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CRITICAL CARE

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TRAUMA

SECTION EDITOR JUKKA TAKALA

Using Advanced Simulation for Recognition and Correction of Gaps in Airway and Breathing Management Skills in Prehospital Trauma Care Daphna Barsuk, MD*†, Amitai Ziv, MD†, Guy Lin, MD§, Amir Blumenfeld, Ilan Keidan, MD‡, Yaron Munz, MD†, and Haim Berkenstadt, MD†‡

MD§,

Orit Rubin†储,

*Department of General Surgery C, †The Israel Center for Medical Simulation, and ‡Department of Anesthesiology and Intensive care, Sheba Medical Center, Tel Hashomer; §Sackler School of Medicine, Tel Aviv University, The Israel Defense Forces Medical Corps; and 储The National Institution for Test & Evaluation, Jerusalem, Israel

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

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ndotracheal intubation is widely used for airway management in the prehospital setting. However, inadequate airway management in this population is the primary cause of preventable mortality (1). The need for immediate primary prehospital trauma airway and breathing management may require the involvement of medical teams generally deficient in skills required for treating trauma casualties. In an effort to promote trauma care and increase consistency of medical treatment, the Advanced Trauma Life Support (ATLS) course has been developed (2). The course is curriculum-based, with lectures aimed at Supported, in part, by a grant from the Israeli Defense Forces Medical Corps. Accepted for publication August 10, 2004. Address correspondence and reprint requests to Haim Berkenstadt, MD, Director of Neuroanesthesia, Department of Anesthesiology and Intensive Care, The Israel Center for Medical Simulation, Sheba Medical Center, Tel Hashomer, Israel. Address e-mail to [email protected]. DOI: 10.1213/01.ANE.0000143390.11746.CF ©2005 by the International Anesthesia Research Society 0003-2999/05

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. (Anesth Analg 2005;100:803–9)

improving cognitive knowledge, development of technical skills (using animal models), and objective structured clinical evaluation using moulage patient care in trauma scenarios. The course is followed by a written standardized multiple-choice examination and a moulage patient-based evaluation of trauma management skills to verify the participant’s competence (3). Advanced medical simulation is a relatively new modality in medical education that was also recently introduced to the field of trauma medical care. For example, Block et al. (4) assessed the Simulab Trauma Man simulator (Simulab, Seattle, WA) as an alternative to the ATLS animal surgical skill station, whereas others evaluated the value of advanced simulationbased training (5) or evaluation (6). The potential benefits from simulator-based education rely on the ability of the system to simulate diverse clinical scenarios, allowing complete interaction with the trainee in a reproducible and safe training environment. Advanced medical simulation has been used in other medical fields, mainly anesthesiology, for the Anesth Analg 2005;100:803–9

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improvement of training, clinical performance, and competence assessment and emergency room or operating room resource management training (7,8). Advanced simulation was also used for learning about errors made during critical emergency situations and for understanding the patterns of human errors during anesthesia, thus providing recommendations for changes in teaching and education (9,10). In the first phase of this study, full-scale prehospital simulated scenarios were used to assess common mistakes in the primary management of airway and breathing, performed by junior physicians who were ATLS course graduates. After this phase, structured hands-on training in the management of airway and breathing problems was added at the beginning of the training, and the performance of another group of physicians was assessed.

Methods Seventy-two postinternship physicians participated in the two stages of this prospective controlled study after an institutional ethics committee approval was accepted and personal informed consent was retrieved. All participants were within the first year after their internship and had a formal two-day ATLS course in the year before the current study. The course included lectures, technical skills training (using animal models), and objective structured clinical training (using moulage patient care in trauma scenarios). The course was followed by a written standardized multiple-choice examination and a moulage patient-based evaluation. The first 36 participants were included in the Preintervention group. In this group, simulated training in prehospital trauma scenarios followed basic training in airway and breathing management. The next 36 participants were included in the Intervention group. In this group, 45 min of simulative training in airway management using the Air-Man simulator were added to the second phase of the study before performing the study scenarios. The content of training was based on common mistakes performed by participants of the Preintervention group. The two groups of participants were equal concerning the time passed between graduating the ATLS course and participating in the study. Among 36 participants of the Preintervention group, 19 participated immediately out of the ATLS course, 7 had taken the course 3 mo before the study, 6 had taken the course 3– 6 mo before the study, and 4 had taken the course 6 –12 mo before the study. Among the 36 participants of the Intervention group, the distribution was 18, 7, 6, and 5, respectively. The study was conducted at the Israel Center for Medical Simulation, Tel Hashomer, Israel. The center is an 800-square meter facility designed as a hospital

ANESTH ANALG 2005;100:803–9

simulation facility and encompasses the whole spectrum of medical simulation modalities including simulated patients, advanced task trainers, and cuttingedge, computer-driven simulators. State-of-the-art audio-visual equipment ensures effective debriefing and constructive feedback to trainers and trainees. The High Fidelity Patient Simulator (HFPS) (Meti, Sarasota, FL), the Sim-Man simulator (Laerdal, Norway), and AirMan were used. The mannequins were located on the floor in a simulated prehospital scene, and standard mobile emergency-vehicle equipment was used for training. While using the HFPS, the treating physician can talk to the mannequin and get an answer from the operator through a speaker in the mannequin mouth, check the pupils, feel the arterial pulses, and listen to the cardiac and lung sounds. Medications can be injected to the simulator, and it responds according to its pharmacokinetics and pharmacodynamics in humans. The Sim-Man simulator is similar with respect to airway, breathing, and circulation management, but its pupils are not interactive, and medications cannot be recognized by the system. The simulated training required the physicians to identify problems and provide solutions based on the act, as if it was a real emergency situation (i.e., by injecting drugs, infusing fluids, performing orotracheal intubation, or inserting a thorax drain). Two scenarios representing immediate airway and breathing problems in trauma casualties in the prehospital environment have been developed by experts in trauma management. In scenario 1, using the HFPS, the physician had to recognize tension pneumothorax, apply an intercostal needle, and then insert a chest drain. Successful treatment of the initial airway and breathing problems was followed by hypovolemic shock, requiring orotracheal intubation and transportation to the nearest medical center for further treatment (severe chest injury). In scenario 2, using the Sim-Man simulator, the physician had to recognize the need for orotracheal intubation in a patient suffering from severe head trauma and use medication, in-line cervical spine immobilization, and cricoid pressure during the procedure. Successful treatment of the initial problem was followed by hypoxemia and the need for airway and breathing re-evaluation in a tracheally intubated patient. For each scenario, a checklist of specific actions was developed, reflecting essential actions for a safe treatment and successful outcome (Appendix). Five independent trauma experts approved the scenarios, the performance assessment tools, and the checklists validated during the training of eight senior residents in anesthesiology and emergency medicine not participating in the study. All eight participants graduated from the ATLS course within 2 yr of training and actively participate in trauma care. Performance during the study was assessed according to the checklist by two experts watching independently



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digital video recordings of the actual performance. Three cameras (Pelco, Colvis, CA), one of them a PTZ (pan-tilt zoom) camera, connected to a digital recording system (Darim, Daejeon, Korea) were used. Clinical actions that were performed later than expected or not in an optimal way were scored as partially performed. The first 36 consecutive participants were included in the Preintervention group. After completing a demographic questionnaire and an individual informed consent form, participants were assigned to one of the scenarios (21 to severe chest trauma and 15 to severe head trauma) and given 15 min of orientation on the simulators used (HFPS or Sim-Man) and the training environment. After assessing the mistakes performed by participants in the Preintervention group, 45 min of simulative training in airway management using the AirMan simulator were added for the 36 participants of the Intervention group before performing the study scenarios. The physicians were trained to assess airway and breathing in a trauma patient, to perform orotracheal intubation, and to assess and treat hypoxemia or increased resistance to ventilation with a selfinflated bag in an intubated trauma patient. The 36 participants of the Intervention group then performed the same scenarios as the Preintervention group: 21 performed the severe chest trauma scenario, and 15 performed the severe head trauma scenario. Upon completion of the study, participants were asked to complete a Likert-scale based questionnaire (5-point scale where 1 is the lowest and 5 the highest) regarding their perception of the level of realism of the simulated scenarios, the level of difficulty and challenge of the cases, and the value of simulation as an adjunct to the ATLS course. Performance in each one of the items on the checklist was assessed in the two stages of the study. To prevent multiple comparisons and increase the power of the analysis the ␹2 test of homogeneity was performed only on checklist items that were common to the two scenarios. P values less then 0.05 were considered to be significant.

and 4 of 15 participants, whereas 8 of 21 and 2 of 15 participants failed to hold the tube during fixation in the chest and head trauma scenarios, respectively. The success rate of orotracheal intubation in the first attempt was 10 of 21 and 6 of 15 (total, 16 of 36), and it was 9 of 21 and 7 of 15 (total, 16 of 36) in second or third attempt. In the severe chest trauma scenario, the technique of chest-drain insertion was optimal in only 10 of 21 scenarios. In the severe head trauma scenario, hyperventilation was not induced when unilateral pupil dilation was induced in 9 of 15 cases, and airway and breathing were not evaluated according to the recommended protocols by 11 of 15 participants when increases in resistance to self-inflated bag ventilation (increased peak inspiratory pressure) was induced. In the Intervention group, the incidence of common mistakes was less than in comparison to the preintervention stage (Tables 1 and 2). (Only action items that were frequently absent in the preintervention stage of the study were included.) Table 3 represents the performance of items common to both scenarios. Significant improvement in performance was detected for three items: use of medication during intubation, cricoid pressure application, and holding of the orotracheal tube during fixation (␹2(2) ⫽ 12.4, ␹2(2) ⫽ 16.3, ␹2(2) ⫽ 11.7, respectively). For the item of administration of oxygen before orotracheal intubation, the difference between the groups was close to significant (␹2(2) ⫽ 5.5; P ⬍ 0.06). Figure 1 represents the distribution of the results of the questionnaire. Scenarios were reported to represent realistic true trauma cases (top level scoring: 5 on the Likert scale) by 82.8% of participants. The difficulty of the severe chest trauma scenario was estimated to be 2 ⫾ 0.4, and the difficulty of the severe head injury scenario was estimated to be 1.8 ⫾ 0.5 (mean ⫾ sd, on 1–5 Likert scale). The majority of participants (97.5%) recommended simulator-based training as part of future training and performance assessment (top level scoring: 5 on the Likert scale).

Results

Discussion

All 72 participants were within the first year after completing their internship, and there was no difference between the participants in the two groups regarding the time elapsed since they successfully graduated the ATLS course. The two scenarios were completed by the 36 participants of the Preintervention group: 21 participants completed the severe chest trauma scenario, and 15 completed the severe head trauma scenario. More than half of the participants did not perform cricoid pressure in both the severe chest (12 of 21) and the severe head (8 of 15) trauma scenarios (total, 20 of 36). Medications were not used for orotracheal intubation by 11 of 21

Computerized patient simulators can be programmed for diverse clinical scenarios and provide a safe and reproducible training environment that focuses on the trainee. Advanced simulation for trauma has been introduced offering training of basic trauma-related surgical skills, for the military emergency personnel in trauma assessment skills (11), and to test the competence of surgery interns after a standard ATLS course (12). Construct validity of advanced simulation in the training of emergency medicine scenarios was demonstrated by Gordon et al. (13), whereas the value of advanced simulation in promoting trauma management was demonstrated by Marshall et al. (14).

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Table 1. Comparison Between the Preintervention and Intervention Groups for Common Mistakes in Performance in the Severe Chest Trauma Scenario (n ⫽ 21 each) Preintervention (n ⫽ 21)

Intervention (n ⫽ 21)

Clinical action

Presence

Partial

Absence

Presence

Partial

Absence

Oxygen application Administration of oxygen Use of medications Cricoid pressure performance Checking tube placement Holding tube during fixation

16 13 6 7 14 11

1 4 4 2 0 2

4 4 11 12 7 8

16 17 14 16 19 18

4 3 5 2 0 3

1 1 2 3 2 0

Table 2. Comparison Between the Preintervention and Intervention Groups for Common Mistakes in Performance in the Severe Head Trauma Scenario (n ⫽ 15 each) Preintervention (n ⫽ 15)


Clinical action

Presence

Partial

Absence

Presence

Partial

Absence

Oxygen application Administration of oxygen Stabilization of cervical spine Use of medications Cricoid pressure performance Holding tube during fixation Successful intubation Hyperventilation Collar application Re-evaluation of airway and breathing Performance of suction through orotracheal tube

10 10 6 7 6 12 6 3 10 3 8

3 2 5 4 1 1 7 3 1 3 0

2 3 4 4 8 2 2 9 4 9 7

11 13 12 12 12 13 9 9 11 12 13

3 2 2 2 2 2 5 4 2 3 1

1 0 1 1 1 0 1 2 2 0 1

Table 3. Comparison Between the Preintervention Groups for Common Mistakes in the Performance in Items Common to Both Scenarios (n ⫽ 36 each) Preintervention (n ⫽ 36)


Clinical action

Presence

Partial

Absence

Presence

Partial

Absence

P value

Oxygen application Administration of oxygen Use of medications Cricoid pressure performance Holding tube during fixation

26 23 13 13 23

4 6 8 3 3

6 7 15 20 10

27 30 26 28 31

7 5 7 4 5

2 1 3 4 0

0.24 0.06 0.002* 0.000* 0.002*

* Statistically significant.

In this study, advanced medical simulation was used to evaluate mistakes in prehospital trauma care, performed by a population of junior physician graduates of the ATLS course. Advanced simulation was used previously for similar purposes in anesthesia practice (7–9) and recently, by our team, to assess the ability of medical personnel to treat chemical warfare casualties while wearing full protective gear (15). The findings of the present study suggest major deviations from the ATLS guidelines, mainly in the performance of rapid sequence induction during orotracheal intubation and in the evaluation of secondary respiratory and hemodynamic deterioration in the intubated trauma patient. Although all 21 participants recognized the need for intubation for the patient who

suffered from severe chest trauma, 4 (19%) failed to administer oxygen to the patient, 11 (52%) did not use medications before laryngoscopy, 12 (57%) did not perform cricoid pressure, and 8 (38%) did not hold the tube properly until fixation. Similar results were found in the case of the head trauma patient, where 3 of 15 participants (20%) failed to administer oxygen to the patient, 4 (26%) did not use medications, 4 (26%) did not stabilize the cervical spine, and 8 (53%) did not apply cricoid pressure. Similar major deviations from common standards of care during the treatment of trauma casualties by emergency medicine residents were described by Olsen et al. (16). Video recording in the emergency room revealed that the most common deviation was inadequate application of cricoid pressure


Figure 1. Distribution of the results (percent of participants) to the questionnaire using the 5-point Likert scale, where 1 is the lowest and 5 the highest. (A) Scenarios represent realistic true trauma cases (n ⫽ 72). (B) Simulator-based training is recommended as part of future training and performance assessment (n ⫽ 72). (C) The difficulty of the severe chest trauma scenario (n ⫽ 42). (D) The difficulty of the severe head trauma scenario (n ⫽ 30).


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in 45% of the cases. Using similar video recording techniques of initial trauma resuscitation, Santora et al. (17) found 23% overall deviation from ATLS resuscitation principles. Furthermore, the study showed that at least one aspect of the resuscitation deviation from expected ATLS performance for 64% of the patients. In another study, video analysis of 48 cases identified 28 performance deficiencies related to airway management in 11 cases (23%) (18). Another common but crucial mistake observed in the present study was the difficulty in the management of secondary deterioration of the intubated trauma patient, related to airway and breathing problems. In the severe head trauma scenario, 60% of participants failed to perform secondary evaluation according to the current guidelines. Thus, assessment of dislodgement, obstruction, pneumothorax, and equipment was not performed when hypoxemia and resistance to ventilation were developed. Mistakes documented in the preintervention stage were debriefed and corrected before the full interactive simulative scenarios in the intervention stage of the study. Recommendations for changes in training curriculum, based on discrepancies in performance, recognized during HFPS training, were previously introduced (19). However, previous authors did not implement these. Changes in the curriculum included the addition of a specially designed airway management training station. In this station, the Air-Man simulator was used, thus concentrating on the correct performance of orotracheal intubation in prehospital trauma setup and on the differential diagnosis and management of secondary deterioration of the intubated severe trauma patient. The incorporation of the airway and breathing training was followed by changes in performance during advance simulation, mainly a more frequent incidence of cricoid pressure application and use of medications to facilitate orotracheal intubation. Although the authors expected such differences, the findings are not trivial in view of the limited data published supporting the beneficial effects of simulation-based training. The report by Chopra et al. (20) demonstrated a positive effect of simulation training on the subsequent management of a similar critical incident. However, in a recent publication, Olympio et al. (21) failed to demonstrate the influence of simulation training on the management of esophageal intubation. The suggested beneficial effect of simulation-based airway management training is further supported by a prospective randomized controlled study, demonstrating that simulator training independently improved in scores achieved by interns treating trauma-related scenarios after graduating from a one-day trauma course compared with training based on moulage patients (4). The present study highlights problems in prehospital trauma management provided by ATLS course


graduates and strengthens the importance and usefulness of simulation based airway and breathing training. Moreover, the subjective feedback from the participants supports the realism of the scenarios and the possible beneficial effect of simulation-based trauma training. However, one can criticize the possible clinical benefits from simulative training in view of the lack of proper studies in proving a true transfer of skills from simulation to reality (22,23). Moreover, determining the rate of skills degradation over time and, thus, deciding what is the correct frequency with which training should be provided requires further investigation (Fig. 1).

Appendix Checklists of specific actions reflecting essential actions for a safe treatment and successful outcome Scenario 1: Severe chest trauma • • • • • • • • • • • • • •

Oxygen application Connection to pulse oximeter Recognition of pneumothorax Needle application Decision on chest drain insertion Technique of chest drain insertion Reevaluation of airway and breathing Decision on orotracheal intubation Administration of oxygen Use of medications Cricoid pressure Successful intubation Checking tube placement Holding tube during fixation

Scenario 2: Severe head injury • • • • • • • • • • • • • •

Oxygen application Connection to pulse oximeter Decision on orotracheal intubation Administration of oxygen Stabilization of cervical spine Use of medications Cricoid pressure performance Checking tube placement Holding tube during fixation Successful intubation Hyperventilation Collar application Recognition of resistance to hand-bag ventilation Reevaluation of airway and breathing according to dislodgement, obstruction, pneumothorax, and equipment • Performance of suction through orotracheal tube • False needle application


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