THE BEST TEACHING MODALITY? - Simulation, Live tissue, Augmented Reality Best Training? - Special Operations Medical ...
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6/21/2018
THE BEST TEACHING MODALITY?
Simulation, Live tissue, Augmented Reality
THE EVIDENCE
MAJOR TANIA ROGERSON
AUSTRALIAN ARMY
Best Training?
• Treating real trauma patients in the field
under supervision
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Next best thing?
• Civilian hospitals
• Cadavers
• Simulators
• Live Tissue (LTT)
LTT or Simulation - the evidence?
• Research difficult to perform.
• Ideal measurement of outcome -
performance on actual human casualties
• Measurement of long term impact of
training requires time
• Technological developments of simulation
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Evaluating teaching programs 1994
Kirkpatrick
• Four levels
1. Reaction
2. Learning
3. Behaviour
4. Results
• Am Surg 2011;77(5)
• Randomised 24 Airmen to LTT or Sim (Trauma MAN)
• CRIC and chest tube, then tested on cadavers.
• LTT trained group quicker to complete procedures but
not statistically significant (may not be the best outcome
indicator.)
• Small study due to cost of cadavers
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• J Trauma Acute Care Surg 2015, 79(4)
• 20 medics randomised LTT Swine/ Simulator (CAESAR)
• No significant difference in performance of 5 TCCC procedures
• Participants felt LTT was better for cric, needle decompression,
arterial wound packing and IO. No difference for TQ
– Realistic tissue handling
– Stress associated with bleeding live models
• Medics preferred the anatomic accuracy of simulators for TQ.
• Training on LTT - more realistic stress
response
• May provide medics training on how to
control their own stress
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• Surgery 2016 Oct 160(4)
• 742 civilian/military medics randomised to LTT/sim (TraumaFX)
• Self reporting, cognitive & psychomotor performance, affective
response (electrodermal activity)
• 12 procedures (CRIC, thoracostomy, IO, chest seal, amputation
management)
• No statistical difference with self reporting/
psychomotor response, but majority thought LTT
better for 7 of the 12 procedures (chest seal and
TQ equivalent)
• All thought LTT should be included in training, 96%
thought Simulation had a role
• Novices showed no benefit from LTT but some
benefit from Simulation. Benefits of LTT may be
better in the experienced practitioner
• Affective response greater in LTT
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• Survey of 38 combat medics who had deployed to
AFG, 89% having done life saving interventions
• Compared LTT/Simulation training
• Self perceived confidence higher in LTT group and
almost all felt LTT should be part of training
• University of Minnesota Combat Casualty Training Consortium
• 2017
• 7 procedures
• 559 subjects
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UMN CCTC
• No difference in mannikin vs LTT for
Junctional haemorrhage, TQ, Chest seal, NPA,
needle decompression
• May be a role for LTT for chest tube and CRIC
Accuracy of crico- thyroidotomy performed in
canine and human cadaver models during surgical
skills training.
McCarthy MC, Ranzinger MR, Nolan DJ
J Am Coll Surg 2002;195:627-9.
• 47 surgical airways in canines and human
cadavers
• 30% misplaced in canine model compared to
3.6% in human cadavers
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LTT or Simulation?
• Few studies, overall quality low
• Studies focused on the lowest level of learning
outcomes.
• Multiple types of learners, different simulators and LTT
models, small sample sizes, lack of controls and blinding,
lack of validity and reliability data.
• No studies comparing LTT models with each other
• Insufficient evidence to determine best practice
Research Questions
• Which model translates to success on a real
patient?
• Skill retention?
• Frequency of re-training?
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Virtual & Augmented Reality
Pokemon Go?
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Travel
Education
Blend digital elements into the physical learning environment.
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Google Glass 2012
CPU creates prism display above the right eye
Camera
Speakers
Microphone
Microsoft Hololens 2016
Semitransparent lenses generate colour holograms
Sensors to ensure holograms are relevantly placed in the real
environment.
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Virtual Reality
Playstation
VR
• Fully immersive computer simulated environment
• Accelerometers, sensors
• Well established in aviation industries
Samsung Google
Oculus Rift HTC Vive Daydream
Gear VR
Haptics
126/21/2018
Virtual simulation
• Oculus VR and Children's Hospital Los Angeles
• Paediatric trauma situations
• Recreate paramedics handing over, monitors,
team discussions, distraught parents.
Has to render full
representation of the
construct
Cost and technical difficulties.
Trauma Management
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Augmented Reality
US Army Research Laboratory
• Virtual scenarios
• Land/Air/Sea/Space synthetic environment
• Joint/ Interagency partners
• Dense urban areas with large population
• Provide realism
Visualising anatomy
• 3D better than static lecture slides, textbooks.
Allows understanding spacial relationships
• Limited access to cadavers
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Vimidex VR Ultrasound simulator
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• Anat Sci Educ 10:549-559 (2017)
• Compared anatomy learning between VR, AR
and Tablet
• Looked at whether the novel technology was
distracting or difficult to use
• All three modalities equally effective
• Some side effects
Research in AR
• Laparoscopic surgical training
• Neurosurgical procedures
• Training Echocardiography
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• 95 Surgical residents using VR for Le Fort Osteotomy
• Required some time for familiarity with the technology
• Appreciated the interactive 360 environment, 3D interaction
with anatomy and close up visualisation of the surgery.
• First year residents showed most significant improvement in
their confidence
• Paramedic wearing Google Glass during
disaster triage, physician via telepresence
• Allow receiving hospital to conduct secondary
triage
• Hardware limitations - need for
wifi/bluetooth, video streaming, microphone
background noise
• Training in Disaster Medicine
186/21/2018
• 14 paramedics used Google Glass during mock disaster
exercise for telemedicine
• Questionnaire
– 13 rated the technology as very useful/extremely useful
– 9 rated easy/very easy to use
– 11 felt that it would minimally impede their duties
• Improving telemedicine - provide expert assistance
closer to the point of injury
• Remote surgeon can see what the practitioner sees,
can annotate onto the operating field using tablet
• Tablet avoids the need for bulky headwear
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System for Telemonitoring with Augmented Reality STAR
AR Research
• Research to date focused on the development, usability
and initial implementation of AR as a learning tool
• Most look at particular technical skills
• Research doesn’t confirm which type of virtual training is
most effective or how training should best be organised
• True value in training medicine unknown
• Impact on society and medical education in next 5 years
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Best modality?
Best training method involves care of real trauma
casualties - EXPERIENCE
Multimodal Training
• Neither LTT nor Simulation is complete solution
• Lectures, Problem based learning, Hospital placements
• Simulation
– Mannikins/ Part Task Trainers - Skills training, Resus team
– Role Players - Mass casualty, Different evac platforms, PFC
• LTT - Experienced practitioners, Procedural skills, Stressful training
• Exact anatomy of humans can vary so may be prudent to practice
on multiple models
• AR
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References
Barnes SL, Bukoski A, Kerby JD, et al. Live tissue versus simulation training for emergency procedures: is simulation ready to replace live
tissue? Surgery 2016;160:997–1007.
Block E, Lottenberg L, Flint L, Jakobsen J, Liebnitzky D: Use of a human patient simulator for the advanced trauma life support course. Am
Surg 2002; 68(7): 648–51
Barsom, Graafland, M. P. Schijven Systematic review on the effectiveness of augmented reality applications in medical training Surg Endosc
(2016) 30:4174–4183
da Luz LT, Nascimento B, Tien H, Kim MJ, Nathens AB, Vlachos S, Glassberg E: Current use of live tissue training in trauma: a descriptive
systematic review. Can J Surg 2015; 58(3 Suppl 3): S125–34.
Gerhardt RT, Hermstad EL, Oakes M, Wiegert RS, Oliver J: An experi- mental predeployment training program improves self-reported patient
treatment confidence and preparedness of army combat medics. Prehosp Emerg Care 2008; 12(3): 359–65
Hall AB: Randomized objective comparison of live tissue training versus simulators for emergency procedures. Am Surg 2011; 77(5): 561–5.
Iverson K, Riojas R, Sharon D, Hall AB. Objective comparison of animal training versus artificial simulation for initial cricothyroidotomy
training. A mSurg 2015;81:515–8.
Kamphuis C, Barsom E, Schijven, M, Noor C Augmented reality in medical education Perspect Med Educ (2014) 3:300–311
Kirkpatrick DL, Kirkpatrick JD: Evaluating Training Programs. San Francisco, CA: Berrett-Koehler Publishers, Inc., 1994
McCarthy MC, Ranzinger MR, Nolan DJ, et al. Accuracy of crico- thyroidotomy performed in canine and human cadaver models during
surgical skills training. J Am Coll Surg 2002;195:627-9.
Savage EC, Tenn C, Vartanian O, et al: A comparison of live tissue train- ing and high-fidelity patient simulator: a pilot study in battlefield
trauma training. J Trauma Acute Care Surg 2015; 79: S157–63
Sohn VY, Miller JP, Koeller CA, et al. From the combat medic to the forward surgical team: the Madigan model for improving trauma readiness
of brigade combat teams fighting the global war on terror. J Surg Res 2007;138:25-31.
Sweet R, Hart D, McClellan M, et al: Priming the pump: improvement in performance of life-saving airway, breathing and hemorrhage skills
after pretesting antraining on a simulator versus live tissue: an anal- ysis of critical failures [abstract]. Proceedings of the 2015 annual meeting
of the Society for Academic Emergency Medicine; 2015 May 12–15; San Diego, CA. Abstract nr 50
Zhu et al. (2014), Augmented reality in healthcare education: an integrative review. PeerJ 2:e469; DOI 10.7717/peerj.469
Wang, Parsons, Stone-McLean, Rogers, Boyd, Hoover, Meruvia-Pastor, Gong, Smith Augmented Reality as a Telemedicine Platform for
Remote PRoecural Training . Sensors 2017 17,2294
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