONA) technique and training, DAM outside the operation room, and difficult extubation management.We received 1935 replies (44%). Mouth opening and Mallampati classification were the most common methods to evaluate difficult airways. When suffering from unanticipated difficult airway 63% less than 10 years anesthesiologists (LA) and 65% more than 10 years anesthesiologists (MA) would ask for help after trying 1 to 2 times (P = .000). More than 70% of LA and MA respondents reported preferring cannula cricothyrotomy to deal with emergency airway, 507 (41.6%) MA respondents reported that they used FONA techniques to save patients' lives (P = .000). Nearly 70% respondents worried full stomach when intubated outside operation room and more than 80% respondents selected auscultation to identify the placement. More than 80% respondents had not used Bougie to assist extubation. A 73.2% respondents know ABS algorithm and 96.4% know Chinese airway expert consensus among MA respondents, this was significant to LA respondents (P = .000).The respondents in the LA and MA have a training gap in their evaluation of difficult airways, trained and used FONA emergency skills, facilitated of the airway guidelines at home and abroad. Also, we should provide more airway theory and skill training to our young doctors to advanced airway skills.

Technical validation of multi-section robotic bronchoscope with first person view control for transbronchial biopsies of peripheral lung

This study aims to validate the advantage of the new engineering method to maneuver multi-section robotic bronchoscope with first person view control in transbronchial biopsy. Six physician operators were recruited and tasked to operate a manual and a robotic bronchoscope to the peripheral area placed in patient-derived lung phantoms. The metrics collected were the furthest generation count of the airway the bronchoscope reached, force incurred to the phantoms, and NASA-Task Load Index. The furthest generation count of the airway the physicians reached using the manual and the robotic bronchoscopes were 6.6 +/- 1.2th and 6.7 +/- 0.8th. Robotic bronchoscopes successfully reached the 5th generation count into the peripheral area of the airway, while the manual bronchoscope typically failed earlier in the 3rd generation. More force was incurred to the airway when the manual bronchoscope was used (0.24 +/- 0.20 [N]) than the robotic bronchoscope was applied (0.18 +/- 0.22 [N], p<0.05). The manual bronchoscope imposed more physical demand than the robotic bronchoscope by NASA-TLX score (55 +/- 24 vs 19 +/- 16, p<0.05). These results indicate that a robotic bronchoscope facilitates the advancement of the bronchoscope to the peripheral area with less physical demand to physician operators. The metrics collected in this study would expect to be used as a benchmark for the future development of robotic bronchoscopes.

Flexible fibreoptic intubation in swine - improvement for resident training and animal safety alike

Background

Efficient airway management to facilitate tracheal intubation encompasses essential skills in anaesthesiologic and intensive care. The application of flexible fibreoptic intubation in patients with difficult airways has been identified as the recommended method in various international guidelines. However, providing the opportunity to adequately train residents can be challenging. Using large animals for practice during ongoing studies could help to improve this situation, but there is no recent data on fibreoptic intubation in swine available.

Methods

Thirty male German landrace pigs were anesthetized, instrumented and randomized into two groups. The animals were either intubated conventionally using direct laryngoscopy or a single-use flexible video-endoscope. The intervention was carried out by providers with 3 months experience in conventional intubation of pigs and a brief introduction into endoscopy. Intubation attempts were supervised and aborted, when SpO2 dropped below 93%. After three failed attempts, an experienced supervisor intervened and performed the intubation. Intubation times and attempts were recorded and analysed.

Results

Flexible fibreoptic intubation showed a significantly higher success rate in first attempt endotracheal tube placement (75% vs. 47%) with less attempts overall (1.3 ± 0.6 vs. 2.1 ± 1.3, P = 0.043). Conventional intubation was faster (42 s ± 6 s vs. 67 s ± 10s, P < 0.001), but showed a higher complication rate and more desaturation episodes during the trial.

Conclusions

Flexible fibreoptic intubation in swine is feasible and appears to be a safer and more accessible method for inexperienced users to learn. This could not only improve resident training options in hospitals with animal research facilities but might also prevent airway complications and needless animal suffering.

Augmented and Virtual Reality in Anatomical Education - A Systematic Review

Learning anatomy traditionally has depended on traditional techniques like human cadaveric dissection and the use of textbooks. As technology advances at an ever-rapid speed, there are revolutionary ways to learn anatomy. A number of technologies, techniques and methodologies are utilised in anatomical education, but ones specifically receiving a lot of interest and traction is that of augmented reality and virtual reality. Although there has been a surge in interest in the use of these technologies, the literature is sparse in terms of its evaluation as to the effectiveness of such tools. Therefore, the purpose of this study is to examine in greater detail the literature specifically to see what the best practice in this field could be. By undertaking a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched for articles in both Web of Science and PubMed. Using the terms "augmented reality and teaching anatomy" yielded 88 articles. We then used "virtual reality and teaching anatomy" which resulted in 200 articles. We examined these articles, including that on augmented reality and virtual reality used to teach anatomy to undergraduate and postgraduate students, residents, dentistry, nursing and veterinary students. Articles were excluded if they were systematic reviews, literature reviews, review articles, news articles, articles not written in English and any literature that presented how a virtual model was created without the evidence of students testing it. The inclusion and exclusion criteria for virtual reality were the same as augmented reality. In addition, we examined the articles to identify if they contained data which was quantitative, qualitative or both. The articles were further separated into those which were pro, neutral or against for the use of these digital technologies. Of the 288 articles, duplicate articles totalling 67 were removed and 134 articles were excluded according to our exclusion criteria. Of the 31 articles related to augmented reality, 30 were pro, one neutral and no articles against the use of this technology. Fifty-six articles related to virtual reality were categorised resulted in 45 pro, eight neutral and three against the use of this technology. Overall, the results indicate most articles identified related to both virtual and augmented reality were for the use of those technologies, than neutral or against. This systemic review highlights the recent advances of both augmented reality and virtual reality to implementing the technology into the anatomy course.

Decay of Competence with Extended Research Absences During Residency Training: A Scoping Review

A significant number of residents in postgraduate training programs pursue dedicated research training. Currently, no formal curricula exist to transition residents back into clinical roles following dedicated research leave. This scoping review aims to determine what literature exists on the challenges faced by trainees who interrupt their clinical training for extended periods of time for research leave. The Pubmed and Medline databases were searched for all study designs related to postgraduate trainees taking academic or research leave. A three-step selection process including title, abstract and full-article review was employed to identify articles that mentioned decay of knowledge, skill or competence. A narrative review of the literature was generated to present key themes identified within the studies. The search yielded 174 articles of which five investigated resident skill decay during research leave. The five studies included for analysis were cohort studies that used general surgery residents' self-perception and faculty members' perception of residents' skill decay as a measure. Residents and faculty perceived decay of residents' technical skills, leadership skills and knowledge following dedicated research leave. The greatest decay perceived was in technical skills, specifically with more complex tasks and longer periods of non-use. This review identified that residents and faculty perceive a decay of resident skills following dedicated research training. To provide the necessary support to limit this potential decay, as well as to assist in the transition back into clinical training, the needs of and challenges faced by research residents and postgraduate programs must be better understood.

Endotracheal Intubation by Paramedics Using Neodymium Magnet and Modified Stylet in Simulated Difficult Airway: A Prospective, Randomized, Crossover Manikin Study

BACKGROUND

The present study evaluates the success and efficacy of endotracheal intubation (ETI) using a modified intubation stylet and a magnet system to direct the stylet into the trachea. The system was developed by the researchers in an attempt to increase the success and efficacy of ETI.

METHODS

ETI procedures were performed on an airway management manikin by emergency medical technicians with at least four years of experience in ETI. The technicians used a stylet modified with an iron ball affixed to the tip and a neodymium magnet, designed specifically for the study. The intention was to guide the endotracheal tube into the trachea at the level of the thyroid and cricoid cartilages on the manikin with the aid of the modified stylet and the magnetic force of the neodymium magnet. The success rate, completion time, and degree of difficulty of two procedures were compared: magnetic endotracheal intubation (METI) and classic ETI (CETI).

RESULTS

The success rate was 100% in both groups. The mean completion times for the METI and CETI procedures were 18.31 ± 2.46 s and 20.01 ± 1.95 s, respectively. There were significant differences in completion time and degree of difficulty between the METI and CETI procedures (both p=0.001).

CONCLUSIONS

We found the use of a neodymium magnet and modified stylet to be an effective method to guide the endotracheal tube into the trachea. The present study may provide a basis for future studies.

Virtual Reality Distraction during Endoscopic Urologic Surgery under Spinal Anesthesia: A Randomized Controlled Trial

Sedation protocols during spinal anesthesia often involve sedative drugs associated with complications. We investigated whether virtual reality (VR) distraction could be applied during endoscopic urologic surgery under spinal anesthesia and yield better satisfaction than pharmacologic sedation. VR distraction without sedative was compared with pharmacologic sedation using repeat doses of midazolam 1–2 mg every 30 min during urologic surgery under spinal anesthesia. We compared the satisfaction of patients, surgeons, and anesthesiologists, as rated on a 5-point prespecified verbal rating scale. Two surgeons and two anesthesiologists rated the scale and an overall score was reported after discussion. Thirty-seven patients were randomized to a VR group (n = 18) or a sedation group (n = 19). The anesthesiologist’s satisfaction score was significantly higher in the VR group than in the sedation group (median (interquartile range) 5 (5–5) vs. 4 (4–5), p = 0.005). The likelihood of both patients and anesthesiologists being extremely satisfied was significantly higher in the VR group than in the sedation group. Agreement between the scores for surgeons and those for anesthesiologists was very good (kappa = 0.874 and 0.944, respectively). The incidence of apnea was significantly lower in the VR group than in the sedation group (n = 1, 5.6% vs. n = 7, 36.8%, p = 0.042). The present findings suggest that VR distraction is better than drug sedation with midazolam in terms of patient’s and anesthesiologist’s satisfaction and avoiding the respiratory side effects of midazolam during endoscopic urologic surgery under spinal anesthesia.

Absolute clinical skill decay in the medical, nursing and allied health professions: a scoping review protocol

REVIEW QUESTIONS/OBJECTIVES

The objective of this scoping review is to examine and map absolute clinical skill decay in the medical, nursing and allied health professions and to map the range of approaches used to address decay of clinical skills in these professions.Specifically, the review questions are: which clinical skills, performed by which professional groups, are reported to be most susceptible to absolute clinical skill decay, and what approaches have been reported for addressing absolute clinical skill decay in the medical, nursing and allied health professions?In addressing the review questions, the following sub-questions will also be addressed:It is anticipated that this scoping review will inform further systematic review/s on the topic of addressing clinical skill decay in the medical, nursing and allied health professions, as well as identify gaps in the research knowledge base that will inform further primary research.

Creation and Validation of a Simulator for Neonatal Brain Ultrasonography: A Pilot Study

RATIONALE AND OBJECTIVES

Historically, skills training in performing brain ultrasonography has been limited to hours of scanning infants for lack of adequate synthetic models or alternatives. The aim of this study was to create a simulator and determine its utility as an educational tool in teaching the skills that can be used in performing brain ultrasonography on infants.

MATERIALS AND METHODS

A brain ultrasonography simulator was created using a combination of multi-modality imaging, three-dimensional printing, material and acoustic engineering, and sculpting and molding. Radiology residents participated prior to their pediatric rotation. The study included (1) an initial questionnaire and resident creation of three coronal images using the simulator; (2) brain ultrasonography lecture; (3) hands-on simulator practice; and (4) a follow-up questionnaire and re-creation of the same three coronal images on the simulator. A blinded radiologist scored the quality of the pre- and post-training images using metrics including symmetry of the images and inclusion of predetermined landmarks. Wilcoxon rank-sum test was used to compare pre- and post-training questionnaire rankings and image quality scores.

RESULTS

Ten residents participated in the study. Analysis of pre- and post-training rankings showed improvements in technical knowledge and confidence, and reduction in anxiety in performing brain ultrasonography. Objective measures of image quality likewise improved. Mean reported value score for simulator training was high across participants who reported perceived improvements in scanning skills and enjoyment from simulator use, with interest in additional practice on the simulator and recommendations for its use.

CONCLUSIONS

This pilot study supports the use of a simulator in teaching radiology residents the skills that can be used to perform brain ultrasonography.