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PubMedDate not supplied

Physical reality simulation for training of laparoscopists in the 21st century. A multispecialty, multi-institutional study.

BACKGROUND: Simulation is the most effective and safe way to train laparoscopic surgeons in an era of limited work hours, lack of funding, and increasing malpractice costs. However, the costs associated with the use of virtual reality simulators are significant, and although very technically sophisticated they still lack tactile feedback. We are proposing a physical reality simulator, the LTS 2000, as a reliable and effective alternative to virtual reality. This study was carried out to establish how reliably the simulator was able to differentiate between different levels of laparoscopic experience and to analyze the detection of skills improvement after simulation and clinical training. METHODS: This study was carried out, between July 2002 and August 2003, in the departments of Surgery and Obstetrics and Gynecology at 2 separate institutions. We enrolled 40 individuals in the study who had experience ranging from postgraduate year-1 to full-time faculty level. Five postgraduate year-3 residents were subsequently retested after rotating on clinical services, performing advanced laparoscopic procedures to assess whether the simulator was sensitive enough to detect improvements in laparoscopic skills at the intermediate level. Six tasks were included in the test, and they were scored for speed and precision with the McGill system. Two scores were obtained: a coordination score and a suturing score combined in a total score. Other variables analyzed were handedness, specialty, number of laparoscopic procedures performed, and hours spent on the simulator. RESULTS: Forty-five tests were performed. The number of subjects in each group based on level of experience was equally distributed. No difference occurred in scores between institutions, specialty, and right- or left-handed surgeons. A significant increase occurred in the coordination score and suturing score combined in the total score with increasing experience (P < 0.05) at each level. Furthermore, the simulator was sensitive enough to detect a significant difference in all 3 scores between subjects who had practiced with the simulator before being tested (P < 0.05). The scores of the 5 postgraduate year-3 participants doubled when tested, without reaching statistical significance due to the small sample size. CONCLUSIONS: Our study shows that the LTS 2000 reliably and reproducibly detects different levels of laparoscopic expertise and progression of the learning curve. LTS 2000 as a model of physical reality simulation should be considered a reliable alternative to virtual reality simulation.

Adult↗

PubMedDate not supplied

[Real life simulations to train nurses].

Nurses must confront critical potential life threatening situations daily. These are very tense situations which must be solved in a rapid, adequate manner in coordination with the rest of the professional health team. How to deal with these crises, which usually follow an established protocol, must be learned and practiced in a safe environment which provides the greatest possible guarantee of success. The best way to acquire this knowledge and skill is through a real life simulation. Nurses from various disciplines carry out their work in the Training Center for Critical Crises at the Marqués de Valdecilla University Hospital in Santander, the only center in Spain which runs this type of simulation. In 2003, this center initiated a specific training simulation for nurses whose purpose is to increase scientific-technical knowledge to the maximum and accelerate the learning of non-technical social and cognitive fundamentals within the working environment of a professional health team. The following article describes a simulation meeting these characteristics, its teaching methods, advantages, importance for professional health teams, and its repercussions on patients.

Education, Nursing↗

PubMed1999

Induction and maintenance of gastric ulceration in horses in simulated race training.

Gastric ulceration is a prevalent condition of racehorses. A number of models of gastric ulceration have been described, but none mimic the conditions of a horse in training. The objectives of this study were to determine whether gastric ulcers could be induced and maintained in a group of horses in simulated race training. In addition, serum cortisol was measured on a weekly basis to investigate the possibility that stress may be important in the pathogenesis of gastric ulceration. Thirty horses used in the trial were fed Bermuda grass hay and 6 kg of a concentrate diet, and exercised 6 days/week at speed over a distance of 1.6-2.4 km. Serum was collected and gastroendoscopic examinations performed on a weekly basis for the duration of the trial. All horses developed moderate to severe ulceration, and ulcers were maintained for the 56 day period of the trial. Only one horse had signs of abdominal discomfort, which resolved with minimal symptomatic treatment and without the use of anti-ulcer medications. Serum cortisol remained within reference ranges for the duration of the trial. Although there was some variation between the weekly examinations, serum cortisol concentrations were decreased from values obtained at the start of the trial. In this study ulcers developed without the administration of nonsteroidal anti-inflammatory agents or withholding of feed. This model provides a method to study the condition, and to investigate the effects of medications on the healing of ulcers in racehorses.

Analysis of Variance↗

PubMed1988

Effects of training at simulated altitude on performance and muscle metabolic capacity in competitive road cyclists.

Differences between the effects of training at sea level and at simulated altitude on performance and muscle structural and biochemical properties were investigated in 8 competitive cyclists who trained for 3-4 weeks, 4-5 sessions/week, each session consisting of cycling for 60-90 min continuously and 45-60 min intermittently. Four subjects, the altitude group (AG), trained in a hypobaric chamber (574 torr = 2300 m above sea level), and the other four at sea level (SLG). Before and after training work capacity was tested both at simulated altitude (574 torr) and at sea level, by an incremental cycle ergometer test until exhaustion. Work capacity was expressed as total amount of work performed. Venous blood samples were taken during the tests. Leg muscle biopsies were taken at rest before and after the training period. AG exhibited an increase of 33% in both sea level and altitude performance, while SLG increased 22% at sea level and 14% at altitude. Blood lactate concentration at a given submaximal load at altitude was significantly more reduced by training in AG than SLG. Muscle phosphofructokinase (PFK) activity decreased with training in AG but increased in SLG. All AG subjects showed increases in capillary density. In conclusion, work capacity at altitude was increased more by training at altitude than at sea level. Work capacity at sea level was at least as much improved by altitude as by sea level training. The improved work capacity by training at altitude was paralleled by decreased exercise blood lactate concentration, increased capillarization and decreased glycolytic capacity in leg muscle.

Adolescent↗

PubMed2002

Flexible tubular replicas of abdominal aortic aneurysms.

The aim of this study was to manufacture life-size, flexible, tubular replicas of human abdominal aortic aneurysms and the associated vasculature, suitable for use in a training simulator for endovascular procedures. Selective laser sintering was used to create a geometrically correct master model for each of ten anatomical variations. The masters were used to generate flexible latex replicas. The use of the replicas in the training simulator was demonstrated. In total ten silicone rubber models were produced. When connected into the training simulator and perfused at arterial pressure it was possible to deploy an endovascular stent under fluoroscopic control and to perform angiography. The study has shown that conventional rapid prototyping technology can be used to manufacture flexible, radiolucent replicas which provide a realistic training environment for endovascular procedures.

Angiography, Digital Subtraction↗

PubMed2003

Survey of change in practice following simulation-based training in crisis management.

We investigated the long-term effects on clinical practice of a simulation-based course in anaesthesia crisis management. A questionnaire was posted to all anaesthetists who had attended a course in the preceding year. The response rate was 69% (66/96). The crisis management course was valued highly by respondents, who perceive a change in practice as a result of the training. This change in practice was not limited to the specific clinical events simulated in the course, but applied to a wide range of events and to routine practice. The high rate of subsequent critical events reported in the survey supports the need for training in this area. This survey suggests that simulation-based training in crisis management is an effective form of continuing medical education for anaesthetists.

Anesthesiology↗

PubMed2005

Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care.

In this prospective study, we used two full-scale prehospital trauma scenarios (severe chest injury and severe head injury) and checklists of specific actions, reflecting essential actions for a safe treatment and successful outcome, were used to assess performance of postinternship physician graduates of the Advanced Trauma Life Support (ATLS) course. In the first 36 participants, simulated training followed basic training in airway and breathing management, whereas in the next 36 participants, 45 min of simulative training in airway management using the Air-Man simulator (Laerdal, Norway) were added before performing the study scenarios. The content of training was based on common mistakes performed by participants of the first group. After the change in training, the number of participants not performing cricoid pressure or not using medication during intubation decreased from 55% (20 of 36) to 8% (3 of 36) and from 42% (15 of 36) to 11% (4 of 36), respectively (P < 0.05). The number of participants not holding the tube properly before fixation decreased from 28% (10 of 36) to 0% (0 of 36) (P < 0.05). In the severe head trauma scenario, performed by 15 of 36 participants in each group, the incidence of mistakes in the management of secondary airway or breathing problems after initial intubation decreased from 60% (9 of 15) to 0% (0 of 15) (P < 0.05). The present study highlights problems in prehospital trauma management, as provided by the ATLS course. It seems that graduates may benefit from simulation-based airway and breathing training. However, clinical benefits from simulation-based training need to be evaluated.

Clinical Competence↗

PubMed1989

Dendritic transformations on random synaptic inputs as measured from a neuron's spike train--modeling and simulation.

Extracellular spike trains recorded from central nervous system neurons reflect the random activations from a multitude of presynaptic cells making contacts mainly on the extensive dendritic trees. The dendritic potential variations are propagated towards the trigger zone where action potentials are generated. In this paper, two dendritic propagation modes are modeled: passive and quasi-active. Synaptic bombardments are modeled as being applied apically, somatically, or distributed over the dendritic tree. The resulting simulated neuronal spike trains are analyzed by point process techniques. Dendritic inputs resulted in a tendency for random bursting, interspike interval histograms with a long tail and coefficients of variation larger than one. The autocorrelation histograms reflected dynamics of the dendritic tree and they were able to discriminate between a passive or a quasi-active propagation mode and between dendritic and somatic synaptic inputs.

Action Potentials↗

PubMed1989

Helicopter crash in water: effects of simulator escape training.

Findings are presented from an interview study of five crew members who survived a helicopter crash. Four of the five surviving men had received simulated helicopter accident training prior to the crash. One untrained crew member died. The four previously trained survivors claimed that the training was of decisive moment in their escape and survival. Contributions from training appeared to be provision of confidence and thought control. The author discusses these as the development of a positive response-outcome expectancy.

Accidents, Aviation↗

PubMed1997

Continuous concurrent feedback degrades skill learning: implications for training and simulation.

In two experiments we investigated the role of continuous concurrent visual feedback in the learning of discrete movement tasks. During practice the learner's actions either were or were not displayed on-line during the action; in both conditions the participant received kinematic feedback about errors afterward. Learning was evaluated in retention tests on the following day. We separated (a) errors in the fundamental spatial-temporal pattern controlled by the generalized motor program from (b) errors in scaling controlled by parameterization processes. During practice concurrent feedback improved parameterization but tended to decrease program stability. Based on retention tests, earlier practice with continuous feedback generally interfered with the learning of an accurate motor program and reduced the stability of time parameterization. Continuous feedback during acquisition degrades the learning of not only closed-loop processes in slower movements (as has been found in earlier studies) but also motor programs and their parameterization in more rapid tasks. Implications for feedback in training and simulation are discussed.

Analysis of Variance↗

PubMed2002

Bronchoscopy training: is simulated surgery effective?

Intensive surgical skills courses have become an essential part of surgical skill acquisition for surgeons in training. There is a need to monitor the value of these courses in terms of skill attainment. The aim of this study was to determine the effectiveness of skills-laboratory-based training in rigid bronchoscopy and bronchial foreign body removal. Bronchoscopies were recorded, analysed and categorized by a single observer according to time to completion and four predetermined parameters of surgical error. An overall quality score was obtained by simple summation of the number of errors and determined as acceptable or unacceptable (scoring 0 or 1 respectively). The data was analysed using a t-test for paired groups. P < 0.05 was considered to be significant. In total, 20 trainee otolaryngologists performed 80 separate bronchoscopies. The time to complete the task pre versus post training showed significant improvement; P < 0.001. The overall quality score pre training was 66 and post training 17; P < 0.001. We conclude that intensive surgical simulation-based courses appear to be an effective means of training surgical trainees in surgical skill proficiency.

Animals↗

PubMed2006

Surgical training and simulation laboratory at Baystate Medical Center.

The work hour restrictions imposed by the surgical residency review committee, without a curriculum change, essentially reduces training programs by 30%. The logical result of this is the risk that a higher percentage of surgeons beginning independent practice will fall below the competence level. We believe that simulation will play a vital role in the curriculum to enhance the clinical environment and make the learning environment better and more efficient. Baystate Medical Center (Springfield, Mass) is an affiliate of Tufts University School of Medicine and provides tertiary medical care for the western portion of the state. Our surgical residency program has developed and maintained a simulation center specifically to augment training of surgical knowledge and manual skills. We are also actively involved in education research and curriculum design locally and on a national level. Our center is rapidly becoming a multidisciplinary environment incorporating other residency and clinical programs within the health system and beyond. We are actively pursuing the development of novel assessment technology that will not only integrate the simulation center with the clinical arena but also link educational and clinical outcomes. This will allow us to automatically tailor the educational environment to the individual needs of the learner as they change over time, as well as look at quality improvement related to our educational and research endeavors.

Academic Medical Centers↗

PubMed2006

Validation of a new basic virtual reality simulator for training of basic endoscopic skills: the SIMENDO.

BACKGROUND: The aim of this study was to establish content, face, concurrent, and the first step of construct validity of a new simulator, the SIMENDO, in order to determine its usefulness for training basic endoscopic skills. METHODS: The validation started with an explanation of the goals, content, and features of the simulator (content validity). Then, participants from eight different medical centers consisting of experts (> or =100 laparoscopic procedures performed) and surgical trainees (<100) were informed of the goals and received a "hands-on tour" of the virtual reality (VR) trainer. Subsequently, they were asked to answer 28 structured questions about the simulator (face validity). Ratings were scored on a scale from 1 (very bad/useless) to 5 (excellent/very useful). Additional comments could be given as well. Furthermore, two experiments were conducted. In experiment 1, aimed at establishing concurrent validity, the training effect of a single-handed hand-eye coordination task in the simulator was compared with a similar task in a conventional box trainer and with the performance of a control group that received no training. In experiment 2 (first step of construct validity), the total score of task time, collisions, and path length of three consecutive runs in the simulator was compared between experts (>100 endoscopic procedures) and novices (no experience). RESULTS: A total of 75 participants (36 expert surgeons and 39 surgical trainees) filled out the questionnaire. Usefulness of tasks, features, and movement realism were scored between a mean value of 3.3 for depth perception and 4.3 for appreciation of training with the instrument. There were no significant differences between the mean values of the scores given by the experts and surgical trainees. In response to statements, 81% considered this VR trainer generally useful for training endoscopic techniques to residents, and 83% agreed that the simulator was useful to train hand-eye coordination. In experiment 1, the training effect for the single-handed task showed no significant difference between the conventional trainer and the VR simulator (concurrent validity). In experiment 2, experts scored significantly better than novices on all parameters used (construct validity). CONCLUSION: Content, face, and concurrent validity of the SIMENDO is established. The simulator is considered useful for training eye-hand coordination for endoscopic surgery. The evaluated task could discriminate between the skills of experienced surgeons and novices, giving the first indication of construct validity.

Adult↗

PubMed2001

Training high--living low: changes of aerobic performance and muscle structure with training at simulated altitude.

This study was undertaken to test the hypothesis that endurance training in hypoxia is superior to training of the same intensity in normoxia. To avoid adaptation to hypoxia, the subjects lived under normoxic conditions when not training. A secondary objective of this study was to compare the effect of high- vs. moderate-intensity training on aerobic performance variables. Thirty-three men without prior endurance training underwent a cycle ergometer training of 6 weeks, 5 d/week, 30 minutes/d. The subjects were assigned to 4 groups, N-high, N-low, H-high and H-low based on the training criteria normoxia (N; corresponding to a training altitude of 600 m), vs. hypoxia (H; training altitude 3850 m) and intensity (high; corresponding to 80% and low: corresponding to 67% of VO2max). VO2max measured in normoxia increased between 8.5 to 11.1%, independent of training altitude or intensity. VO2max measured in hypoxia increased between 2.9 and 7.2%. Hypoxia training resulted in significantly larger increases than normoxia training. Maximal power that subjects could maintain over a thirty-minute period (measured in normoxia or hypoxia) increased from 12.3 - 26.8% independent of training altitude. However, subjects training at high intensity increased performance more than subjects training at a low intensity. Muscle volume of the knee-extensors as measured by magnetic resonance imaging increased significantly in the H-high group only (+ 5.0%). Mitochondrial volume density measured by EM-morphometry in biopsy samples of m. vastus lat. increased significantly in all groups with the highest increase seen in the H-high group (+ 59%). Capillary length density increased significantly in the H-high group only (+ 17.2%). The main finding of this study is that in previously untrained people, training in hypoxia while living at low altitude increases performance in normoxia to the same extent as training in normoxia, but leads to larger increases of aerobic performance variables when measured under hypoxic conditions. Training intensity had no effect on the gain of VO2max. On the level of skeletal muscle tissue, the combination of hypoxia with high training intensity constitutes the most effective stimulus for increasing muscle oxidative capacity.

Acclimatization↗

PubMedDate not supplied

Initial experience using an endoscopic simulator to train surgical residents in flexible endoscopy in a community medical center residency program.

INTRODUCTION: The importance of training surgical residents in GI endoscopy has been recognized for years. Despite advice from SAGES and the RRC, few programs have managed to incorporate effective flexible endoscopy training into their curriculum, making it difficult for their graduates to be credentialed in GI endoscopy. Prior to October 2001, our residents obtained their entire clinical experience in the endoscopy unit with staff surgical endoscopists. Attendance was inconsistent because of their many other responsibilities, and residents often used much of their clinical endoscopic exposure gaining basic familiarity with the equipment, precluding the development of therapeutic facility. Since October 2001, we have used the Simbionix endoscopic simulator to supplement resident training in GI endoscopy. With the advent of virtual-reality simulators, and studies validating their effectiveness in teaching fundamental technical skills, we report our initial success in implementing a formal GI endoscopy curriculum using a virtual reality endoscopic simulator to provide basic experience before the clinical endoscopic experience begins. METHODS: Residents are given monthly assignments of simulated cases on the GI Mentor simulator. Junior residents complete the diagnostic case modules; senior residents complete the therapeutic modules. Data were accumulated over the course of two years with a total of five PGY-I and eight senior surgical residents completing assigned cases on the simulator. Objective criteria were measured from their performance on the simulator to determine the efficiency of the examination for each case completed. RESULTS: Preliminary data collected over the course of two years indicates that residents improve the efficiency of their endoscopic examinations over time as measured by objective criteria. Junior surgery residents attained an aggregate average of 59% efficiency in their examinations whereas senior surgical residents who had previous experience with the simulator, attained an aggregate efficiency of 80%. CONCLUSIONS: A formal flexible endoscopy curriculum enhances surgical resident training and positively impacts careers in general and gastrointestinal surgery. Endoscopic simulators allow surgical residents to master the technical aspects of GI endoscopy quickly, thereby permitting them more benefit from their clinical exposure in the endoscopy unit. We anticipate that our formal curriculum in GI endoscopy training will prepare our graduates well for careers that include flexible endoscopy as a component of their clinical practices, and position them to be credentialled in GI endoscopy upon graduation.

Colonoscopy↗

PubMed2000

Discrete event simulation in the health policy and management program.

Students in Health Policy and Management at the Faculty of Health Sciences of Maastricht University must learn to analyze and design workflow processes in health care. To attain this, a discrete event simulation training, using MedModel is used. This paper describes the training in two consecutive years. In both years the training was evaluated systematically. The evaluation results demonstrate that the simulation training increased the students' knowledge about analyzing and designing workflow processes in healthcare. Students considered the training as a very important part of their program.

Computer Simulation↗

PubMed2005

Use of a hemorrhage simulator to train military medics.

BACKGROUND: The leading cause of preventable battlefield death is extremity hemorrhage. This study examines how current first aid training for the management of severe extremity hemorrhage can be improved by using a patient simulator. METHODS: This was a prospective trial involving two cohorts of U.S. Army combat medic trainees. The control group received the standard first aid training for bleeding, including lectures and practical exercises. The study group received the same lectures but was exposed to a hemorrhage simulator during the practical exercises. Both groups were then evaluated during a field exercise 7 weeks later. RESULTS: The study group showed a statistically significant improvement in the time it took to stop severe extremity hemorrhage in a simulated patient. CONCLUSIONS: Simple innovations in training may play a significant role in preparing medics (and combatants) to care for injuries they will encounter on the battlefield.

Cohort Studies↗

PubMed2004

Simulation-based training to improve acute care skills in medical undergraduates.

AIM: Acquisition of clinical skills by medical undergraduates can be problematic, especially in the context of medical emergencies. Simulation using computerised manikins may be an effective and ethical solution. We assessed the ability of undergraduates to manage medical emergencies, and evaluated simulation as an educational and assessment tool. METHOD: Medical undergraduates were assessed in standardised, highly contextualised simulations of medical emergencies using both checklists and global ratings, and were reassessed following a simulation-based educational intervention to measure learning effect. The scores for groups at different levels of training were compared to test construct validity of global ratings of simulator performance. We explored student perspectives of simulation through thematic analysis of questionnaire responses. RESULTS: Seventy-one students were studied. Final year students performed significantly better than fourth year students, but the ability to initiate management of medical emergencies was unsatisfactory in both groups. Performance improved significantly over the course of the simulation workshop. The learning processes in simulation-based education were perceived as more effective than traditional methods, and consistent with known principles of effective learning. Students felt the simulations were a reasonable measure of their abilities and 91% felt that such simulations should be included in their end-of-year assessment. CONCLUSION: Current medical undergraduate training does not ensure new graduates can intervene effectively in an emergency. Simulation-based workshops are effective and should be incorporated into the undergraduate curriculum both for education and assessment of competence in emergency management.

Clinical Competence↗