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PubMed2007

[Teaching and simulation. Methods, demands, evaluation and visions].

Since 1st October 2003 the new German "Approbationsordnung für Arzte" (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training program. Basic requirements for a successful training program using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor-student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios "induction of anaesthesia", "acute pulmonary embolism", "acute management of a multiple trauma patient" and "postoperative hypotension" as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1-6. These scores were better than those given for other segments of the curriculum.

Anesthesia↗
PubMed1992

Comparison of staff training strategies to promote generalized teaching skills.

Two studies compared the effectiveness of different strategies for promoting generalization of staff skills in teaching self-care routines to clients with developmental disabilities. In Study 1, 9 direct-care staff members of group homes were trained sequentially through four conditions; (a) the provision of written instructions, (b) performance-based training using a single client program exemplar and simulated clients (single case training), (c) performance-based training using actual developmentally delayed clients as trainees (common stimuli training), and (d) performance-based training using multiple client program exemplars with simulated clients (general case training). The results indicated that staff members did not reach all generalization criteria until general case training was provided. Because staff members had been trained sequentially through several conditions in Study 1, a second study controlled for potential sequence effects. In Study 2, 7 staff members were trained using only the general case strategy after baseline. All staff members reached generalizations criteria with only general case training, replicating the findings of Study 1. Together, the two studies demonstrated that the general case training strategy was more effective at promoting generalized training effects across clients, settings, and client programs than other commonly used staff training approaches.

Activities of Daily Living↗
PubMed2006

Teaching technical skills to surgical residents: a survey of empirical research.

We review a series of empirical studies on the use of simulators and bench models in training technical skills and subsequent retention of those skills. We discuss recent research on the transfer of training from bench models and simulators to the clinical setting and provide a theoretical structure to organize the findings. The transfer of training from inanimate bench models and simulators to live patients has recently been demonstrated in a number of areas. The effectiveness of this training is enhanced if focus is placed on the operative, or process-oriented, aspects of the procedure, with suspension of disbelief regarding the physical structure of the training platform. The retention of trained skills is an area of research only beginning to evolve, with recent results suggesting that effective retention can be demonstrated if training is tightly focused and involves an entire procedure. An emerging area of research involves the use of simulators as assessment instruments for high-stakes testing, and recent results involving simulated trauma management support this novel application. Based on these findings, we encourage the use of a wide variety of high- and low-fidelity platforms, with emphasis on training procedural knowledge involving an entire procedure.

Clinical Competence↗
PubMed1988

Training and validating the use of geriatric simulated patients.

After presenting four patient roles during an audio-taped final examination of 68 second-year medical students' interview skills, seven geriatric simulated patients evaluated the interview skills of the students. Reviews of randomly-selected audiotapes revealed that the patients were highly consistent and accurate in their evaluations, indicating that geriatric simulated patients may be an untapped resource for medical training.

Aged↗
PubMed2006

Surgical simulation: a systematic review.

OBJECTIVE: To evaluate the effectiveness of surgical simulation compared with other methods of surgical training. SUMMARY BACKGROUND DATA: Surgical simulation (with or without computers) is attractive because it avoids the use of patients for skills practice and provides relevant technical training for trainees before they operate on humans. METHODS: Studies were identified through searches of MEDLINE, EMBASE, the Cochrane Library, and other databases until April 2005. Included studies must have been randomized controlled trials (RCTs) assessing any training technique using at least some elements of surgical simulation, which reported measures of surgical task performance. RESULTS: Thirty RCTs with 760 participants were able to be included, although the quality of the RCTs was often poor. Computer simulation generally showed better results than no training at all (and than physical trainer/model training in one RCT), but was not convincingly superior to standard training (such as surgical drills) or video simulation (particularly when assessed by operative performance). Video simulation did not show consistently better results than groups with no training at all, and there were not enough data to determine if video simulation was better than standard training or the use of models. Model simulation may have been better than standard training, and cadaver training may have been better than model training. CONCLUSIONS: While there may be compelling reasons to reduce reliance on patients, cadavers, and animals for surgical training, none of the methods of simulated training has yet been shown to be better than other forms of surgical training.

Computer Simulation↗
PubMed2000

Improvement of surgical simulation using dynamic volume rendering.

In the last years high efforts have been taken to develop surgical simulators for computer assisted training. However, most of these simulators use simple models of the human's anatomy, which are manually created using modeling software. Nevertheless, medical experts need to perform the training directly with the patient's complex anatomy, which can be received, for example, from digital imaging datasets (CT, MR). A common technique to display these datasets is volume rendering. However, even with high-end hardware only static models can be handled interactively. In surgical simulators a dynamic component is also needed because tissues must be deformed and partially removed. With the combination of springmass models, which are improved by neuro-fuzzy systems, and the recently developed OpenGL Volumizer, surgical simulation using real-time deformable (or dynamic) volume rendering became possible. As an application example the simulator ROBOSIM for minimally invasive neurosurgery is presented.

Cephalometry↗
PubMed1991

The distribution of the intervals between neural impulses in the maintained discharges of retinal ganglion cells.

Simulated neural impulse trains were generated by a digital realization of the integrate-and-fire model. The variability in these impulse trains had as its origin a random noise of specified distribution. Three different distributions were used: the normal (Gaussian) distribution (no skew, normokurtic), a first-order gamma distribution (positive skew, leptokurtic), and a uniform distribution (no skew, platykurtic). Despite these differences in the distribution of the variability, the distributions of the intervals between impulses were nearly indistinguishable. These inter-impulse distributions were better fit with a hyperbolic gamma distribution than a hyperbolic normal distribution, although one might expect a better approximation for normally distributed inverse intervals. Consideration of why the inter-impulse distribution is independent of the distribution of the causative noise suggests two putative interval distributions that do not depend on the assumed noise distribution: the log normal distribution, which is predicated on the assumption that long intervals occur with the joint probability of small input values, and the random walk equation, which is the diffusion equation applied to a random walk model of the impulse generating process. Either of these equations provides a more satisfactory fit to the simulated impulse trains than the hyperbolic normal or hyperbolic gamma distributions. These equations also provide better fits to impulse trains derived from the maintained discharges of ganglion cells in the retinae of cats or goldfish. It is noted that both equations are free from the constraint that the coefficient of variation (CV) have a maximum of unity.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2006

Perceptual, visuospatial, and psychomotor abilities correlate with duration of training required on a virtual-reality flexible endoscopy simulator.

BACKGROUND: Trainees acquire endoscopic skills at different rates. Fundamental abilities testing could predict the amount of training required to reach a performance goal on a virtual-reality simulator. METHODS: Eleven medical students were tested for fundamental abilities. Baseline endoscopic proficiency was evaluated with the GI Mentor II VR simulator (Simbionix, USA, Cleveland, OH). Subjects trained on the simulator with a defined performance goal. Subjects who achieved the goal were then reassessed. RESULTS: All subjects completed at least 10 trials or reached the performance goal. The <10 trial group (n=6) tested better for all fundamental abilities and baseline endoscopic performance than the >10 trial group (n=5). The number of trials required to reach the performance goal correlated significantly with both perceptual (r=.92, P=0.001) and visuospatial ability (r=.76, P=.03). Multiple regression showed strong correlation of all three abilities with duration of training (r=.95, P=.015). CONCLUSIONS: Most of the variability in acquisition of endoscopic skills can be accounted for by differences in fundamental abilities of trainees. Testing of fundamental abilities could help identify trainees who will require additional training to achieve desired performance objectives.

Adult↗
PubMed2004

Bellows-less lung system for the human patient simulator.

A new bellows-less lung simulator utilising a fixed-volume pressure controller to simulate spontaneous breathing is presented as an alternative to the traditional bellows-driven mechanical lung system in the human patient simulator (HPS). The HPS is a fully interactive, life-like simulator used to train medical students and anaesthesia residents. The lung simulator simulates carinal pressure, which allows for simulation of actively breathing or ventilated patients. In the current HPS implementation, breathing is physically simulated with a pair of bellows and a computer-controlled piston, but, owing to physical and dynamic constraints, the model suffers from a lot of dead space. Furthermore, the set-up incorporates several mechanical components that require time-consuming calibrations, which drives up manufacturing costs. A bellows-less lung simulator has been designed and built which successfully simulates airflow in and out of the mouth by controlling the carina pressure. The new system is able to simulate tidal volumes between 400 and 500 ml, with flow rates of 4.3-5.71 min(-1) at a respiratory rate of 12 breaths per minute. The new design not only matches the ventilation performance of the HPS, but also simulates at 60 breaths per minute, which the HPS cannot maintain.

Education, Medical↗
PubMed2001

Accomplishments and challenges of surgical simulation.

For nearly a decade, advanced computer technologies have created extraordinary educational tools using three-dimensional (3D) visualization and virtual reality. Pioneering efforts in surgical simulation with these tools have resulted in a first generation of simulators for surgical technical skills. Accomplishments include simulations with 3D models of anatomy for practice of surgical tasks, initial assessment of student performance in technical skills, and awareness by professional societies of potential in surgical education and certification. However, enormous challenges remain, which include improvement of technical fidelity, standardization of accurate metrics for performance evaluation, integration of simulators into a robust educational curriculum, stringent evaluation of simulators for effectiveness and value added to surgical training, determination of simulation application to certification of surgical technical skills, and a business model to implement and disseminate simulation successfully throughout the medical education community. This review looks at the historical progress of surgical simulators, their accomplishments, and the challenges that remain.

Anatomy, Cross-Sectional↗
PubMed2006

Simulation of surgery for craniosynostosis: a training model in a fresh cadaveric sheep cranium. Technical note.

The authors present a training model in sheep crania that allows residents in neurosurgery and plastic surgery to practice the frontoorbital remodeling procedure used in the surgical correction of simple craniosynostoses such as plagiocephaly, trigonocephaly, and brachiocephaly. The model comprises a three-step approach: subperiosteal and subperiorbital dissection; elevation of the bifrontal bone flap and the supraorbital bar; and finally, frontoorbital remodeling. The authors conclude that this training model, based on the use of cadaveric sheep crania, represents a fairly useful method to accustom trainees to the required surgical techniques and simulates well the steps of standard pediatric and adult craniofacial surgery for simple craniosynostosis.

Animals↗
PubMed2004

Identifying and reducing errors with surgical simulation.

The major determinant of a patient's safety and outcome is the skill and judgment of the surgeon. While knowledge base and decision processing are evaluated during residency, technical skills-which are at the core of the profession-are not evaluated. Innovative state of the art simulation devices that train both surgical tasks and skills, without risk to patients, should allow for the detection and analysis of errors and "near misses". Studies have validated the use of a sophisticated endoscopic sinus surgery simulator (ES3) for training residents on a procedural basis. Assessments are proceeding as to whether the integration of a comprehensive ES3 training programme into the residency curriculum will have long term effects on surgical performance and patient outcomes. Using various otolaryngology residencies, subjects are exposed to mentored training on the ES3 as well as to minimally invasive trainers such as the MIST-VR. Technical errors are identified and quantified on the simulator and intraoperatively. Through a web based database, individual performance can be compared against a national standard. An upgraded version of the ES3 will be developed which will support patient specific anatomical models. This advance will allow study of the effects of simulated rehearsal of patient specific procedures (mission rehearsal) on patient outcomes and surgical errors during the actual procedure. The information gained from these studies will help usher in the next generation of surgical simulators that are anticipated to have significant impact on patient safety.

Computer-Assisted Instruction↗
PubMedDate not supplied

The effectiveness of a novel, algorithm-based difficult airway curriculum for air medical crews using human patient simulators.

INTRODUCTION: Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, and clinical apprenticeships, are scarce and offer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company. METHODS: Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before and after curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before and after exposure to the airway workshops. RESULTS: First attempt and overall ETI success improved from 71.3% and 89.3% before (n=261) to 87.5% and 94.6% after (n=504) implementation of the algorithm and simulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p<0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops. CONCLUSIONS: A novel, integrated airway management curriculum using treatment algorithms and simulation appeared to be effective for improving RSI success among air medical crews in this program.

Air Ambulances↗
PubMed1993

Discrimination of two-wavefront echoes by the big brown bat, Eptesicus fuscus: behavioral experiments and receiver simulations.

1. Echolocating bats (Eptesicus fuscus) were trained to discriminate between simulated targets consisting of one or two echo-wavefronts with internal time delays of up to 100 microseconds. Spectral and temporal properties and total signal energy of the targets were evaluated and predictions for performances of bats derived from receiver models were compared with measured performances. 2. Eptesicus fuscus was able to discriminate a one-wavefront target from two-wavefront targets with distinct internal time delays (12 microseconds, 32-40 microseconds and 52-100 microseconds). Performance was not affected by changes in total signal energy. Bats also successfully discriminated between two-wavefront targets with different internal time delays. 3. Performance predicted from differences in total energy between targets did not match the measured performance, indicating that bats did not rely on total echo energy. This finding is also supported by the behavioral data. Performance predicted from spectral and temporal receiver models both matched the measured performance and, therefore, neither one of these models can be favored over the other. 4. The behavioral data suggest that Eptesicus fuscus did not transform echo information into estimates of target range separation and, therefore, did not perceive the two wavefronts of each simulated two-wavefront echo as two separate targets.

Acoustic Stimulation↗
PubMed2005

Consensus guidelines for validation of virtual reality surgical simulators.

The Work Group for Evaluation and Implementation of Simulators and Skills Training Programmes is a newly formed sub-group of the European Association of Endoscopic Surgeons (EAES). This work group undertook a review of validation evidence for surgical simulators and the resulting consensus is presented in this article. Using clinical guidelines criteria, the evidence for validation for six different simulators was rated and subsequently translated to a level of recommendation for each system. The simulators could be divided into two basic types; systems for laparoscopic general surgery and flexible gastrointestinal endoscopy. Selection of simulators for inclusion in this consensus was based on their availability and relatively widespread usage as of July 2004. Whilst level 2 recommendations were achieved for a few systems, it was clear that there was an overall lack of published validation studies with rigorous experimental methodology. Since the consensus meeting, there have been a number of new articles, system upgrades and new devices available. The work group intends to update these consensus guidelines on a regular basis, with the resulting article available on the EAES website (http://www.eaes-eur.org ).

Computer Simulation↗
PubMed2004

Catheter simulation system CathI: from patient data generation to cardiological training systems.

In this paper we discuss a new approach to generate 3D models for a simulation system for training an angioplasty. The underlying data for these models are obtained from angiograms that are captured during routine interventions in cardiology. For the extraction of the arteries we use a non-linear classificatory with features based on vesselness information (using a scale-space approach), the gray value, and motion information of the arteries. As result we can correctly find 80% of the arteries in the image and we have 4% pixels incorrectly classified as arteries. These models serve for a virtual catheter laboratory that is based on original instruments like catheters, wires, control instruments for the X-ray, syringes, and pressure pumps for the balloon catheter but instead of a patient an input instrument is used. This instrument sends positional and pressure data to a PC that simulates the patient. The cardiologist then obtains the visual and haptic feedback as if we operated a real patient.

Cardiac Catheterization↗
PubMed1999

Brain norepinephrine changes with simulated weightlessness and relation to exercise training.

Maintenance of nervous system function during periods of a deconditioning syndrome is important to prevent diminished psychological/behavioral, and physiological function observed during periods of bed rest, physical inactivity, and weightlessness. A main neurotransmitter is norepinephrine (NE), and its regulation yields insight into nervous system function. This research tested the hypotheses that, 1) deconditioning syndrome induced by simulated weightlessness of 9 days via the head-down tilt (HDT) model results in a blunted noradrenergic turnover rate in selected brain tissue and, 2) that exercise training acts as a countermeasure for these changes in noradrenergic activity. Male Sprague-Dawley rats (3 months, n = 60) were divided into either a HDT (HDT, n = 20), cage control (CAGE-CN, n = 20) or an exercise trained HDT (HDT-EX, n = 20) group. Each group was further subdivided into a saline (n = 10) or alpha-methyl-tyrosine (AM, n = 10) (200 mg/kg) injected subgroup. Animals in the HDT groups were tail suspended in a 30 degrees head-down tilt position for 9 days. Norepinephrine turnover was determined 3 h following administration of saline or alpha-methyl-para-tyrosine. The NE turnover rate (ng gm(-1) x h(-1)) for the CN, HDT, and HDT-EX groups, respectively, were as follows: locus coeruleus, 63 +/- 33, *134 +/- 65, 85 +/- 61; hypothalamus, 195 +/- 50, *47 +/- 47; *93 +/- 34; cerebellum, 10 +/- 18, *65 +/- 15, *53 +/- 19; cerebral cortex, 6 +/- 20, *28 +/- 15, *68 +/- 22. (*Denotes significant difference from the control group at the p < or = 0.05 level of significance; +denotes significant difference from the HDT group at the p < or = 0.05 level of significance.) These findings suggest that: 1) norepinephrine turnover rate adapts in a tissue-specific manner following a 9-day tail suspension, 2) increased norepinephrine turnover rates and norepinephrine tissue content in the HDT group are consistent with neural adaptation to a chronic stress response.

Analysis of Variance↗