Introduction
Medical education lays emphasis on a curriculum that is based on three domains of learning ie. psychomotor, cognitive and affective domains. Worldwide there is a shift in medical education towards experimental ‘hands-on’ learning. However applying this concept to real patients is less acceptable to society and subject to legal and ethical issues [1]. In medical education, a number of skills are difficult to impart in real life but can be effectively taught using simulations. Changing profile of hospital patients and societal expectations have led to increasing medical accountability with minimal margin for medical errors. A near 5% representation of death primarily related to medical mistakes is simply unacceptable in the world of Medicine. Anything that can assist in bringing this number down is highly recommended and medical simulation can prove to be the key assistant. Simulations help us to replicate situations which may not be possible to get in real settings or where it may be logistically difficult to work on real patients. In disaster and mass trauma, unusual life threatening conditions are seen under unusual circumstances. Since disaster is not an everyday event, there is limited practical experience. Combat casualties, massive destructive outbreaks, chemical spills, gas leakages and other form of large scale negative events can be accurately simulated in a safe, inexpensive and relatively small environment [2]. Trauma is the leading cause of death and disability in the first four decades of life and is recognized as a serious public health problem. It is neglected disease of modern society and remains most common cause of death between 1 and 44 years of age [3]. Many lives can be saved if we strictly resuscitate the trauma patient as per Advance Trauma Life Support protocols which need a hands-on, structured training to the medical students in trauma resuscitation. This study was planned to introduce simulations for learning basic airway resuscitation skills in trauma among surgery residents and to develop an effective training module. The objectives were: 1) To assess the perception of Post Graduate students and faculty members about learning the airway management skills in trauma in a simulated environment. 2) To assess the post-graduates in performing airway resuscitation skills by DOPS (Direct Observation of Procedural Skills) using pre-determined check-list before and after receiving training.
Material and Methods
This cross-sectional study was conducted in Post Graduate Department of General Surgery, Govt. Medical College Jammu. The department has approximately 60 postgraduate scholars spread over three years and 10 senior residents. All the residents were invited for the study and finally those who fulfilled inclusion and exclusion criteria were included. 56 resident doctors were enrolled for study and 5 faculty members were involved.
Inclusion criteria
Post graduate scholar and senior residents in the general surgery department.
Give consent.
Exclusion criteria
Those who have received similar training in some other institute.
Do not give consent
Are on leave, on emergency duty or on district residency programme.
The students and involved faculty were sensitized about the project after taking approval from Institutional Ethical Committee and consent was taken. The participants learned to manage the airway during primary survey of a trauma patient in a simulated environment. After thorough discussion among faculty, a teaching module for workshop was prepared and was validated by senior faculty. Teaching-learning methods used were:
Day-1
Interactive Lecture (1 Hour)
Participants were divided in four groups of 14 students each moderated by a faculty member for focused group discussion and demonstration of airway resuscitation skills using a case scenario, simulated patient and mannequins (3 Hours).
Day-2: Demonstration of airway resuscitation skills (Basic Airway and Endo tracheal intubation) over mannequins and then practice by resident doctors under supervision of faculty (DOAP-Demonstration, Observation, Assistance, Performance) (4 hours).
Day-3: Assessment of perception of the students was taken using pre-structured pre-validated feedback questionnaire based on 5 point Likert Scale.
Outcome measures: Assessment of performance of the students was done by DOPS (Direct Observation of Procedural Skills) using a predetermined checklist. This performance evaluation assessment of the skill was done under the observation of faculty over a skill station based on 13 steps involved in airway resuscitation before and after conducting the training session.
Perception of involved faculty regarding simulations as teaching-learning method was taken by in-depth interviews by the author and pre-structured and pre-validated feed-back questionnaire based on 5 point Likert scale (4 hours).
Statistical analysis: DOPS assessment, students’ and faculty feedback was collected. It was entered and subjected to statistical analysis using SPSS version 20.0. The qualitative data were presented as percentages and proportions while the quantitative data was presented as Mean ± SD. A paired t test was used for conducting pretest and posttest analysis, p-value of <0.05 was taken as statistically significant.
Results
The study was conducted in the Post Graduate Department of General Surgery, Govt. Medical College, Jammu. A total 56 resident doctors including 50 postgraduate scholars and 6 senior residents were enrolled. Five faculty members of surgery department were involved in the conduction of simulation based training, evaluation of the learning technique.
Table 1 shows the perceptions of resident doctors to the simulation technique of learning. All the participants were in agreement that simulation based learning was interesting and important. 96.42% participants thought that this method supported the development of clinical skill and will improve performance. 7.14% respondents did not feel that that it can improve patient’s safety and 12.5% were not in agreement that simulation based learning is better than bedside learning. 89.28% participants felt that simulation based learning can create a highly realistic safe and reproducible environment. All the involved faculty members were satisfied and found session of teaching airway resuscitation skills over mannequins interesting, engaging and involving the students. 80% of faculty was of that opinion that teaching learning method using simulations was better than traditional didactic teaching. They suggested that it should be integrated in medical curriculum (Fig1).
Table 2 shows that all the participants were able to successfully perform the steps of resuscitation except to, ensure adequate ventilation (5.57%) assess patency of tube (12.50%), inspect the endotracheal tube for visible damage (16.07%) and auscultate chest, abdomen with a stethoscope to ascertain the tube position (5.35%). None of the participant scored zero while performing the steps of resuscitation. 78% of the participants performed airway resuscitation skills on mannequins accurately in correct sequence after training.
The mean score of Performance Evaluation Test improved for all the steps of resuscitation after training the participants using simulation learning technique (Table 3). This increase in score was found to be statistically significant for all the steps except directs an assistant to restrict cervical motion, auscultates the chest abdomen with a stethoscope to ascertain the tube position, secures the tube and monitors the oxygen saturation (p=0.08,0.05,0.15&0.32 resp). Participants were able to perform eight out of twelve steps perfectly after training.
| Questions | Strongly Agree No(%) | Agree No(%) | Neutral No(%) | Disagree No(%) | Strongly Disagree No(%) |
| Do you feel that learning of airway resuscitation skill over mannequins was interesting? | 44(78.57) | 12(21.42) | 0 | 0 | 0 |
| Do you think that using mannequins for learning airway management skills is important? | 40(71.42) | 15(26.78) | 1(1.78) | 0 | 0 |
| Can simulations for teaching basic airway management skills support the development of clinical skills? | 42(75) | 12(21.42) | 2(3.57) | 0 | 0 |
| Do you feel the repeated practice of procedure in simulation based learning will improve the performance? | 41(73.21) | 13(23.21) | 2(3.37) | 0 | 0 |
| Do you feel that simulation based learning might improve patient’s safety? | 40(71.42) | 9(16.07) | 3(5.35) | 4(7.14) | 0 |
| Do you believe that simulation based learning is better than lecturers/bed side teaching? | 39(69.64) | 3(5.35) | 7(12.5) | 7(12.5) | 0 |
| Will simulation based learning help to increase the confidence levels of the students while dealing with real patients? | 40(71.42) | 6(10.71) | 10(17.87) | 0 | 0 |
| Do you feel that simulation based learning can create a highly realistic safe and reproducible learning environment? | 43(76.78) | 7(12.5) | 4(7.14) | 2(3.57) | 0 |
| Do you feel that session was helpful in understanding the technique? | 44(78.57) | 8(14.28) | 4(7.14) | 0 | 0 |
| Performance Evaluation Test (DOPS) Questions | Scores | ||
| ZERO No(%) | ONE No(%) | TWO No(%) | |
| Ensures and checks equipments | 0 | 0 | 56(100) |
| Applies oxygen mask and suction | 0 | 0 | 56(100) |
| Ensures adequate ventilation and oxygenation | 0 | 2(5.57) | 54(96.42) |
| Inspects the End tracheal tube for visible damage and cuff | 0 | 9(16.07) | 47(83.92) |
| Assesses patency of airway for ease of intubation | 0 | 7(12.5) | 49(87.5) |
| Directs an assistant to restrict cervical motion | 0 | 0 | 56(100) |
| Visually identifies the epiglottis and vocal chords | 0 | 0 | 56(100) |
| Gently inserts the tube through vocal chords into the trachea correctly | 0 | 0 | 56(100) |
| Applies bag ventilation | 0 | 0 | 56(100) |
| Auscultates the chest abdomen with a stethoscope to ascertain the tube position | 0 | 3(5.35) | 53(100) |
| Secures the tube | 0 | 0 | 56(100) |
| Monitors the oxygen saturation | 0 | 0 | 56(100) |
| Performance Evaluation Test (DOPS) Questions | Score Mean±SD | t | p | |
| Before training | After training | |||
| Ensures and checks equipments | 1.50±0.78 | 2±0.00 | 4.75 | 0.00* |
| Applies oxygen mask and suction | 1.39±0.84 | 2±0.00 | 5.37 | 0.00* |
| Ensures adequate ventilation and oxygenation | 1.26±0.82 | 1.96±0.18 | 5.97 | 0.00* |
| Inspects the End tracheal tube for visible damage and cuff | 0.91±0.81 | 1.83±0.37 | 8.39 | 0.00* |
| Assesses patency of airway for ease of intubation | 0.75±0.79 | 1..87±0.33 | 10.38 | 0.00* |
| Directs an assistant to restrict cervical motion | 1.94±0.22 | 2±0.00 | 1.76 | 0.08 |
| Visually identifies the epiglottis and vocal chords | 1.91±0.28 | 2±0.00 | 2.32 | 0.02* |
| Gently inserts the tube through vocal chords into the trachea correctly | 1.85±0.35 | 2±0.00 | 3.02 | 0.00* |
| Applies bag ventilation | 1.80±0.40 | 2±0.00 | 3.66 | 0.00* |
| Auscultates the chest abdomen with a stethoscope to ascertain the tube position | 1.82±0.38 | 1.94±0.22 | 1.90 | 0.05 |
| Secures the tube | 1.96±0.18 | 2±0.00 | 1.42 | 0.15 |
| Monitors the oxygen saturation | 1.98±0.13 | 2±0.00 | 1.00 | 0.32 |
* P<0.05-statistcally significant.
Discussion
Medical simulation mimics clinical care, allowing health professionals to develop and maintain skills necessary for safe and effective clinical care. It enables trainee surgeon practice remotely from patients thereby gaining confidence and becoming more efficient [4]. In our study most of the students agreed that technique of learning skills using simulations was understandable, safe and reproducible. They found this very important in learning and supporting the development of clinical skills. Karnath B, Frye AN, Holden MD 2002 in their study concluded that simulation based education is seen to supplement the clinical education of medical students in a safe and supportive manner. It is a rapidly developing area which provides the learner with opportunities without any fear of harm to patient, in a controlled setting [5]. In our study 82.14% (46/56) of participants agreed that simulation based learning increased their confidence level in providing airway resuscitation if encountered with real life situation. Ruesseler M etal.,[6] advocated that practicing on mannequins enhanced student’s skill in recognizing and handling emergencies. Students felt knowledgeable and confident in providing airway resuscitation in trauma after the workshop. A general feedback was that this was more interesting and engaging than a didactic lecture resulting in better involvement and learning. Students themselves felt that this knowledge and skill would be better retained and practiced if repeated at regular intervals to reinforce learning. This has also been a finding of authors of studies by Cooper S et al.,[7] and Roshana S et al. [8].
In our study whole the faculty was satisfied teaching airway resuscitation skills using simulations. The feedback from the faculty was also very encouraging as they found teaching-learning methods using simulations very good and interactive which engaged and involved the students and improved their learning skills. They further suggested that it should be integrated in the curriculum of medical students. 80% of faculty members were of the opinion that teaching learning methods using simulations was better than traditional didactic teaching. Compared with other teaching-learning methods, simulation is noninvasive, convenient, repeatable and inexpensive. It is likely to become a commonly used teaching method [9]. Therefore, for residents and medical students at various stages, practice with medical simulation models and evaluation of training on those models are very important. Simulation Based Medical Education works well with all forms of classroom learning such as lectures, problem solving, in hospital teaching and other traditional forms of education [10].
After the workshop it was found that 78% participants could perform steps in basic airway resuscitation skills in correct sequence and accurately thus achieving our goal of imparting competency based training. Various studies [6,11] have reported that a simulation based training offered a better possibility to enhance skills in recognizing and handling emergencies Regarding simulation based competency assessment for procedural performance, the United States Food and Drug Administration (USFDA) will now only certify competency of a clinician to perform carotid stenting procedure of a patient if competency is demonstrated in a simulator first [12]. Future prospects are good for simulation, simulators and part task trainers to have a strong positive impact on healthcare, especially by lowering risk to patients of training, providing a method of learning about care processes and by helping to establish a strong culture of team work and collaboration within the clinical workforce [13-15].
Limitations
Cost of high fidelity mannequins and inadequate number of mannequins. Absence of realism and lack of exposure. No interval reinforcement and assessment. Further research is recommended to see the long term effect of this training on student’s performance once they actually perform their duties independently in real life situations in the field.
Conclusions
Introduction of simulations for teaching basic airway management skills in trauma among postgraduate students results in remarkable improvement in clinical skills and increases their confidence level. It also improves patient safety, minimizes stressful learning environment and improves training standards in medical institutions.
Implications
This study will help to develop standardized training modules tailored to needs and competencies of General Surgery post graduate scholars. Such modules will ultimately result in more confident, competent and skilled Indian Medical Graduates ready to serve the society as envisaged in Medical Regulations.
Declarations
Ethical Clearance
Not Applicable
Acknowledgements
None
Conflict of Interest
There is no Conflict Interest
Funding/ financial support
None