Development and evaluation of a trauma decision-making simulator in Oculus virtual reality

Exploring mobile mixed reality for critical thinking in nursing and healthcare education: A systematic review

BACKGROUND

The shortage of nursing and healthcare clinical placements has prompted the investigation of ways to supplement authentic learning. Mobile mixed reality has become increasingly available, however, the affordances and design principles for the facilitation of critical thinking are yet to be explored.

OBJECTIVE

To examine how mobile mixed reality facilitates critical thinking in nursing and healthcare higher education.

DESIGN

Systematic review.

REVIEW METHODS

A search in seven databases (MEDLINE, PsychINFO, AMED, ERIC, Scopus, Cochrane, and Web of Science) was conducted with 3488 titles and abstracts screened. The quality of the included studies was evaluated using the Mixed Methods Assessment Tool (MMAT).

RESULTS

A total of 12 studies with 1108 participants were included. The breadth of healthcare disciplines was limited to five disciplines that utilised bespoke scenarios on head-mounted displays. Most scenarios were emergency or critical response, with limited time for pre-brief, debrief, or overall user time. Only two studies directly measured critical thinking, with others including indirect reference to diagnoses, interpretation, analysis, or evaluation of healthcare scenarios. Affordances and design principles for the future development of mobile mixed reality for critical thinking in nursing and healthcare higher education are identified.

CONCLUSIONS

While some pedagogical affordances of mobile mixed reality can be identified in a narrow number of healthcare disciplines, there remain to be limited valid measures of critical thinking used to quantify effectiveness. Future studies would benefit from considering scenarios beyond emergency and critical responses, including longitudinal studies that reflect the development of critical thinking over time, and exploration of co-designed scenarios with and by nursing and healthcare students.

Virtual Reality Simulation for Suicide Risk Assessment Training: Prevalence of Adverse Effects

OBJECTIVE

Virtual reality (VR) simulation is changing the landscape of simulation-based medical education. Immersive VR allows users to interact with a computer-generated environment and digital avatars using a VR headset and controllers. However, current literature regarding the use of immersive VR simulation in psychiatric medical education is sparse. This study describes its use and considerations regarding tolerability.

METHODS

At a mental health hospital in Canada, two immersive VR suicide risk assessment (SRA) case simulations were developed. These simulations have participants interview VR patients to characterize their suicide risk, offering a novel and safe way to engage healthcare providers in SRA training. Regarding user tolerability of these VR simulations, the Simulator Sickness Questionnaire (SSQ) was administered to participants after the simulation to characterize any motion sickness symptoms experienced.

RESULTS

Of the 22 participants in this study, the overall SSQ scores demonstrated good tolerability of the VR SRA, with the majority of participants reporting no or minimal simulator sickness symptoms. Moreover, the majority of participants reported being satisfied with this training and that the VR SRA simulation enhanced their learning experience.

CONCLUSION

These study findings are novel, given the current dearth of data regarding the use of immersive VR in simulation-based psychiatric medical education. Further studies exploring the educational effectiveness of VR SRA in simulation-based psychiatric medical education are indicated.

A Systematic Review of Immersive Virtual Reality for Nontechnical Skills Training in Surgery

OBJECTIVE

Immersive virtual reality (IVR) can be utilized to provide low cost and easily accessible simulation on all aspects of surgical education. In addition to technical skills training in surgery, IVR simulation has been utilized for nontechnical skills training in domains such as clinical decision-making and pre-operative planning. This systematic review examines the current literature on the effectiveness of IVR for nontechnical skill acquisition in surgical education.

DESIGN

A literature search was performed using MEDLINE, EMBASE, and Web of Science for primary studies published between January 1, 1995 and February 9, 2022. Four reviewers screened titles, abstracts, full texts, extracted data, and analyzed included studies to answer 5 key questions: How is IVR being utilized in nontechnical skills surgical education? What is the methodological quality of studies? What technologies are being utilized? What metrics are reported? What are the findings of these studies?

RESULTS

The literature search yielded 2340 citations, with 12 articles included for qualitative synthesis. Of included articles, 33% focused on clinical decision-making and 67% on anatomy/pre-operative planning. Motion sickness was a recorded metric in 25% of studies, with an aggregate incidence of 13% (11/87). An application score was reported in 33% and time to completion in 16.7%. A commercially developed application was utilized in 25%, while 75% employed a noncommercial application. The Oculus Rift was used in 41.7% of studies, HTC Vive in 25%, Samsung Gear in 16.7% of studies, Google Daydream in 8%, and 1 study did not report. The mean Medical Education Research Quality Instrument (MERSQI) score was 10.3 ± 2.3 (out of 18). In all studies researching clinical decision-making, participants preferred IVR to conventional teaching methods and in a nonrandomized control study it was found to be more effective. Averaged across all studies, mean scores were 4.33 for enjoyment, 4.16 for utility, 4.11 for usability, and 3.73 for immersion on a 5-point Likert scale.

CONCLUSIONS

The IVR nontechnical skills applications for surgical education are designed for clinical decision-making or anatomy/pre-operative planning. These applications are primarily noncommercially produced and rely upon a diverse array of HMDs for content delivery, suggesting that development is primarily coming from within academia and still without clarity on optimal utilization of the technology. Excitingly, users find these applications to be immersive, enjoyable, usable, and of utility in learning. Although a few studies suggest that IVR is additive or superior to conventional teaching or imaging methods, the data is mixed and derived from studies with weak design. Motion sickness with IVR remains a complication of IVR use needing further study to determine the cause and means of mitigation.

Advances in Pediatric Surgery Simulation-Based Training

Pediatric surgery is the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases. The early history of the specialty followed the classic "see one, do one, teach one" philosophy of training but has since evolved to modern methods including simulation-based training (SBT). Current trainees in pediatric surgery face numerous challenges, such as the decreasing incidence of congenital disease and reduced work hours. SBT consists of several modalities that together assist in the acquisition of technical skills and improve performance in the operating room. SBT has evolved to incorporate simulator models and video gaming technology, in parallel with the development of simulation in other surgical and non-surgical pediatric fields. SBT has advanced to a level of sophistication that means that it can improve the skills of not only pediatric surgery trainees but also practicing attending surgeons. In this review, we will discuss the history of pediatric surgery, simulation in pediatric surgery training, and the potential direction of pediatric surgical simulation training in the future.

Virtual reality in simulation-based emergency skills training: A systematic review with a narrative synthesis

Objective

An important role is predicted for virtual reality (VR) in the future of medical education. We performed a systematic review of the literature with a narrative synthesis, to examine the current evidence for VR in simulation-based emergency skills training. We broadly define emergency skills as any clinical skill used in the emergency care of patients across all clinical settings.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The data sources accessed during this study included: PubMed, CINAHL, EMBASE, AMED, EMCARE, HMIC, BNI, PsychINFO, Medline, CENTRAL, SCOPUS, Web of Science, BIOSIS Citation Index, ERIC, ACM Digital Library, IEEE Xplore, and ProQuest Dissertations and Thesis Global. Cochrane's Rob 2 and ROBVIS tools were used during study quality assessment. No ethical review was required for this work.

Results

Thirty-four articles published between 14th March 1998 and 1st March 2022 were included in this review. Studies were predominantly conducted in the USA and Europe and focussed on a variety of healthcare disciplines including medical, nursing, and allied health. VR education was delivered using head-mounted displays, Cave Automatic Virtual Environment systems, and bespoke setups. These systems delivered education in a variety of areas (emergency medicine, equipment training, obstetrics, and basic/advanced life support). Subjective potential advantages of this technology included realism, replayability, and time-effectiveness. Reports of adverse events were low in frequency across the included studies. Whilst clear educational benefit was generally noted, this was not reflected in changes to patient-based outcomes.

Conclusion

There may be educational benefit to using VR in the context of simulation-based emergency skills training including knowledge gain and retention, skill performance, acceptability, usability, and validity. Currently, there is insufficient evidence to demonstrate clear cost-effectiveness, or direct improvement of patient or institutional outcomes, at this stage.

Physiologic Fidelity as a Domain in Assessing Mixed Reality Trauma Simulation

INTRODUCTION

Mixed reality has been used in trauma and emergency medicine simulation for more than a decade. As mixed reality potential in trauma simulation continues to expand, so too does the need to validate it as a surrogate for real-life emergency scenarios. Validation of these simulations can occur by measuring fidelity, or the degree to which a computing system can reproduce real-world experiences. After performing a literature review, we determined that most fidelity assessments of trauma and emergency simulations focus on how the user subjectively experiences the simulation. Although subjective user assessment is an important component of determining fidelity, we pose an introductory three-part framework that may assess mixed reality trauma simulation more adequately.

MATERIALS AND METHODS

A literature review was conducted using Google Scholar, PubMed, and the Uniformed Services University PowerER search database. Relevant articles were assessed to identify how studies measured fidelity in trauma simulation. We then designed the three-part framework to aid researchers in assessing the fidelity of mixed reality trauma simulations.

RESULTS

The domains we determined to best assess mixed reality emergency simulation are as follows:1. Continue assessing fidelity via subjective user assessments. This allows the researcher to know how real the simulation looked and felt to the user based on their individual report.2. Determine whether the trauma simulation changes the medical decision-making capacity of the user. If the user's decision-making capacity changes with a stress-inducing trauma simulation versus a non-stress-inducing simulation, then the stress-inducing trauma environment would be approaching greater fidelity.3. Study the domain of our newly proposed concept: physiologic fidelity. We define physiologic fidelity as the degree to which the simulation elicits a measurable, autonomic response independent of observed emotion or perceived affect. Recreating objective autonomic arousal may be the best way to ensure a trauma simulation reaches fidelity.

CONCLUSION

We propose a methodology to assess mixed reality trauma simulation fidelity. Once fidelity is more fully known to the researcher and the simulation user, adjustments can be made to approach reality more closely. Improved simulators may enrich the preparedness of both junior and senior learners for real-life emergencies. We believe assessing the three domains using the Wide Area Virtual Experience at the Val G. Hemming simulation center in Bethesda, MD, will validate mixed reality-trauma simulators as invaluable surrogates for real-life emergency scenarios and ultimately contribute to improved clinical outcomes for clinicians and their patients.

Injured Avatars: The Impact of Embodied Anatomies and Virtual Injuries on Well-Being and Performance

Human cognition relies on embodiment as a fundamental mechanism. Virtual avatars allow users to experience the adaptation, control, and perceptual illusion of alternative bodies. Although virtual bodies have medical applications in motor rehabilitation and therapeutic interventions, their potential for learning anatomy and medical communication remains underexplored. For learners and patients, anatomy, procedures, and medical imaging can be abstract and difficult to grasp. Experiencing anatomies, injuries, and treatments virtually through one's own body could be a valuable tool for fostering understanding. This work investigates the impact of avatars displaying anatomy and injuries suitable for such medical simulations. We ran a user study utilizing a skeleton avatar and virtual injuries, comparing to a healthy human avatar as a baseline. We evaluate the influence on embodiment, well-being, and presence with self-report questionnaires, as well as motor performance via an arm movement task. Our results show that while both anatomical representation and injuries increase feelings of eeriness, there are no negative effects on embodiment, well-being, presence, or motor performance. These findings suggest that virtual representations of anatomy and injuries are suitable for medical visualizations targeting learning or communication without significantly affecting users' mental state or physical control within the simulation.

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.

Effectiveness of virtual reality in nursing education: a systematic review and meta-analysis

OBJECTIVE

This study aims to assess the transformative potential of Virtual Reality (VR) has shown significant potential in transforming nursing education by providing immersive and interactive learning experiences. Our objective is to systematically evaluate and conduct a meta-analysizes on the impact effect of virtual reality technology in teaching nursing students.

METHODS

To achieve this, we conducted comprehensive computer searches on platforms including of PubMed, Web of Science, Wiley Online Library, Zhiwang database, Wanfang database, and China Biomedical Literature Service (SinoMed), were conducted to collect randomized controlled trial studies on the use of virtual reality's technology for teaching nursing students built up to until March 2023., and the Cochrane Furthermore, the quality of the included literature was assessed evaluated using the quality evaluation criteria specified for randomized controlled trial studies within the Cochrane provided in the evaluation handbook manual. In addition, a meta-analysis was performed using Review Manager 5.3 software.

RESULTS

The aggregate outcomes from a total of 12 randomized controlled trials, encompassing including 1167 students, indicate were included. Meta-analysis results showed that virtual reality technology significantly enhances could better improve nursing students'' theoretical knowledge [(SMD = 0.97, 95% CI [0.48, 1.46], p < 0.001)], practical skills (SMD = 0.52, 95% CI [0.33, 1.46], p < 0.001), skill retention, (SMD = 0.52, 95% CI [0.33, 0.71], p < 0.001), and satisfaction levels (SMD = 1.14, 95% CI [0.85, 1.43], p < 0.001), in comparison with traditional or alternative teaching methodologies. However, no statistically significant impact was observed on the enhancement of critical thinking skills (SMD = 0.79, 95% CI [-0.05, 1.64], p = 0.07) among nursing students.

CONCLUSION

Our findings underscore that compared to conventional teaching methods, virtual reality offers superior potential in advancing nursing students' theoretical knowledge, practice proficiencies, and overall satisfaction, while not yielding a significant advantage in enhancing critical thinking skills. The incorporated literature consisted exclusively of randomized controlled trials, albeit a subset of these studies omitted descriptions of the allocation concealment strategy.

Developing a virtual reality (VR) application for practicing the ABCDE approach for systematic clinical observation

BACKGROUND

The Airways, Breathing, Circulation, Disability, Exposure (ABCDE) approach is an international approach for systematic clinical observation. It is an essential clinical skill for medical and healthcare professionals and should be practiced repeatedly. One way to do so is by using virtual reality (VR). The aim was therefore to develop a VR application to be used by inexperienced health students and professionals for self-instructed practice of systematic clinical observation using the ABCDE approach.

METHODS

An iterative human-centred approach done in three overlapping phases; deciding on the ABCDE approach, specifying the requirements, and developing the application.

RESULTS

A total of 138 persons were involved. Eight clinical observations were included in the ABCDE approach. The requirements included making it possible for inexperienced users to do self-instructed practice, a high level of immersion, and a sense of presence including mirroring the physical activities needed to do the ABCDE approach, allowing for both single and multiplayer, and automatic feedback with encouragement to repeat the training. In addition to many refinements, the testing led to the development of some new solutions. Prominent among them was to get players to understand how to use the VR hand controllers and start to interact with the VR environment and more instructions like showing videos on how to do observations. The solutions in the developed version were categorised into 15 core features like onboarding, instructions, quiz, and feedback.

CONCLUSION

A virtual reality application for self-instructed practice of systematic clinical observation using the ABCDE approach can be developed with sufficient testing by inexperienced health students and professionals.

Examining the impact of virtual reality on clinical decision making - An integrative review

BACKGROUND

Clinical decision making is an essential cognitive skill in nursing. It is a process undertaken daily by nurses as they make judgements about patient care and manage complex issues as they arise. Virtual reality is an emerging technology that is increasingly being used pedagogically to teach non-technical skills including CDM, communication, situational awareness, stress management, leadership, and teamwork.

OBJECTIVE

The objective of this integrative review are to synthesise the research findings regarding the impact of virtual reality on clinical decision making in undergraduate nurses.

DESIGN

An integrative review using Whittemore and Knafl's framework for integrated reviews.

DATA SOURCES

An extensive search was conducted of healthcare databases including CINAHL, Medline and Web of Science between 2010 and 2021 using the terms virtual reality, clinical decision and undergraduate nursing.

REVIEW METHODS

The initial search located 98 articles. After screening and checking for eligibility, 70 articles were critically reviewed. Eighteen studies were included in the review and were critically appraised using the Critical Appraisal Skills Program checklist for qualitative papers and McMaster's Critical appraisal form for quantitative papers.

RESULTS

Research in the use of VR has demonstrated its potential to improve undergraduate nurses' critical thinking, clinical reasoning, clinical judgement and clinical decision-making skills. Students perceive these teaching modalities to be beneficial to the development of their clinical decision-making ability. There is lack of research related to the use of immersive virtual reality in developing and enhancing undergraduate nursing students' clinical decision-making skills.

CONCLUSION

Current research on the impact of virtual reality on the development of nursing CDM has demonstrated positive results. VR is one pedagogical approach that could further assist, however, there are no identified studies that focus on its impact in developing CDM, therefore further studies are required to address this gap in the literature.

The Effects of Immersive Virtual Reality Applications on Enhancing the Learning Outcomes of Undergraduate Health Care Students: Systematic Review With Meta-synthesis

BACKGROUND

Immersive virtual reality (IVR) applications are gaining popularity in health care education. They provide an uninterrupted, scaled environment capable of simulating the full magnitude of sensory stimuli present in busy health care settings and increase students' competence and confidence by providing them with accessible and repeatable learning opportunities in a fail-safe environment.

OBJECTIVE

This systematic review aimed to evaluate the effects of IVR teaching on the learning outcomes and experiences of undergraduate health care students compared with other teaching methods.

METHODS

MEDLINE, Embase, PubMed, and Scopus were searched (last search on May 2022) for randomized controlled trials (RCTs) or quasi-experimental studies published in English between January 2000 and March 2022. The inclusion criteria were studies involving undergraduate students majoring in health care, IVR teaching, and evaluations of students' learning outcomes and experiences. The methodological validity of the studies was examined using the Joanna Briggs Institute standard critical appraisal instruments for RCTs or quasi-experimental studies. The findings were synthesized without a meta-analysis using vote counting as the synthesis metric. A binomial test with P<.05 was used to test for statistical significance using SPSS (version 28; IBM Corp). The overall quality of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation tool.

RESULTS

A total of 17 articles from 16 studies totaling 1787 participants conducted between 2007 and 2021 were included. The undergraduate students in the studies majored in medicine, nursing, rehabilitation, pharmacy, biomedicine, radiography, audiology, or stomatology. The IVR teaching domains included procedural training (13/16, 81%), anatomical knowledge (2/16, 12%), and orientation to the operating room setting (1/16, 6%). The quality of the 75% (12/16) of RCT studies was poor, with unclear descriptions of randomization, allocation concealment, and outcome assessor blinding procedures. The overall risk of bias was relatively low in the 25% (4/16) of quasi-experimental studies. A vote count showed that 60% (9/15; 95% CI 16.3%-67.7%; P=.61) of the studies identified similar learning outcomes between IVR teaching and other teaching approaches regardless of teaching domains. The vote count showed that 62% (8/13) of the studies favored using IVR as a teaching medium. The results of the binomial test (95% CI 34.9%-90%; P=.59) did not show a statistically significant difference. Low-level evidence was identified based on the Grading of Recommendations Assessment, Development, and Evaluation tool.

CONCLUSIONS

This review found that undergraduate students had positive learning outcomes and experiences after engaging with IVR teaching, although the effects may be similar to those of other forms of virtual reality or conventional teaching methods. Given the identification of risk of bias and low level of the overall evidence, more studies with a larger sample size and robust study design are required to evaluate the effects of IVR teaching.

TRIAL REGISTRATION

International prospective register of systematic reviews (PROSPERO) CRD42022313706; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=313706.

Use of Extended Reality in Medical Education: An Integrative Review

Extended reality (XR) has emerged as an innovative simulation-based learning modality. An integrative review was undertaken to explore the nature of evidence, usage, and effectiveness of XR modalities in medical education. One hundred and thirty-three (N = 133) studies and articles were reviewed. XR technologies are commonly reported in surgical and anatomical education, and the evidence suggests XR may be as effective as traditional medical education teaching methods and, potentially, a more cost-effective means of curriculum delivery. Further research to compare different variations of XR technologies and best applications in medical education and training are required to advance the field.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01698-4.

Virtual Reality Head-Mounted Displays in Medical Education: A Systematic Review

SUMMARY STATEMENT

Simulation-based training using virtual reality head-mounted displays (VR-HMD) is increasingly being used within the field of medical education. This article systematically reviews and appraises the quality of the literature on the use of VR-HMDs in medical education. A search in the databases PubMed/MEDLINE, Embase, ERIC, Scopus, Web of Science, Cochrane Library, and PsychINFO was carried out. Studies were screened according to predefined exclusion criteria, and quality was assessed using the Medical Education Research Study Quality Instrument. In total, 41 articles were included and thematically divided into 5 groups: anatomy, procedural skills, surgical procedures, communication skills, and clinical decision making. Participants highly appreciated using VR-HMD and rated it better than most other training methods. Virtual reality head-mounted display outperformed traditional methods of learning surgical procedures. Although VR-HMD showed promising results when learning anatomy, it was not considered better than other available study materials. No conclusive findings could be synthesized regarding the remaining 3 groups.

Watching me … watching you: Training and assessment in a virtual world

Virtual education isn't new. Teaching has been delivered remotely for many years, although it came to prominence with the enforced move to online learning during the COVID-19 pandemic. Technologies provide tools that are integral to our everyday lives, and training and assessment are no different. Stepping back from the obligatory remote delivery of practical skills training, now we have the opportunity to review and evaluate our own learning (as educators) about the value of resources for training delivery. Combining sound educational principles with the available technologies, we can use remotely delivered learning to enhance our teaching and to increase access to learning, without hindrance because of distance or the type of facility. Remote connections allow expertise and best practice to become suddenly available to a wider cohort of researchers, rapidly spreading new ideas about refinement of in vivo procedures and supporting colleagues to learn and develop. We currently use only a few of the technological tools available, and there is much to learn from other disciplines where virtual and augmented reality are assisting surgeons, aircraft pilots and others daily. By harnessing remote and assisted technologies in teaching, we can also develop the mindset and ability of the biomedical community to use them to augment, or even to replace, animal studies in future and to democratise training globally.

Cross-cultural factors influencing the adoption of virtual reality for practical learning

Education is one area that was significantly affected by the COVID-19 pandemic with much of the education being transferred online. Many subjects that require hands-on experimental experience suffer when taught online. Education is also one area that many believe can benefit from the advances in virtual reality (VR) technology, particularly for remote, online learning. Furthermore, because the technology shows overall good results with hands-on experiential learning education, one possible way to overcome online education barriers is with the use of VR applications. Given that VR has yet to make significant inroads in education, it is essential to understand what factors will influence this technology's adoption and acceptance. In this work, we explore factors influencing the adoption of VR for hands-on practical learning around the world based on the Unified Theory of Acceptance and Use of Technology and three additional constructs. We also performed a cross-cultural analysis to examine the model fit for developed and developing countries and regions. Moreover, through open-ended questions, we gauge the overall feeling people in these countries have regarding VR for practical learning and how it compares with regular online learning.

Simulation-Based Education in Trauma Management: A Scoping Review

Trauma injuries are an important healthcare problem and one of the main leading causes of death worldwide. The purpose of this review was to analyze current practices in teaching trauma management using simulations, with the aim of summarizing them, identifying gaps and providing a critical overview on what has already been achieved. A search on the Web of Science website for simulation-based trauma training articles published from 2010 onwards was performed, obtaining 1617 publications. These publications were screened to 35 articles, which were deeply analyzed, gathering the following information: the authors, the publication type, the year of the publication, the total number of citations, the population of the training, the simulation method used, the skills trained, the evaluation type used for the simulation method presented in the paper, if skills improved after the training and the context in which the simulation took place. Of the 35 articles included in this review, only a few of them had students as the target audience. The more used simulation method was a high-fidelity mannequin, in which the participants trained in more technical than non-technical skills. Almost none of the studies introduced an automated evaluation process and most of the evaluation methods consisted of checklists or questionnaires. Finally, trauma training focused more on treating trauma patients in a hospital environment than in a pre-hospital one. Overall, improvements in the evaluation method, as well as in the development of trauma training on undergraduate education, are important areas for further development.

The Need for Trauma Management Training and Evaluation on a Prehospital Setting

Trauma is one of the leading causes of death in the world, being the main cause of death in people under 45 years old. The epidemiology of these deaths shows an important peak during the first hour after a traumatic event. Therefore, learning how to manage traumatic injuries in a prehospital setting is of great importance. Medical students from Universidad Autónoma performed 66 different simulations to stabilize a trauma patient on a prehospital scene by using a web-based trauma simulator. Then, a panel of trauma experts evaluated the simulations performed, observing that, on average, an important number of simulations were scored below 5, being the score values provided from 0, minimum, to 10, maximum. Therefore, the first need detected is the need to further train prehospital trauma management in undergraduate education. Additionally, a deeper analysis of the scores provided by the experts was performed. It showed a great dispersion in the scores provided by the different trauma experts per simulation. Therefore, a second need is identified, the need to develop a system to objectively evaluate trauma management.

Trauma Bay Virtual Reality - A Game Changer for ATLS Instruction and Assessment

BACKGROUND

Medical educational research highlights the need for high-fidelity, multidisciplinary simulation training to teach complex decision-making skills such as those taught in ATLS. This approach is, however, expensive and time intensive. Virtual reality (VR) education simulation may improve skill acquisition in a cost-effective and time-sensitive manner. We developed a novel trauma VR simulator (TVRSim) for providers to apply ATLS principles. We hypothesized in this pilot study that TVRSim could differentiate practitioner competency with increasing experience and would be well accepted.

METHODS

Providers at a level 1 trauma center (acute care surgeons, novice (MS4 & PGY1), junior (PGY2 & 3), senior (PGY4-6) residents) ran a blunt, polytrauma VR code. Ten critical decision points were assessed: intubation, cricothyroidotomy, chest tube, IV access, FAST, pelvic binder, activation of MTP, administration of hypertonic saline (HTS), hyperventilation and decision to go to the OR. Learner assessment was based upon frequency and time to correct decisions. Participant satisfaction was measured using validated surveys.

RESULTS

All 31 providers intubated and obtained IV access. Novices and juniors frequently failed at HTS and hyperventilation decisions. Juniors often failed at cricothyroidotomy (60%), and OR (100%) decisions. Mean time to all decisions except going to the OR was longer for all groups compared to ACS surgeons. Mean number of decisions/min was significantly higher for surgeons and seniors compared to juniors and novices. Mortality was 92.3% for novices, 80% for juniors, 25% for seniors and 0% for the attendings. Participants found TVRSim comfortable, easy to use/interact with/performance enhancing, and helped develop skills and learning.

CONCLUSIONS

In this pilot study using a sample of convenience, TVRSim was able to discern decision-making abilities among trainees with increasing experience. All trainees felt the platform enhanced their performance and facilitated skill acquisition and learning. TVRSim could be a useful adjunct to teach and assess ATLS skills.

LEVEL OF EVIDENCE

III, diagnostic test/education.

Development of virtual reality content for learning Japan Prehospital Trauma Evaluation and Care initial assessment procedures

Aim

The Japan Prehospital Trauma Evaluation and Care (JPTEC) is a standardized educational program for prehospital trauma care in Japan. The initial assessment in the JPTEC course comprises a training segment that includes a 30‐min session. Given the limited face‐to‐face training due to the coronavirus disease 2019, virtual reality (VR) content has become an alternative. However, creating VR content typically requires the assistance of expert technicians. We aimed to create VR content for the initial assessment segment of the JPTEC and verify its educational effectiveness.

Methods

We created VR content for learning the initial assessment of the JPTEC using our easy‐to‐use VR content creation system. The participants played the VR content for 15 min. The number of times they “cleared” (i.e., made a correct decision and completed the initial assessment) was recorded every 5 min. Then, a JPTEC‐certified instructor tested their practical skills through face‐to‐face simulation.

Results

The authors had no specialized skills and created the VR content in 2 days. Fourteen students used the material. They cleared the scenario 3 (3–4) times in the first 5 min in 15 min, 5 (4–5) times in the second 5 min, and 5 (5–5) times in the third 5 min (P < 0.05). All participants passed the practical evaluation.

Conclusion

A shorter VR training developed using our easy‐to‐use VR content creation system can replace the 30‐min JPTEC session on the initial assessment. This system allows for the free and easy creation of VR content.

Virtual, Augmented, and Alternate Reality in Medical Education: Socially Distanced but Fully Immersed

BACKGROUND

Advancements in technology continue to transform the landscape of medical education. The need for technology-enhanced distance learning has been further accelerated by the coronavirus disease (COVID-19) pandemic. The relatively recent emergence of virtual reality (VR), augmented reality (AR), and alternate reality has expanded the possible applications of simulation-based education (SBE) outside of the traditional simulation laboratory, making SBE accessible asynchronously and in geographically diverse locations.

OBJECTIVE

In this review, we will explore the evidence base for use of emerging technologies in SBE as well as the strengths and limitations of each modality in a variety of settings.

METHODS

PubMed was searched for peer-reviewed articles published between 1995 and 2021 that focused on VR in medical education. The search terms included medical education, VR, simulation, AR, and alternate reality. We also searched reference lists from selected articles to identify additional relevant studies.

RESULTS

VR simulations have been used successfully in resuscitation, communication, and bronchoscopy training. In contrast, AR has demonstrated utility in teaching anatomical correlates with the use of diagnostic imaging, such as point-of-care ultrasound. Alternate reality has been used as a tool for developing clinical reasoning skills, longitudinal patient panel management, and crisis resource management via multiplayer platforms.

CONCLUSION

Although each of these modalities has a variety of educational applications in health profession education, there are benefits and limitations to each that are important to recognize prior to the design and implementation of educational content, including differences in equipment requirements, cost, and scalability.

Immersive technologies for total knee arthroplasty surgical education

The need to adapt surgical curricula to meet the demands of an increasingly restrictive training environment is rising. Modern constraints of surgical trainees including work-hour restrictions and concerns surrounding patient safety have created an opportunity to supplement traditional teaching methods with developing immersive technologies including virtual and augmented reality. Virtual reality (VR) and augmented reality (AR) have been preliminarily investigated as it relates to total joint arthroplasty. The purpose of this article is to discuss VR and AR as it applies to modern total knee replacement (TKR) surgical education.

Teams managing civilian and military complex trauma: What are the competencies required in austere environments and the potential of simulation technology to address them?

Surgical training in civilian hospitals may not be sufficient for managing complex trauma in a setting where such care is not commonly practiced. Understanding the challenges that civilian teams face when moving to austere environments can inform the competencies that need to be trained. The aim of this study was to explore the competencies required in austere environments for teams managing complex trauma, and how they can be trained with simulation technologies. Ethnographic field observations were conducted, and field notes were synthesized. The field notes were structured with the elements of Activity Theory to generate the teams' competencies that need to be trained. A literature review was conducted to verify the results and identify examples of relevant simulation modalities. The analysis resulted in a structured list of competencies for civilian teams to manage complex trauma in an austere environment and recommendations which simulation technologies could be used in training of those competencies based on published studies. Our study contributes to understanding the challenges that civilian teams face when operating in an austere environment. A systematized list of competencies with suggested simulation technologies directs future research to improve quality of complex trauma training in civilian and military collaboration.

Design and Development of an Interactive Web-Based Simulator for Trauma Training: A Pilot Study

Trauma is the leading cause of death in people under 45 years old and one of the leading causes of death in the world. Therefore, specific trauma training during medical school as well as after it is crucial. Web-based learning is an important tool in education, offering the possibility to create realistic trauma scenarios. A web-based simulator has been developed and a pilot study has been accomplished to trial the simulator. A pelvic trauma scenario was created and 41 simulations were performed, 28 by medical students and 13 by doctors. The data analyzed are the actions taken to treat the trauma patient, the evolution of the vital signs of the patient, the timing spent on deciding which action to take, when each action was performed and the consequence that it had on the patient. Moreover, a post-simulation questionnaire was completed related to the usability of the simulator. The clinical treatment performance of doctors is better than the performance of medical students performing more actions correctly and in the right sequence as per ATLS recommendations. Moreover, significant differences are obtained in the time response provided to the patients which is key in trauma. With respect to the usability of the tool, responses provide a positive usability rating. In conclusion, this pilot study has demonstrated that the web-based training developed can be used to train and evaluate trauma management. Moreover, this research has highlighted a different approach to trauma treatment between medical students and doctors.

Application of technology to educational needs in surgery

Innovations in surgical education follow advancing clinical technology. New surgical methods have prompted demand for systematic methods to leverage computing power and internet tools to achieve proficiency-based training goals. Virtual reality, high-fidelity patient simulation, web-based resources to facilitate performance assessment, and telementoring have become mainstream practices, although patient outcomes benefits are not well studied. Remote virtual meeting and mentoring have had transformative effects on resident experiences, the full effects of which remain to be seen.

Upskilling health and care workers with augmented and virtual reality: protocol for a realist review to develop an evidence-informed programme theory

INTRODUCTION

Augmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they 'work'.

METHODS AND ANALYSIS

This realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.

ETHICS AND DISSEMINATION

Ethics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

Development of the Second Prototype of an Oral Care Simulator

Oral care is crucial to preventing diseases and maintaining the quality of life of elderly people. To create an effective training environment for nursing students, we developed a second prototype of an oral care simulator that can guide and record oral care practices. The simulator has three components: (1) a dentition model with pressure sensors, (2) a microcomputer to record signals, and (3) software for visualization. We proposed a novel mechanism to detect brushing behavior using pressure sensors and developed software to visualize the records of oral care practice. We calibrated the system to estimate the weights applied in the dentition model using a brush and verified that the calibration increased the accuracy of the estimation.

Improvement of the Interaction Model Aimed to Reduce the Negative Effects of Cybersickness in VR Rehab Applications

Virtual reality (VR) has the potential to be applied in many fields, including medicine, education, scientific research. The e-health impact of VR on medical therapy for people cannot be ignored, but participants reported problems using them, as the capabilities and limitations of users can greatly affect the effectiveness and usability of the VR in rehabilitation. Previous studies of VR have focused on the development and use of the technology itself, and it is only in recent years that emphasis has been placed on usability problems that include the human factor. In this research, different ways of adapting interaction in VR were tested. One approach was focused on means of navigating through a VR, while the second dealt with the impact of the amount of animation and moving elements through a series of tests. In conclusion, the way of navigation and the amount of animation and moving elements, as well as their combination, are proven to have a great influence on the use of VR systems for rehabilitation. There is a possibility to reduce the occurrence of problems related to cybersickness if the results of this research are taken into consideration and applied from an early stage of designing VR rehabilitation applications.

Virtual Reality Simulation for Pediatric Airway Intubation Readiness Education

Background

The objective of this study was to provide education to inexperienced trainees regarding preparation for airway intubation using virtual reality (VR) tutorial and comparison of performance with that of experienced trainees without VR training. We hypothesized that after the VR tutorial, junior fellows and residents will have comparable recall of the proper steps as experienced trainees.

Methods

This project was initiated in the pediatric intensive care unit from July 1, 2019, to July 30, 2019. Volunteer residents and pediatric critical care medicine fellows participated. The VR group completed a 19-minute immersive tutorial and then demonstrated learned skills with a traditional manikin. Non-VR group fellows listed steps to prepare for airway intubation from memory with scoring on a 24-point timed checklist.

Results

Seventeen subjects participated; two residents were excluded. The VR group had seven trainees (47%) and scored similarly to the other group based on checklist items (50.5% vs 50.8%, P=1).

Conclusion

VR technologies can be used for education in preparation for pediatric airway intubation. There was no difference in the performance accuracy between the two groups. Larger studies are essential to study benefits of VR in preparation and performance of airway intubation.

Training outcomes for audiology students using virtual reality or traditional training methods

Due to limited space and resources, it can be difficult to train students on audiological procedures adequately. In the present study, we compared audiology training outcomes between a traditional approach and a recently developed immersive virtual reality (VR) approach in audiology students. Twenty-nine first-year audiology students participated in the study; 14 received traditional training (“TT group”), and 15 received the VR training (“VRT group”). Pre- and post-training evaluation included a 20-item test developed by an audiology educator. Post-training satisfaction and self-confidence were evaluated using Likert scales. Mean post-training test scores improved by 6.9±9.8 percentage points in the TT group and by 21.1±7.8 points in the VRT group; the improvement in scores was significant for both groups. After completing the traditional training, the TT group was subsequently trained with the VR system, after which mean scores further improved by 7.5 points; there was no significant difference in post-VR training scores between the TT and VRT groups. After training, the TT and VRT groups completed satisfaction and self-confidence questionnaires. Satisfaction and self-confidence ratings were significantly higher for the VR training group, compared to the traditional training group. Satisfaction ratings were “good” (4 on Likert scale) for 74% of the TT group and 100% of the VRT group. Self-confidence ratings were “good” for 71% of the TT group and 92% of the VRT group. These results suggest that a VR training approach may be an effective alternative or supplement to traditional training for audiology students.

Development and Usability of a Virtual Reality-Based Filler Injection Training System

Purpose

As filler procedures have increased in popularity, serious injection-related complications (e.g., blindness and stroke) have also increased in number. Proper and effective training is important for filler procedure safety; however, limitations exist in traditional training methods (i.e. anatomical illustrations and cadaver studies). We aimed to describe the development process and evaluate the usability of a virtual reality (VR)-based aesthetic filler injection training system.

Materials and Methods

We developed the virtual reality hardware for the training system and a short guide, with a lecture regarding safe filler injection techniques. One hundred clinicians who attended a conference tested the training system. Participants completed system usability scale (SUS) and satisfaction questionnaires.

Results

Nearly half of the participants were aged 35–50 years, and 38% had more than 5 years of aesthetic experience. The mean SUS score was 59.8 (standard deviation, 12.23), with no significant differences among the evaluated subgroups. Approximately 76% of participants provided SUS scores of more than 51, indicating acceptable usability. Participants aged 35–50 years were more likely to rate the system as having poor usability than were those aged < 35 years (odds ratio = 5.20, 95% confidence interval: 1.35–20.08).

Conclusions

This study was the first to develop and explore the usability of a VR-based filler training system. Nearly three-fourths of participants indicated that the training system has an acceptable level of usability. However, assessments in precise target audiences and more detailed usability information are necessary to further refine the training system.

Level of evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01872-2) contains supplementary material, which is available to authorized users.

IoT Based Virtual Reality Game for Physio-therapeutic Patients

Biofeedback therapy trains the patient to control voluntarily the involuntary process of their body. This non-invasive and non-drug treatment is also used as a means to rehabilitate the physical impairments that may follow a stroke, a traumatic brain injury or even in neurological aspects within occupational therapy. The idea behind this study is based on using immersive gaming as a tool for physical rehabilitation that combines the idea of biofeedback and physical computing to get a patient emotionally involved in a game that requires them to do the exercises in order to interact with the game. This game is aimed towards addressing the basic treatment for ‘Frozen Shoulder’. In this work, the physical motions are captured by the wearable ultrasonic sensor attached temporarily to the various limbs of the patient. The data received from the sensors are then sent to the game via serial wireless communication. There are two main aspects to this study: motion capturing and game design. The current status of the application is a single ultrasonic detector. The experimental result shows that physio-therapeutic patients are benefited through the IoT based virtual reality game.

Surgeons With Five or More Actual Cricothyrotomies Perform Significantly Better on a Virtual Reality Simulator

BACKGROUND

Discriminating performance of learners with varying experience is essential to developing and validating a surgical simulator. For rare and emergent procedures such as cricothyrotomy (CCT), the criteria to establish such groups are unclear. This study is to investigate the impact of surgeons' actual CCT experience on their virtual reality simulator performance and to determine the minimum number of actual CCTs that significantly discriminates simulator scores. Our hypothesis is that surgeons who performed more actual CCT cases would perform better on a virtual reality CCT simulator.

METHODS

47 clinicians were recruited to participate in this study at the 2018 annual conference of the Society of American Gastrointestinal and Endoscopic Surgeons. We established groups based on three different experience thresholds, that is, the minimal number of CCT cases performed (1, 5, and 10), and compared simulator performance between these groups.

RESULTS

Participants who had performed more clinical cases manifested higher mean scores in completing CCT simulation tasks, and those reporting at least 5 actual CCTs had significantly higher (P = 0.014) simulator scores than those who had performed fewer cases. Another interesting finding was that classifying participants based on experience level, that is, attendings, fellows, and residents, did not yield statistically significant differences in skills related to CCT.

CONCLUSIONS

The simulator was sensitive to prior experience at a threshold of 5 actual CCTs performed.

Fully Immersive Virtual Reality for Total Hip Arthroplasty: Objective Measurement of Skills and Transfer of Visuospatial Performance After a Competency-Based Simulation Curriculum

BACKGROUND

Fully immersive virtual reality (VR) uses headsets to situate a surgeon in a virtual operating room to perform open surgical procedures. The aims of this study were to determine (1) if a VR curriculum for training residents to perform anterior approach total hip replacement (AA-THR) was feasible, (2) if VR enabled residents' performance to be measured objectively, and (3) if cognitive and motor skills that were learned with use of VR were transferred to the physical world.

METHODS

The performance of 32 orthopaedic residents (surgical postgraduate years [PGY]-1 through 4) with no prior experience with AA-THR was measured during 5 consecutive VR training and assessment sessions. Outcome measures were related to procedural sequence, efficiency of movement, duration of surgery, and visuospatial precision in acetabular component positioning and femoral neck osteotomy, and were compared with the performance of 4 expert hip surgeons to establish competency-based criteria. Pretraining and post-training assessments on dry bone models were used to assess the transfer of visuospatial skills from VR to the physical world.

RESULTS

Residents progressively developed surgical skills in VR on a learning curve through repeated practice, plateauing, on average, after 4 sessions (4.1 ± 0.6 hours); they reached expert VR levels for 9 of 10 metrics (except femoral osteotomy angle). Procedural errors were reduced by 79%, assistive prompts were reduced by 70%, and procedural duration was reduced by 28%. Dominant and nondominant hand movements were reduced by 35% and 36%, respectively, and head movement was reduced by 44%. Femoral osteotomy was performed more accurately, and acetabular implant orientation improved in VR assessments. In the physical world assessments, experts were more accurate than residents prior to simulation, but were matched by residents after simulation for all of the metrics except femoral osteotomy angle. The residents who performed best in VR were the most accurate in the physical world, while 2 residents were unable to achieve competence despite sustained practice.

CONCLUSIONS

For novice surgeons learning AA-THR skills, fully immersive VR technology can objectively measure progress in the acquisition of surgical skills as measured by procedural sequence, efficiency of movement, and visuospatial accuracy. Skills learned in this environment are transferred to the physical environment.

Edgar Dale's Pyramid of Learning in medical education: Further expansion of the myth

INTRODUCTION

A mythical Pyramid of Learning, usually attributed to Edgar Dale (or the National Training Laboratories [NTL]) and giving student learning retention rates, has been cited in a wide range of educational literature. A 2013 literature review indicated that medical education literature similarly cites this Pyramid. It was hoped that highlighting this myth in that review would reduce references to the Pyramid in future medical education literature. This study aimed at determining what change in Pyramid citation has occurred in the past 5 years.

METHODS

A documented literature review, following the same process as the original review, was conducted. The search dates were September 2012 to April 2018, and the databases were Academic Search Complete, CINAHL, Medline and Google Scholar. Sources were from peer-reviewed journals or conferences, in English.

RESULTS

From an initial search result of 992 documents, 41 were found to match the criteria. Trends discovered are: the number of Pyramid citations in medical education literature is increasing dramatically, new sources of the Pyramid are now being used, refutations of the Pyramid are being used to support it, and even researchers who acknowledge the weakness of the Pyramid still cite it.

DISCUSSION AND CONCLUSION

In spite of the 2013 review, the situation has become worse. One possible reason is that refutations use too polite academic wording, and other researchers then consider the Pyramid to be merely "disputed" or "debated." To kill the myth of the Pyramid, it is necessary for this article's Abstract to state unequivocally: The Pyramid is rubbish, the statistics are rubbish, and they do not come from Edgar Dale. Until the NTL can provide details about the original research, their version must also be treated as rubbish.

Virtual reality and the transformation of medical education

Medical education is changing. Simulation is increasingly becoming a cornerstone of clinical training and, though effective, is resource intensive. With increasing pressures on budgets and standardisation, virtual reality (VR) is emerging as a new method of delivering simulation. VR offers benefits for learners and educators, delivering cost-effective, repeatable, standardised clinical training on demand. A large body of evidence supports VR simulation in all industries, including healthcare. Though VR is not a panacea, it is a powerful educational tool for defined learning objectives and implementation is growing worldwide. The future of VR lies in its ongoing integration into curricula and with technological developments that allow shared simulated clinical experiences. This will facilitate quality interprofessional education at scale, independent of geography, and transform how we deliver education to the clinicians of the future.

Can an Augmented Reality Headset Improve Accuracy of Acetabular Cup Orientation in Simulated THA? A Randomized Trial

BACKGROUND

Accurate implant orientation reduces wear and increases stability in arthroplasty but is a technically demanding skill. Augmented reality (AR) headsets overlay digital information on top of the real world. We have developed an enhanced AR headset capable of tracking bony anatomy in relation to an implant, but it has not yet been assessed for its suitability as a training tool for implant orientation.

QUESTIONS/PURPOSES

(1) In the setting of simulated THA performed by novices, does an AR headset improve the accuracy of acetabular component positioning compared with hands-on training by an expert surgeon? (2) What are trainees' perceptions of the AR headset in terms of realism of the task, acceptability of the technology, and its potential role for surgical training?

METHODS

Twenty-four study participants (medical students in their final year of school, who were applying to surgery residency programs, and who had no prior arthroplasty experience) participated in a randomized simulation trial using an AR headset and a simulated THA. Participants were randomized to two groups completing four once-weekly sessions of baseline assessment, training, and reassessment. One group trained using AR (with live holographic orientation feedback) and the other received one-on-one training from a hip arthroplasty surgeon. Demographics and baseline performance in orienting an acetabular implant to six patient-specific values on the phantom pelvis were collected before training and were comparable. The orientation error in degrees between the planned and achieved orientations was measured and was not different between groups with the numbers available (surgeon group mean error ± SD 16° ± 7° versus AR 14° ± 7°; p = 0.22). Participants trained by AR also completed a validated posttraining questionnaire evaluating their experiences.

RESULTS

During the four training sessions, participants using AR-guidance had smaller mean (± SD) errors in orientation than those receiving guidance from the surgeon: 1° ± 1° versus AR 6° ± 4°, p < 0.001. In the fourth session's assessment, participants in both groups had improved (surgeon group mean improvement 6°, 95% CI, 4-8°; p < 0.001 versus AR group 9°, 95% CI 7-10°; p < 0.001). There was no difference between participants in the surgeon-trained and AR-trained group: mean difference 1.2°, 95% CI, -1.8 to 4.2°; p = 0.281. In posttraining evaluation, 11 of 12 participants would use the AR platform as a training tool for developing visuospatial skills and 10 of 12 for procedure-specific rehearsals. Most participants (11 of 12) stated that a combination of an expert trainer for learning and AR for unsupervised training would be preferred.

CONCLUSIONS

A novel head-mounted AR platform tracked an implant in relation to bony anatomy to a clinically relevant level of accuracy during simulated THA. Learners were equally accurate, whether trained by AR or a surgeon. The platform enabled the use of real instruments and gave live feedback; AR was thus considered a feasible and valuable training tool as an adjunct to expert guidance in the operating room. Although there were no differences in accuracy between the groups trained using AR and those trained by an expert surgeon, we believe the tool may be useful in education because it demonstrates that some motor skills for arthroplasty may be learned in an unsupervised setting. Future studies will evaluate AR-training for arthroplasty skills other than cup orientation and its transfer validity to real surgery.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Modified GoPro Hero 6 and 7 for Intraoperative Surgical Recording-Transformation Into a Surgeon-Perspective Professional Quality Recording System

Recent innovations in wearable action cameras with high-definition video recording enable surgeons to use cameras for their surgical procedures. In this study, the GoPro HERO 6 (and 7) Black edition camera was modified step by step to allow for a completely wireless surgeon-perspective recording with a battery life and memory capacity never previously obtained with such a high level of digital video quality. With this system, a surgeon can record for more than 14 hours 26 minutes in 1,080 pixels at 60 frames per second without breaking scrub and capture the operating surgeon's direct view of the field. By modifying the newest generation of devices, the authors successfully eliminated all shortcomings of the prior generation of GoPro cameras for surgical recording. The modified GoPro HERO6 camera produced professional recording quality for a total cost lower than US$850. This is critically important, because video-based surgical training will continue to be a primary area of development in the future and represents a novel and effective way for young generations of surgeons to attain technical excellence and knowledge in surgery.

Surgeons' expertise during critical event in laparoscopic cholecystectomy: An expert-novice comparison using protocol analysis

BACKGROUND

The purpose of this study was to examine differences in thought processes between novice and experienced surgeons when they were presented with a critical situation during laparoscopic cholecystectomy.

METHODS

A group of experienced and novice surgeons were shown a recording of a laparoscopic cholecystectomy with an intraoperative bleeding event. The think-aloud method was used to capture surgeons' thought processes. Verbal reports were recorded, transcribed and analyzed using the protocol analysis method.

RESULTS

Sixteen subjects (8 in each group) participated at two centers. Experienced surgeons demonstrated deeper comprehension of the operative field, richer mental image of future events and superior awareness of potentially dangerous situations. They also spent more time engaged in metacognitive activity.

CONCLUSIONS

This study highlights the differences and similarities between surgeons with different levels of experience during a challenging intraoperative encounter. The domains of cognition and mental image as well as metacognition appear to be key elements of surgical expertise.

Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations

Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60 Seconds to Survival^© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P = 0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P = 0.101), instances of undertriage (P = 0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P = 0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.