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Evaluation of a teaching laboratory using a cadaver model for tube thoracostomy1

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Abstract

A prior study evaluated the efficacy of a dog laboratory to teach residents chest tube thoracostomy. This study evaluated a similarly structured program using human cadavers. A prospective repeat measure study of chest tube thoracostomy placement training was performed in a university laboratory setting using human cadavers. Ten Emergency Medicine residents were given a written pretest, followed by training. Resident attempts were then timed. The following day, a repeat test was administered. Three weeks later, a third written post-test was conducted. The written test scores improved for every participant. Mean times for procedure completion improved from 86 sec to 34 sec during the first session, and remained stable over 4 attempts from 30 sec to 32 sec during the second session. This approach to teaching clinical procedures should be considered for Emergency Medicine residency programs and for continuing education courses that emphasize procedural skills.

Introduction

Emergency Medicine residents must learn procedural skills in the course of their training. Some of these skills are difficult to teach effectively in the clinical arena, as they require rapid performance and do not offer the opportunity for practice as often as other skills such as suturing.

Historically, many Emergency Medicine training programs have utilized procedure skills laboratories, employing animals such as dogs, cats, and pigs to teach residents these procedures and provide them with an opportunity to practice these skills in a controlled, comfortable setting (1). However, one study revealed that many Emergency Medicine programs do not have formal structured training in these areas outside of the clinical arena (2). Many programs now use such formal training but the practice is not universal.

In the programs that do exist, the structure, frequency and curriculum varies considerably. In addition, training programs in specialties other than Emergency Medicine have used animal procedure laboratories to teach operative procedural skills 3, 4, 5, 6, 7, 8. Procedural training has even been shown to be of value in military casualty care training (9).

Until recently, there were few data documenting or evaluating the efficacy of these training efforts. One such study did look at this concept to evaluate, in an objective fashion, the true efficacy of a procedural skills laboratory using a dog model (10). It demonstrated that using an animal model procedure laboratory teaches the information and skills desired, and that there is retention of those skills and knowledge over time.

Our program in Emergency Medicine uses a two-day emergency procedure skills laboratory as a component of the first month of orientation training for incoming Emergency Medicine residents. The participants are given didactic and practical demonstrations, and practice time in a number of areas. These include emergency venous access, arthrocentesis, emergency airway access, abdominal procedures, chest procedures, and the anatomy of common hand injuries.

Our study was designed and conducted to examine the usefulness of a cadaver-based emergency procedure skills laboratory, and to test its efficacy in a manner similar to that of the earlier related study that used dogs as subjects. In this prior study, after a didactic and practicum, the written test scores improved (p = 0<.001) and mean times for procedures completion decreased (p = 0.005) for every participant. Retention of skills was indicated by significant shortening of the time to completion from the first attempt of the first session to that of the second session (121 sec to 58 sec, p = 0.002). The study concluded that such a dog-based procedure laboratory, which emphasized skill repetition, led to improvement in procedural speed and retention of tube thoracostomy skills over time.

With this in mind, the intent of our study was to determine:

  • 1.

    Whether such a cadaver-based procedure laboratory is effective in teaching the residents the skill of chest tube thoracostomy;

  • 2.

    Whether repetition enhances the resident’s ability to perform the procedure rapidly; and

  • 3.

    Whether there is retention over a three week interval between laboratory sessions.

While the use of dogs for such a skills laboratory already has been demonstrated to be an effective teaching modality, the use of a human cadaver model might offer a more realistic model for residents in training. In addition, a cadaver model may actually be more readily developed and conducted at many hospital teaching programs than the use of dogs, which requires a great deal of facility allocation, support, and maintenance.

Section snippets

Study design

We performed a prospective sequential assessment of chest tube thoracostomy performances by first year Emergency Medicine residents. Using this Pre-Test/Post-Test design, the participants were evaluated by written multiple choice examinations as well as human cadaver simulations of chest tube thoracostomy.

Subjects and setting

Ten first year Emergency Medicine residents participated in this study conducted during one of the annual two-day laboratory courses in emergency procedures. The course is given each year as

Written examinations

The scores on the written Pretest ranged from 38–63% correct, with a mean of 51% (SD = 6.5). The scores on Post-test 1 ranged from 59 to 81, with a mean of 71 (SD = 7.8). The scores on Post-test 2 ranged from 50–81, with a mean of 66 (SD = 7.8) (Figure 1).

The scores were significantly different between the pre-test and each of the two post-tests (t = −8.05, p < 0.00005; t = 6.58, p = 0.0001, respectively), and between the two post-tests (t = 3.31, p = 0.009).

All ten residents showed

Discussion

The need to teach invasive procedures to Emergency Medicine residents is essential, yet the most appropriate way to impart those skills is unclear. There are many reports of Emergency Medicine training programs using various animal models, didactic, and even computer models to impart competency in those techniques 2, 11, 12, 13, 14.

Procedures in an Emergency Department (ED) often need to be done in a timely manner, and a patient’s outcome may hang in the balance. Delegating such a procedure to

Conclusion

Procedural competency assessment remains poorly defined and has typically hinged on the number of procedures performed as predictive of competency 2, 11, 12, 13, 14. Therefore, the use of a human cadaver laboratory may be a viable alternative to assess competency in a more controlled and noncritical setting. It also may be a valuable method that can be utilized in postgraduate medical education courses that emphasize acquisition of clinical procedural skills. Future studies may identify which

References (14)

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Education is coordinated by Stephen R. Hayden, MD, of the University of California San Diego Medical Center, San Diego, California

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