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A series of graded exercises for use in laparoscopic simulation is described. These exercises are designed to introduce the basic skills required for laparoscopic surgery, and have been found to be useful both for the training of junior surgeons and in workshops.
Video-assisted thoracoscopic surgery should be within the armamentarium of every thoracic surgeon today. Rapid expansion in this field has led to an unprecedented demand from practising surgeons to acquire the new skills. Five levels of training can be described: (1) didactic lectures; (2) demonstration of procedures; (3) practice on simulators; (4) animal surgery; (5) preceptorship. The first four are usually provided in training courses or workshops, while the last requires proctering or attachment to a training centre. The ultimate goal is to integrate all these into the surgical residency programs. Developments in the virtual reality module may revolutionise training in the future.
OBJECTIVE: As the first step toward finding noninvasive alternatives to the traditional methods of surgical training, we have developed a small, stand-alone computer program that simulates insertion of pedicle screws in different spinal vertebrae (T10-L5). METHODS: We used Delphi 5.0 and DirectX 7.0 extension for Microsoft Windows. This is a stand-alone and portable program. RESULTS: The program can run on most personal computers. It provides the trainee with visual feedback during practice of the technique. At present, it uses predefined three-dimensional images of the vertebrae, but we are attempting to adapt the program to three-dimensional objects based on real computed tomographic scans of the patients. The program can be downloaded at no cost from the web site: www.tums.ac.ir/downloads CONCLUSION: As a preliminary work, it requires further development, particularly toward better visual, auditory, and even proprioceptive feedback and use of the individual patient's data.
OBJECTIVE: To evaluate the efficiency of training for advanced minimally-invasive surgery in rats. SETTING: Teaching hospital, Germany. SUBJECTS: 10 surgical residents with few laparoscopic training skills had two days laparoscopic microsurgical training using rats. INTERVENTIONS: Increasingly difficult procedures started using a rubber model, followed by 'open' and 'closed' rat models simulating laparoscopic conditions. MAIN OUTCOME MEASURES: The surgical skills of all participants were assessed before and after the laparoscopic training course by applying 5 defined tasks in a simulation trainer. As a control group, 8 surgical residents with the same amount of minimal-invasive training were tested after a 2-day interval. RESULTS: All participants of the laparoscopic training programme significantly improved their surgical skills for all 5 tasks (p < 0.05). In the control group only one of the 5 tasks was significantly improved after repetition. Participants of the complete training programme consistently improved their surgical skills significantly compared with the controls before and after repetition (p < 0.05). CONCLUSION: Surgical training in minimal-invasive techniques in the rat model is effective and reproducible especially to improve laparoscopic skills such as bimanual tissue handling, knot tying and microsurgical suturing.
We examined the initial effect of sleeping at a simulated moderate altitude of 2,650 m on the frequency of apneas and hypopneas, as well as on the heart rate and blood oxygen saturation from pulse oximetry (SpO2) during rapid eye movement (REM) and non-rapid eye movement (NREM) sleep of 17 trained cyclists. Pulse oximetry revealed that sleeping at simulated altitude significantly increased heart rate (3 +/- 1 beats/min; means +/- SE) and decreased SpO2 (-6 +/- 1%) compared with baseline data collected near sea level. In response to simulated altitude, 15 of the 17 subjects increased the combined frequency of apneas plus hypopneas from baseline levels. On exposure to simulated altitude, the increase in apnea was significant from baseline for both sleep states (2.0 +/- 1.3 events/h for REM, 9.9 +/- 6.2 events/h for NREM), but the difference between the two states was not significantly different. Hypopnea frequency was significantly elevated from baseline to simulated altitude exposure in both sleep states, and under hypoxic conditions it was greater in REM than in NREM sleep (7.9 +/- 1.8 vs. 4.2 +/- 1.3 events/h, respectively). Periodic breathing episodes during sleep were identified in four subjects, making this the first study to show periodic breathing in healthy adults at a level of hypoxia equivalent to 2,650-m altitude. These results indicate that simulated moderate hypoxia of a level typically chosen by coaches and elite athletes for simulated altitude programs can cause substantial respiratory events during sleep.
BACKGROUND: Microvascular anastomosis using 10-0 nylon needs a higher level of technical dexterity compared with routine neurosurgical maneuvers. Although this technique remains an important part of treating complex intracranial aneurysms or cerebrovascular disease, the surgeon's clinical experience in using this technique is not so common. METHODS: To improve dexterity and maneuverability in the limited clinical case volume, we developed an easily accessible training system, using commercially available desk type microscope and simply suturing neighboring fibers of the gauze with 10-0 nylon under fixed and highest (x 20) magnification. RESULT: This training system is somewhat of a drawback compared to the simulation of a real clinical setting. However, because of the extremely easy availability and accessibility of the dark type microscope repeated training and the accumulation of more than 10000 stitches, on average, was accomplished. This resulted in a steep learning curve of the technique. CONCLUSION: For residency and post-residency year young neurosurgeons, who need to brush up their skills due to lower surgical case volume compared with what senior neurosurgeons have experienced this easily available training would contribute to establishing daily and long-lasting microsurgical practice.
Because of the increasing complexity of emergency medical care, medical staffs require increasingly sophisticated training systems. Virtual environments offer a low cost means to achieve a widely usable yet sophisticated training capability. We describe the Virtual Emergency Room (VER) project, a simulation system designed to enable emergency department personnel within level I and II emergency rooms to practice emergency medical procedures and protocols. Because emergency rooms are manned by a wide variety of medical professionals, we are developing a simulation facility that uses a distributed virtual environment architecture to enable real-time, multi-participant simulations. The potential advantages of this system include the ability to evaluate and refine treatment skills, and the ability to provide scenario-specific training for mobile military field hospital teams. These advantages will ultimately improve the readiness of emergency department staffs for a wide variety of trauma situations. This paper describes the VER and the major components of its distributed virtual environment. The current capabilities of our system are described followed by a discussion of recommended follow-on work.
The effect of a preparartory course in the medical interview ("taking history") followed by four months of practice was studied by comparison of a sample of trained students with a large group of untrained students, using the ACIRS rating scale. The course was 13 hours, spread out over one month. Training methods were 2 demonstrations and 3 videorecordings of interviews with simulated patients followed by feedback. Untrained students had severe gaps in important professional communication skills. About half of the trained students filled in these gaps as a result of the training. It is concluded that a short preparatory course followed by clinical experience is not enough to secure necessary interviewing skills in most medical students.
BACKGROUND: This study assesses the acquisition of skill and the learning curve associated with the performance of the clip-and-cut task on the Xitact LS 500 virtual reality (VR) simulator in laparoscopic cholecystectomy. METHODS: A group of 33 residents and interns with no previous laparoscopic experience participated in the study. All participants received a 1-h familiarization tour on the simulator. Thirty participants completed a full course of 30 simulation runs over 3 days (10 runs per day). The outcome parameters were a previously validated sum-score and time to complete performance. RESULTS: Group demographics were similar. Of the participants who completed the full study, 16.7% appeared to have such a high level of innate psychomotor abilities that they were considered proficient in the task immediately after the initial familiarization tour. Most participants (63.3%) had a moderate level of innate abilities, and their performance improved through repetitive VR training. In our study, 20% of the participants had such a low level of innate abilities that they were unable to achieve an acceptable performance in our minimal-access surgery (MAS) simulation. CONCLUSIONS: Learning curves cannot be assessed by examining the repetitive training of only one person. There seem to be four different performance profiles, reflecting the fact that some people are more adept than others to be trained by MAS procedural VR simulation. For participants receptive to training--63.3% in this study--proficiency in the task occurs after approximately 25 simulative runs.
The human cone electroretinogram (ERG) to flash trains and double flashes at different interflash intervals was studied. A double ganzfeld stimulator was used in which computer controlled flashes were presented independently in the presence of strong rod saturating backgrounds. Corneal ERGs were examined at different frequencies of flash train presentations. Flash trains with individual flashes of high frequency (100 Hz) simulate a cone ERG to light pulses of long duration by producing a corneal positive off-response (d-wave) time locked to the cessation of the train. A second flash can reduce and delay the cone b-wave produced by a first flash. This effect is maximal when the second flash occurs 10-12 msec later. There is an antagonistic mechanism in the cone system of the retina which can catch and reduce the cone b-wave produced by an earlier flash.
In this paper, we describe a practical approach to the gastrointestinal endoscopy. We comment on the basic clinical education, endoscopy training with static models, basic courses with animals, as well as a reference to audiovisual media as books, journals, videotapes and CDs. Also we deal with the computer simulation. We describe the strategies for the interventional endoscopy training, as well as the education in the future developments. At the end, we introduce a structured training in gastrointestinal endoscopy.
BACKGROUND: Technically challenging professions such as those of the defense and transportation industries increasingly use computer-based simulation and written self-learning instruments for education and to determine competency. A structured learning curriculum does not exist, however, for flexible bronchoscopy, a minimally invasive diagnostic procedure performed on thousands of patients by respiratory specialists, otolaryngologists, anesthesiologists, and surgeons worldwide. OBJECTIVE: To explore an analogous strategy of measuring theoretical knowledge in flexible bronchoscopy and specific technical skills using written knowledge assessments and a virtual reality bronchoscopy simulator. METHODS: Twelve trainees from a university pulmonary medicine training program were asked to identify and enter five specific bronchial segments on command using a virtual reality bronchoscopy skill station, and to complete a 50-question examination pertaining to bronchoscopy theory. Their performance scores and opinions pertaining to the use of these methods of assessment were then recorded. RESULTS: Trainees correctly identified and entered 71% of the bronchial segments required on command (median 60%, range 40-100%). Fifty percent (3/6) of the trainees who had performed more than 200 flexible bronchoscopies successfully entered all segments required. None (0/6) of those who had performed less than 200 flexible bronchoscopies correctly located, identified and entered all required segments. Despite disparate performance, all trainees believed that technical skills could be improved through practice and instruction using computer-based simulation. On the written assessment, only 51% of questions were answered correctly (median 52%, range 32-60%). No relationship between technical skill and theoretical knowledge was noted. In addition, neither bronchoscopy skill nor theoretical knowledge were associated with years of training or number of bronchoscopies previously performed. CONCLUSIONS: Trainees concluded that (1) bronchoscopy simulation was realistic, (2) simulator-based practice would help improve technical skills, and (3) a written questionnaire would benefit theoretical knowledge acquisition if designed as a learning instrument. The wide variability noted in this study as well as the lack of a relationship between technical skill, knowledge of bronchoscopy theory, extent of training, and bronchoscopy experience suggest that competency should not be assumed based on years of bronchoscopy training or on an arbitrary number of procedures performed.
In orthopaedics more than 50 different clinical knee joint evaluation tests exist that have to be trained in orthopaedic education. Often it is not possible to obtain sufficient practical training in a clinical environment. The training can be improved by Virtual Reality technology. In the frame of the Munich Knee Joint Simulation project an artificial leg with anatomical properties is attached by a force-torque sensor to an industrial robot. The recorded forces and torques are the input for a simple biomechanical model of the human knee joint. The robot is controlled in such way that the user gets the feeling he moves a real leg. The leg is embedded in a realistic environment with a couch and a patient on it.
One major limitation in the use of human patient simulators is a lack of objective, validated measures of human performance. Objective measures are necessary if simulators are to be used to evaluate the skills and training of medical practitioners and teams or to evaluate the impact of new processes or equipment design on overall system performance. Situation awareness (SA) refers to a person's perception and understanding of their dynamic environment. This awareness and comprehension is critical in making correct decisions that ultimately lead to correct actions in medical care settings. An objective measure of SA may be more sensitive and diagnostic than traditional performance measures. This paper reviews a theory of SA and discusses the methods required for developing an objective measure of SA within the context of a simulated medical environment. Analysis and interpretation of SA data for both individual and team performance in health care are also presented.
In only a few minutes, a normal birth turns into a crisis situation. The pregnant patient is rushed from the labor room and down a long corridor to the operating room. Surgeons quickly perform an emergency cesarean section, removing the baby from the womb so that it can be resuscitated. This scenario is very realistic, but the patients are only a simulation. Kaiser Permanente is using computerized mannequins to train physicians and nurses in its California hospitals how to better communicate and react under stressful situations.
Neurons in the functioning cortex fire erratically, with highly variable intervals between spikes. How much irregularity comes from the process of postsynaptic integration and how much from fluctuations in synaptic input? We have addressed these questions by recording the firing of neurons in slices of rat visual cortex in which synaptic receptors are blocked pharmacologically, while injecting controlled trains of unitary conductance transients, to electrically mimic natural synaptic input. Stimulation with a Poisson train of fast excitatory (AMPA-type) conductance transients, to simulate independent inputs, produced much less variability than encountered in vivo. Addition of NMDA-type conductance to each unitary event regularized the firing but lowered the precision and reliability of spikes in repeated responses. Independent Poisson trains of GABA-type conductance transients (reversing at the resting potential), which simulated independent activity in a population of presynaptic inhibitory neurons, failed to increase timing variability substantially but increased the precision of responses. However, introduction of synchrony, or correlations, in the excitatory input, according to a nonstationary Poisson model, dramatically raised timing variability to in vivo levels. The NMDA phase of compound AMPA-NMDA events conferred a time-dependent postsynaptic variability, whereby the reliability and precision of spikes degraded rapidly over the 100 msec after the start of a synchronous input burst. We conclude that postsynaptic mechanisms add significant variability to cortical responses but that substantial synchrony of inputs is necessary to explain in vivo variability. We suggest that NMDA receptors help to implement a switch from precise firing to random firing during responses to concerted inputs.
Standardised patients (SPs) are a powerful form of simulation that has now become commonplace in training and assessment in medical education throughout the world. Standardised patients are individuals, with or without actual disease, who have been trained to portray a medical case in a consistent manner. They are now the gold standard for measuring the competence of physicians and other health professionals, and the quality of their practice. A common way in which SPs are used in performance assessment has been as part of an objective structured clinical examination (OSCE). The use of an SP based OSCE can be a powerful tool in measuring continued competence in human reliability and skill performance where such skills are a critical attribute to maintaining patient safety. This article will describe how an OSCE could be used as a patient safety tool based on cases derived from actual events related to postdonation information in the blood collection process. The OSCE was developed as a competency examination for health history takers. Postdonation information events in the blood collection process account for the majority of errors reported to the US Food and Drug Administration. SP based assessment is an important patient safety tool that could be applied to a variety of patient safety settings and situations, and should be considered an important weapon in the war on medical error and patient harm.
BACKGROUND: Stress affects surgeons both during training and during professional activity. OBJECTIVE: To compare stress levels affecting surgical residents during the simulated initial assessment and management in the Advanced Trauma Life Support practical exam vs initial assessment and management of trauma patients in the emergency room. METHOD: Eighteen surgical residents were evaluated under basal conditions, during the Advanced Trauma Life Support simulation, and during emergency room initial care. Heart rate, systolic arterial pressure, and diastolic arterial pressure were measured. The Student t test was used to test for differences between means, with statistical significance declared when P < .05. RESULTS: Heart rate and systolic arterial pressure were increased at the beginning and at the end of Advanced Trauma Life Support simulation and emergency room initial care. Diastolic arterial pressure was only increased at the end of the Advanced Trauma Life Support simulation. Comparing values obtained during the Advanced Trauma Life Support simulation with those obtained during emergency room initial care, heart rate and systolic arterial pressure were significantly higher during the Advanced Trauma Life Support simulation both at the beginning and end of the test events. However, diastolic arterial pressure was only significantly higher for Advanced Trauma Life Support simulation compared emergency room at the end of the procedures. These results suggest that the simulation in the practical exam portion of the Advanced Trauma Life Support course is more stressful for the resident surgeon than is the actual initial assessment and care of trauma patients in an emergency room.