Teaching Endotracheal Intubation Using a Cadaver Versus a Manikin-based Model: a Randomized Controlled Trial

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel.

OBJECTIVES

To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams.

METHODS

Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired.

RESULTS

Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%).

CONCLUSIONS

An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Practicing Emergency Medicine in the Metaverse: A Novel Mixed Reality Casualty Care Training Platform

BACKGROUND

Current casualty care training modalities present several challenges, including limited simulation facilities, instructor dependence, lack of standardization, documentation of trainees' performance and training personalization. The study presents the design, development and preliminary evaluation of a novel hybrid training platform to address these challenges.

METHODS

A mixed reality platform was chosen and developed to address field operators' requirements. The platform is easy to operate and can be set up by laypeople within 20-min in multiple environments. Individual-level training documentation is generated autonomously following each session, evaluating 30 aspects of performance. From this, a unique aggregated dataset emerges as a substrate for executives' dashboards and intelligent planning of future sessions.

RESULTS

An evaluation process took part using simulator-based training in different stages along the project using a questionnaire (Likert-scale based). Fifty military physicians took part in an identical head injury scenario requiring airway management by endotracheal intubation and were immediately surveyed.

CONCLUSION

TrauMR is an agile hybrid training that harbors the potential to address many of the emerging challenges of training for prehospital care in combat and civilian environments.

Efficacy of a single-day task trainer-based extracorporeal membrane oxygenation training course

Background

Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology used to treat respiratory and heart failure. The coronavirus pandemic has resulted in significantly more ECMO patients worldwide. However, the number of hospitals with ECMO capabilities and ECMO-trained staff are limited. Training of personnel in ECMO could supplement this demand.

Objective

To evaluate our previously developed ECMO course using a task trainer-based training, as opposed to an existing live tissue-training model, and determine if such a program was adequate and could be expanded to other facilities.

Methods

Seventeen teams, each consisting of a physician and nurse, underwent a 5 hour accelerated ECMO course in which they watched prerecorded ECMO training lectures, primed circuit, cannulated, initiated ECMO, and corrected common complications. Training success was evaluated via knowledge and confidence assessments and observation of each team attempting to initiate ECMO while troubleshooting complications on a Yorkshire swine.

Results

Seventeen teams successfully completed the course. Sixteen teams (94%, 95% CI = 71%-100%) successfully placed the swine on veno-arterial ECMO. Of those 16 teams, 15 successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments and confidence levels of physicians and nurses increased by 24.3% from pretest (mean of 65.3%, SD 14.4%) to posttest (mean of 89.6%, SD 10.3%), p < 0.0001.

Conclusions

An abbreviated one day lecture and hands-on task trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live tissue training program.

Emergency Critical Skills Training for Pre-clinical Physician Assistant Students: Mixed Method Comparison of Training Method

INTRODUCTION

The fast-paced nature of physician assistant (PA) programs warrants an emphasis on high-fidelity, critical care skills training. Generally, manikins or task trainers are used for training and assessing. Soft-preserved cadavers provide a high-fidelity model to teach high-acuity, low-opportunity procedures; however, their effectiveness in PA pre-clinical training is not well understood.

OBJECTIVE

This study compared procedural competency of task trainer and soft-preserved cadaver trained pre-clinical PA (pcPA) students in completing tube thoracostomy, endotracheal intubation, intraosseous infusion, and needle thoracostomy.

METHODS

A randomized controlled study was conducted with pcPA students (n = 48) at a midwestern program. Participants were randomly assigned to cadaver trained (CT), task trainer (TT), or control group (CG). We assessed procedural competency using skill-specific rubrics and performed qualitative analysis of student comments regarding skill-specific procedural preparedness.

RESULTS

Intervention groups surpassed the control group on all skills. The CT students exhibited significantly higher procedural competency compared to TT-trained students in endotracheal intubation (p = 0.0003) and intraosseous infusion (p = 0.0041). Thematic analysis of student comments revealed pre-training students consistently felt unprepared and lacked confidence to perform needle thoracostomy, tube thoracostomy, and endotracheal intubation. Post-training perceptions, CT/TT, focused on preparedness and confidence. The CT group also consistently described the impact of realistic simulation.

CONCLUSION

High-fidelity training with soft-preserved cadavers may be the most effective way to prepare pcPA students to perform endotracheal intubation and intraosseous infusion. Student perspectives on procedural preparedness highlight the importance of multidimensional, realistic training methods.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01575-0.

Re-creating reality: validation of fresh frozen full cadaver airway training with videolaryngoscopy and bougie FIRST strategy

Background

Tracheal intubation is the gold standard in emergency airway management. One way of measuring intubation quality is first pass success rate (FPSR). Mastery of tracheal intubation and maintenance of the skill is challenging for non-anesthesiologists. A combination of individual measures can increase FPSR. Videolaryngoscopy is an important tool augmenting laryngeal visualization. Bougie-first strategy can further improve FPSR in difficult airways. Standardized positioning maneuvers and manipulation of the soft tissues can enhance laryngeal visualization. Fresh frozen cadavers (FFC) are superior models compared to commercially manufactured manikins. By purposefully manipulating FFCs, it is possible to mimic the pre-hospital intubation conditions of helicopter emergency medical service (HEMS).

Methods

Twenty-four trauma surgeons (12 per Group, NOVICES: no pre-hospital experience, HEMS: HEMS physicians) completed an airway training course using FFCs. The FFCs were modified to match airway characteristics of 60 prospectively documented intubations by HEMS physicians prior to the study (BASELINE). In four scenarios the local HEMS airway standard (1: unaided direct laryngoscopy (DL), OLD) was compared to two scenarios with modifications of the intubation technique (2: augmented DL (bougie and patient positioning), 3: augmented videolaryngoscopy (aVL)) and a control scenario (4: VL and bougie, positioning by participant, CONTROL). FPSR, POGO score, Cormack and Lehane grade and duration of intubation were recorded. No participant had anesthesiological qualifications or experience in VL.

Results

The comparison between CONTROL and BASELINE revealed a significant increase of FPSR and achieved C&L grade for HEMS group (FPSR 100%, absolute difference 23%, p ≤ .001). The use of videolaryngoscopy, bougie, and the application of positioning techniques required significantly more time in the CONTROL scenario (HEMS group: mean 34.0 s (IQR 28.3–47.5), absolute difference to BASELINE: 13.0 s, p = .045). The groups differed significantly in the median number of real-life intubations performed in any setting (NOVICES n = 5 (IQR 0–18.75), HEMS n = 68 (IQR 37.25–99.75)). In the control scenario no significant differences were found between both groups. The airway characteristics of the FFC showed no significant differences compared to BASELINE.

Conclusion

Airway characteristics of a pre-hospital patient reference group cared for by HEMS were successfully reproduced in a fresh frozen cadaver model. In this setting, a combination of evidence based airway management techniques results in high FPSR and POGO rates of non-anesthesiological trained users. Comparable results (FPSR, POGO, duration of intubation) were achieved regardless of previous provider experience. The BOAH concept can therefore be used in the early stages of airway training and for skill maintenance.

The time required to achieve endotracheal intubation in dogs: a comparison of veterinary students and qualified veterinary surgeons

OBJECTIVE

To determine whether final year veterinary students take longer to perform endotracheal intubation than qualified veterinary surgeons.

STUDY DESIGN

Observational cohort study.

ANIMALS

A total of 38 healthy mesocephalic dogs undergoing general anaesthesia for a clinical purpose unrelated to this study.

METHODS

Time to successful endotracheal intubation, measured from termination of intravenous induction drug administration to confirmation of endotracheal intubation, was recorded for two groups: final year veterinary students (group S) and qualified veterinary surgeons (group V). Animal age, breed and anaesthetic induction agent were also recorded. Following normality testing the groups were compared for each variable using the Student's t test or Mann-Whitney U test where appropriate. The level of significance was defined as p < 0.05. Timed data are presented as median and interquartile range.

RESULTS

Time to successful intubation was 54.2 (31.3) seconds in group S and 11.7 (8.5) seconds in group V, the difference being significant (p < 0.001). There was also a significant difference between groups for animal age (p = 0.036) but not for breed (p = 0.573) or induction agent (p = 0.239).

CONCLUSIONS

and clinical relevance Veterinary students take longer to achieve successful endotracheal intubation of anaesthetized healthy dogs compared with qualified veterinary surgeons. To mitigate any additional risk of dogs developing hypoxaemia, it is recommended that a 55 second time limit is set after which the supervisor intervenes and takes over the intubation procedure. Preoxygenation may be used as an additional mitigation strategy.

Barrier Enclosure for Endotracheal Intubation in a Simulated COVID-19 Scenario: A Crossover Study

Introduction

Barrier enclosures have been developed to reduce the risk of COVID-19 transmission to healthcare providers during intubation, but little is known about their impact on procedure performance. We sought to determine whether a barrier enclosure delays time to successful intubation by experienced airway operators.

Methods

We conducted a crossover simulation study at a tertiary academic hospital. Participants watched a four-minute video, practiced one simulated intubation with a barrier enclosure, and then completed one intubation with and one without the barrier enclosure (randomized to determine order). The primary outcome measure was time from placement of the video laryngoscope at the lips to first delivered ventilation. Secondary outcomes were periprocedural complications and participant responses to a post-study survey.

Results

Proceduralists (n = 50) from emergency medicine and anesthesiology had median intubation times of 23.6 seconds with practice barrier enclosure, 20.5 seconds with barrier enclosure, and 16.7 seconds with no barrier. Intubation with barrier enclosure averaged 4.5 seconds longer (95% confidence interval, 2.7–6.4, p < .001) than without, but was less than the predetermined clinical significance threshold of 10 seconds. Three complications occurred, all during the practice intubation. Barrier enclosure made intubation more challenging according to 48%, but 90% indicated they would consider using it in clinical practice.

Conclusion

Experienced airway operators performed intubation using a barrier enclosure with minimal increased time to procedure completion in this uncomplicated airway model. Given potential to reduce droplet spread, use of a barrier enclosure may be an acceptable adjunct to endotracheal intubation for those familiar with its use.