title: Using advanced simulation for recognition and correction of gaps in airway and breathing management skills in prehospital trauma care.
abstract: 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.
authors.affiliation: *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 ∥The National Institution for Test & Evaluation, Jerusalem, Israel.
authors.forename: Daphna
authors.initials: D
authors.lastname: Barsuk
authors.forename: Amitai
authors.initials: A
authors.lastname: Ziv
authors.forename: Guy
authors.initials: G
authors.lastname: Lin
authors.forename: Amir
authors.initials: A
authors.lastname: Blumenfeld
authors.forename: Orit
authors.initials: O
authors.lastname: Rubin
authors.forename: Ilan
authors.initials: I
authors.lastname: Keidan
authors.forename: Yaron
authors.initials: Y
authors.lastname: Munz
authors.forename: Haim
authors.initials: H
authors.lastname: Berkenstadt
mesh_terms: D002983:Clinical Competence; D003194:Computer-Assisted Instruction; D004503:Education, Medical, Graduate; D006801:Humans; D007442:Intubation, Intratracheal; D008020:Life Support Care; D016544:Patient Simulation; D011446:Prospective Studies; D012119:Respiration; D014947:Wounds and Injuries / Q000628:therapy*
references.citation: Adnet F, Lapostolle F, Richard-Hilbon A, et al. Intubating trauma patients before reaching hospital: revised. Crit Care 2001;5:290–1.
references.citation: Advance trauma life support. In: ATLS Student Manual. 7th ed. Chicago: American College of Surgeons, 2003.
references.citation: Ali J, Adam R, Pierre I, et al. Comparison of performance two years after the old and new (interactive) ATLS courses. J Surg Res 2001;97:71–5.
references.citation: Block EF, Lottenberg I, Flint L, et al. Use of human patient simulator for the advanced trauma life support course. Am Surg 2002;68:648–51.
references.citation: Lee SK, Pardo M, Gaba D, et al. Trauma assessment training with a patient simulator: a prospective, randomized study. J Trauma 2003;55:651–7.
references.citation: Holcomb JM, Dumire RD, Crommett JW, et al. Evaluation of trauma team performance using an advanced human patient simulator for resuscitation training. J Trauma 2002;52:1078–86.
references.citation: Issenberg SB, McGaghie WC, Hart IR, et al. Simulation technology for health care professional skills training and assessment. JAMA 1999;282:561–6.
references.citation: Gaba DM. Improving anesthesiologists performance by simulating reality. Anesthesiology 1992;76:491–4.
references.citation: Schwid HA, O'Donnell D. Anesthesiologists' management of simulated critical incidents. Anesthesiology 1992;76:495–501.
references.citation: De-Anda A, Gaba DM. Unplanned incidents during comprehensive anesthesia simulation. Anesth Analg 1990;71:77–82.
references.citation: Treloar D, Hawayek J, Montgomery JR, Russel W. On site and distance education of emergency personnel with a human patient simulator. Mil Med 2001;51:17–21.
references.citation: Ali J, Gana TJ, Howard M. Trauma mannequin assessment of management skills of surgical residents after advanced trauma life support training. J Surg Res 2000;93:197–200.
references.citation: Gordon JA, Tancredi D, Binder W, et al. Assessing global performance in emergency medicine using high fidelity patient simulator: a pilot study. Acad Emerg Med 2003;10:472.
references.citation: Marshal RL, Smith JS, Gorman P, et al. Use of a human patient simulator in the development of resident trauma management skills. J Trauma 2001;51:17–21.
references.citation: Berkenstadt H, Ziv A, Barsuk D, et al. The use of advanced simulation in the training of anesthesiologists to treat chemical warfare casualties. Anesth Analg 2003;96:1739–42.
references.citation: Olsen JC, Gurr DE, Hughes M. Video analysis of emergency medicine residents performing rapid sequence intubations. J Emerg Med 2000;18:469–72.
references.citation: Santora TA, Trooskin SZ, Blank CA, et al. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med 1996;14:564–9.
references.citation: Mackenzie CF, Jeffries NJ, Hunter WA, et al. Comparison of self reporting of deficiencies in airway management with video analysis of actual performance: LOT group—level one trauma anesthesia simulation. Hum Factors 1996;38:623–35.
references.citation: Morgan PJ, Cleave-Hogg D, DeSousa S, Tarshish J. Identification of gaps in the achievement of undergraduate anesthesia educational objectives using high fidelity patient simulation. Anesth Analg 2003;97:1690–4.
references.citation: Chopra V, Gesink BJ, de Jong J, et al. Does training on an anaesthesia simulator lead to improvement in performance. Br J Anaesth 1994;73:293–7.
references.citation: Olympio MA, Whelan R, Ford RPA, Saunders ICM. Failure of simulation training to change residents management of oesophageal intubation. Br J Anaesth 2003;91:312–8.
references.citation: Tracey MR, Lathan CE. The interaction of spatial ability and motor learning in the transfer of training from a simulator to a real task. Stud Health Technol Inform 2001;8:521–7.
references.citation: Anastakis DJ, Regehr G, Reznick RK, et al. Assessment of technical skills transfer from the bench training model to the human model. Am J Surg 1999;177:167–70.