Self-Debriefing vs Instructor Debriefing in a Pre-Internship Simulation Curriculum: Night on Call.

This study sought to determine if learner self-performance assessment (SPA) and team-performance assessment (TPA) were different when simulation based education (SBE) was supported by self-debriefing (S-DB), compared to traditional facilitator-led debriefing (F-DB). "One-Night-On-Call," an internship preparation curriculum, was selected to provide SBE. Participants worked as team members in 4 sequential bedside acute care problem-solving scenarios. Fifty-seven learners were randomized to 9 F-DB and 10 S-DB Teams. Participants completed SPA and TPA assessment checklist questionnaires immediately following the first and fourth (final) scenarios. Learner SPA and TPA scores improved overall from the first to the fourth scenarios (P <.05). F-DB versus S-DB cohorts did not differ in overall SPA scores. The F-DB average TPA score was 12.8 (SD±2.1) compared to a S-DB score of 14.1 (SD±2.1) (P =.001). F-DB participants' increase in TPA was due to increases in the Patient Assessment and Treatment sub-domains that exceeded corresponding improvements in the S-DB cohort. Self- debriefing strategies are equivalent to facilitator-led debriefing in some situations. Self-debriefing offers opportunities to enable simulation-based education by decreasing the number of required faculty debriefers, and may be uniquely well matched to simulation-based teamwork training.

Out of the wilderness: flipping the classroom to advance scholarship in an internal medicine residency program.

Residents in an internal medicine residency program "flipped the classroom" in a series of learner-centered activities which included the creation of a medical student interest group, a continuing medical education symposium, and a journal supplement focused on wilderness medicine topics in Hawai'i and Asia Pacific. The project encompassed both scholarly activities (discovery, integration, application, and teaching) as well as scholarship (writing for publication). The project advanced the professional formation of residents by developing competencies and producing outcomes that are key features of the ACGME Next Accreditation System.

Takotsubo cardiomyopathy in the setting of acute alcohol withdrawal.

Takotsubo Cardiomyopathy (TCM), also known as stress-induced cardiomyopathy, is a cardiomyopathy characterized by acute reversible apical ventricular dysfunction and apical akinesis in the absence of obstructive coronary artery disease. Although the disease may be precipitated by an acute emotional or physical stressor, the pathophysiology, postulated to involve excess catecholamine release, remains unproven. In contrast, the role of catecholamine excess and hyperadrenergic physiology in acute alcohol withdrawal (AAW) is more established. TCM in the context of acute alcohol withdrawal has been only rarely described. The authors present a new case of TCM in the setting of AAW, along with a review of other reported cases. Current theories on the etiology of TCM and a possible pathophysiologic linkage between TCM and AAW are discussed.

Toward natural selection in virtual reality.

Here we describe a vision of VR games that combine the best features of gaming and VR: large, persistent worlds experienced in photorealistic settings with full immersion. For example, Figure 1 illustrates a hypothetical immersive VR game that could be developed using current technologies, including real-time, cinematic-quality graphics; a panoramic head-mounted display (HMD); and wide-area tracking. We also examine the gap between available VR and gaming technologies, and offer solutions for bridging it.

Mass-casualty triage training for international healthcare workers in the Asia-Pacific region using manikin-based simulations.

INTRODUCTION: More than half of the world's disasters occur in the Asia-Pacific region. A simulation-based exercise to teach healthcare workers prehospital triage, tagging, and treatment methods was used to link disaster management theory to practice with a student-centered, hands-on educational activity. Various strategies for teaching disaster health education have been advocated, and best-practice disaster education models continue to be sought. METHODS: A manikin-based, primary triage and treatment course was adapted for international healthcare providers in the Asia-Pacific region using symbolic representations of triage categories and physical findings. The pedagogical construct that was used was an interactive, formative assessment in which faculty members mediated learner information gathering and interpretation during four simulation scenarios. After establishing a multi-casualty disaster context, a wireless, audience response system anonymously collected learner responses to four clinical situations: (1) leg wound (hemorrhagic shock/immediate); (2) chest wound (tension pneumothorax/immediate); (3) head wound (traumatic brain injury/expectant); and (4) limb trauma (leg fracture/delayed). RESULTS: There were 182 healthcare providers from eight Asia-Pacific countries (including the US) that participated in four simulation seminars. The simulation sessions were successfully tailored to groups of learners that varied in size and professional composition. Expectant and delayed triage categories posed the greatest challenge to learners. In one of two groups that were queried, learner self-confidence in applying principles of triage and treatment improved significantly. At the conclusion of the simulation sessions, learners strongly agreed that manikin-based simulation improved their understanding of triage, and should be used to teach principles of primary triage and treatment. CONCLUSIONS: Simulation training represents an opportunity to engage learners regardless of language and cultural barriers. Simulation-based training can be effective in introducing healthcare professionals to principles of primary triage and treatment in an effective and culturally sensitive manner. The characteristics of the course with respect to planned formative assessment and culturally competent scholarship were reviewed.

Videolaryngoscopy for intubation skills training of novice military airway managers.

An estimated 10% of preventable battlefield deaths are due to Airway obstruction. Improved airway rescue strategies are needed with new tools for airway management by less experienced providers. Airway management and training are improved using video laryngoscopy (VL) compared to direct laryngoscopy (DL). We evaluated if novices could rapidly acquire fundamental skills and compared intubation time and laryngeal visualization using VL compared to DL in a manikin model of normal laryngeal anatomy. For 43 subjects mean intubation time did not differ for DL (25.9 +/- 24.5 seconds) vs. VL (26.4 +/- 31.5 seconds) {p = 0.94 paired t-test}. Self reported novice intubation time was 6.82 +/- 31.0 seconds greater with VL (31.6 +/- 34.6 seconds) vs. DL (24.8 +/- 18.5 seconds) {p = 0.255 paired t-test}. VL vs. DL time difference was not different between self-reported novice and non-novice groups. Mean Cormack-Lehane airway visualization grades (range 1-4) were higher with VL (1.95 +/- 0.97) vs. DL (1.02 +/- 0.15) {Students t-test p < 0.0001}. VL (69.7%) was preferred to DL (18.6%); no preference was indicated by 11.6%.

Teaching mass casualty triage skills using iterative multimanikin simulations.

OBJECTIVE: Effective mass casualty triage requires rapid and accurate decision making. First responders need to be trained, but opportunities to practice triage and receive individualized feedback during traditional mass casualty (MC) exercises are uncommon. It was hypothesized that novice learners would improve in speed, accuracy, and self-efficacy after deliberate practice triaging multiple simulated casualties in a MC exercise using high-fidelity manikins. METHODS: Learners initially developed baseline knowledge of MC triage by listening to four short podcasts and passing a written examination. They then experienced three sequential MC scenarios (A, B, and C) consisting of five manikin simulations each, coupled with individual feedback after each scenario. Students served as their own controls. A triage score (TS) and intervention score (IS) were recorded. For the TS, one point was awarded for each correctly identified main problem, required intervention, and triage category. For the IS, one point was awarded for each correctly applied intervention. Before-and-after surveys measured self-efficacy and reaction to the training. RESULTS: Twenty-one medical students were enrolled and 20 students passed the examination. The TS and IS improved significantly during scenario B (p < 0.001). Time to complete each scenario decreased significantly from scenario A (8 min 27 sec) to scenario B (6 min 19 sec) (p < 0.001), but not from scenario B to scenario C (5 min 40 sec). Self-efficacy improved significantly after scenario C for prioritizing treatment and resources, identifying high-risk casualties, and learning to be an effective first responder. CONCLUSION: Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, multimanikin MC training experience.

Teaching mass casualty triage skills using immersive three-dimensional virtual reality.

OBJECTIVES: Virtual reality (VR) environments offer potential advantages over traditional paper methods, manikin simulation, and live drills for mass casualty training and assessment. The authors measured the acquisition of triage skills by novice learners after exposing them to three sequential scenarios (A, B, and C) of five simulated patients each in a fully immersed three-dimensional VR environment. The hypothesis was that learners would improve in speed, accuracy, and self-efficacy. METHODS: Twenty-four medical students were taught principles of mass casualty triage using three short podcasts, followed by an immersive VR exercise in which learners donned a head-mounted display (HMD) and three motion tracking sensors, one for their head and one for each hand. They used a gesture-based command system to interact with multiple VR casualties. For triage score, one point was awarded for each correctly identified main problem, required intervention, and triage category. For intervention score, one point was awarded for each correct VR intervention. Scores were analyzed using one-way analysis of variance (ANOVA) for each student. Before and after surveys were used to measure self-efficacy and reaction to the training. RESULTS: Four students were excluded from analysis due to participation in a recent triage research program. Results from 20 students were analyzed. Triage scores and intervention scores improved significantly during Scenario B (p < 0.001). Time to complete each scenario decreased significantly from A (8:10 minutes) to B (5:14 minutes; p < 0.001) and from B to C (3:58 minutes; p < 0.001). Self-efficacy improved significantly in the areas of prioritizing treatment, prioritizing resources, identifying high-risk patients, and beliefs about learning to be an effective first responder. CONCLUSIONS: Novice learners demonstrated improved triage and intervention scores, speed, and self-efficacy during an iterative, fully immersed VR triage experience.

An international landmine telehealth symposium between Hawaii and Thailand using an Internet2 and multi-protocol videoconferencing bridge.

An international telehealth symposium was conducted between healthcare institutions in Hawaii and Thailand using a combination of Asynchronous Transfer Mode, and Internet2 connectivity. Military and civilian experts exchanged information on the acute and rehabilitative care of landmine victims in Southeast Asia. Videoconferencing can promote civil-military cooperation in healthcare fields that have multiple international stakeholders.

Remote critical care consultation: telehealth projection of clinical specialty expertise.

Remote critical care consultations have been employed between the Naval Hospital in Guam and the Tripler Army Medical Center in Hawaii, a distance of 5300 km. During a 10-week study period there were physician-physician daily consultation rounds for patients in the intensive care unit at the Naval Hospital. Physiological data, video-images and sound were transmitted via a 768 kbit/s frame relay connection, albeit with a 1-3 s delay. During the study there were 87 consultations concerning 25 patients. Preliminary results showed that a broad range of critical care patients could be managed effectively through daily remote critical care consultation. Broader implementation of this strategy may represent a method of making critical care expertise available to front-line military health-care facilities and to remote civilian facilities with limited critical care expertise.

Interactive nursing skills training using advanced networked technology.

We have developed a Web-based e-learning tool for teaching nursing skills, using educational material from a hospital-based nursing skills 'fair'. Management software was used to track skill certification and continuing education contact hours. The content could be delivered over the Internet and through firewalls using Windows Media Player version 9. The content was structured in a manner that made it adaptable to an e-learning system that used the Sharable Content Object Reference Model (SCORM), a set of specifications for delivering educational materials through technology-based methods.

International medical education between Hawaii and Thailand over Internet2.

International medical education sessions have been successfully conducted by videoconferencing using Internet2. The sessions were between two tertiary care medical centres, in Honolulu and Bangkok. However, video quality was lower than for similar sessions using ISDN and audience satisfaction was less. The main reasons for the lower quality were network congestion and bandwidth allocation by the videoconferencing equipment. Software to ensure quality of service is available, but is not easy to implement. There were also network security problems and the costs were high. Our international videoconferences averaged 40-50 hours per year, an activity level at which connection costs were lower for ISDN than for Internet2. It appears that Internet2 videoconferencing for medical education is best reserved for academic institutions that have other high-bandwidth network requirements.

International distance education and the transition from ISDN to high-bandwidth Internet connectivity.

The Thailand-Hawaii Assessment of Interactive Healthcare Initiative (THAI-HI) is an international distance-education project between two teaching hospitals in Honolulu and Bangkok that uses videoconferencing over three ISDN lines. A 'morning report' format is used to discuss clinical cases primarily covering infectious disease and critical-care topics. An audience response system is used at both sites to add interactivity. From July 2001 to May 2002, 816 health-care providers attended 20 clinical conferences. Audiences rated the conferences as highly relevant and as having high training value. Since the ISDN connection is expensive, we plan to convert the telecommunications to a high-bandwidth Internet connection. The Honolulu site will use a 45 Mbit/s commercial connection to the Hawaii Intranetwork Consortium, which links to the Abilene Network on the US mainland. The Bangkok hospital will use a 155 Mbit/s wireless optical connection to UNINET Thailand, which has a 45 Mbit/s circuit to Abilene.

International distance education and the transition from ISDN to high-bandwidth Internet connectivity.

The Thailand Hawaii Assessment of Interactive Healthcare Initiative (THAI-HI) is an international distance-education project between two teaching hospitals in Honolulu and Bangkok that uses videoconferencing over three ISDN lines. A 'morning report' format is used to discuss clinical cases primarily covering infectious disease and critical-care topics. An audience response system is used at both sites to add interactivity. From July 2001 to May 2002, 816 health-care providers attended 20 clinical conferences. Audiences rated the conferences as highly relevant and as having high training value. Since the ISDN connection is expensive, we plan to convert the telecommunications to a high-bandwidth Internet connection. The Honolulu site will use a 45 Mbit/s commercial connection to the Hawaii Intranetwork Consortium, which links to the Abilene Network on the US mainland. The Bangkok hospital will use a 155 Mbit/s wireless optical connection to UNINET Thailand, which has a 45 Mbit/s circuit to Abilene.