“See One, Do One, Teach One” Using Hyper-Realistic Simulation and Testing in Medical Students

The authors describe a five day pre-post training course attended by second year medical students and the results of the training.

The Intensive Surgical Skills Course piloted by Rocky Vista University College of Osteopathic Medicine for second year medical students and the five skills tested and methods used, showed improved accuracy, efficiency and competency.

The teaching time between attending physicians and residents has decreased since residency work-hour restrictions were introduced in 2003 by the Accreditation Council for Graduate Medical Education (ACGME)1. The restrictions have led to a shift from a time-based system to a competency-based system which emphasizes accuracy versus time of training.

The “see one, do one, teach one” method that was introduced by William Halsted, first chief of surgery at Johns Hopkins Hospital, has been under-utilized with the new work-hour restrictions as patient safety is of utmost concern. Compensating for this gap has proven to be a challenge to programs, but hyper-realistic training must be incorporated in order to enhance competencies among residents.

A five day training course called the Intensive Surgical Skills Course (ISSC) was piloted at Rocky Vista University College of Osteopathic Medicine (RVUCOM) in 2012 using a group of second year medical students to demonstrate the outcomes of adjunctive training using hyper-realistic simulation and the “see one, do one, teach one” methodology. One portion of the course; five skills which students were tested on day one and then retested on day five. Students were predicted to improve in their accuracy, efficiency, and physiological responses to the testing after five days of intermittent instruction, independent practice, and independent peer-to-peer teaching. The materials and methods used as well as the results of two groups are reported here.

Materials & Methods

The following skills were assessed on day one and day five as part of the five day ISSC administered at RVUCOM in May 2012 and 2013: chest tube thoracostomy on a mannequin, chest tube thoracostomy on a person wearing the “Cut-Suit,” cricothyroidotomy on a mannequin, cricothyroidotomy on a person wearing the “Cut-Suit,” peripheral intravenous access on mannequin arms (day one), peripheral intravenous access on peer (day five), two-hand knot tying, and simple-interrupted suturing.

Materials: Chest tube thoracostomy on a mannequin was performed using gloves, betadine prep, a chest tube (24 French), 1% lidocaine, a scalpel, a Kelly clamp, 2-0 monocryl suture, a needle holder, forceps, 4x4 gauze, medical tape (up-to-date). Cricothyroidotomy was performed using a mannequin set at table height with the following materials: gloves, mechanical ventilator and tubing, a suction catheter, tubing, a canister, scalpel, a tracheal hook, a tracheal dilator, a cuffed tracheostomy tube, a 10mL syringe and 3-0 monocryl suture (Blair). Cricothyroidotomy and chest tube thoracostomy on a person wearing the “Cut-Suit” was performed using the above materials but on the human-worn, partial task simulator also known as the “Cut-Suit.” It was originally designed by Special Operations for Tactical Combat Casualty Care and has now become a staple model for surgical operations and other procedures. Peripheral intravenous access was performed using peripheral venous catheters (for this course, 22G was used), connective tubing, skin preparation (alcohol wipes were used), 2x2 gauze, medical tape, gloves (Frank). Suturing was performed using “fake” skin samples, needle holders, forceps, and 2-0 monocryl sutures. Knot-tying was done using “fake” mesentery that was set up as part of the “Cut-Suit” materials, 3-0 monocryl suture, and a Kelly clamp.

Methods: On day one, students were broken into groups of four to rotate through the various skill stations. The following is the basic format followed for each of the skills excluding the knot-tying and suturing. Students were given a short briefing on how to complete each of the skills at each station. They then recorded baseline vital signs on each other, including blood pressure, heart rate, oxygen saturation, and temperature, using their own medical equipment.

Students then performed to the best of their ability and were graded by a preceptor using an objective, step-wise checklist chest-list and given a percent score based on the number of steps accurately performed. Immediately following the skill assessment, students repeated their vital signs as listed above. Students then were given feedback and proper instruction via their assigned preceptor, including physicians and third year medical students. Students were given hand-outs on each of the skills after completion of the skills assessment. Throughout the week, the mannequins were in the classroom, and students were expected to practice and teach each other. On day five, the skills were re-assessed. Students were again in groups of four, assigned to a skill station, recorded baseline vital signs on each other, did not receive a briefing from the preceptor, and were tested on that given skill. Again, immediately following the testing, students recorded vital signs on each other. Preceptor feedback was also administered. For two-handed knot-tying and simple-interrupted suturing, students were not timed or required to measure vital signs. On day one, they attempted each and were graded using a scale that included “Poor,” “Unsatisfactory,” “Satisfactory,” “Good,” and “Excellent” by a preceptor. Throughout the week, they were expected to practice and teach each other the skills.

Chest Tube thoracostomy on mannequin and “Cut-Suit” was assessed using the following steps:

1. Gather equipment
2. Pre-medicate if hemodynamically stable
3. Locate 4th or 5th intercostal space at MAL
4. Prepare site with Betadine
5. Make a small incision in the skin with a scalpel over the chosen site
6. With a sterile hemostat, insert into the incision and dissect to penetrate the fascia
7. Firmly inert hemostat over the top of the rib into chest cavity
8. Insert chest tube into opening with sterile Pean clamp and advance chest tube into place
9. Connect chest tube to chest tube drainage system or may leave open to air if minimal or no blood return and patient is intubated
10. Secure chest tube in place
11. Record output
12. Reassess hemodynamic status and ventilator status following procedure
13. Document

Cricothyroidotomy on mannequin and “Cut-Suit” was assessed using the following steps:

1. Gather equipment
2. Stabilize patient’s head in a neutral position
3. Identify the cricothyroid membrane
4. Stabilize the cricoid and thyroid cartilages with the non-dominant hand
5. Prep area with Betadine
6. Make a vertical incision 5-7cm through the skin
7. Identify the cricoid membrane and insert the tracheal hook
8. Using the hook, now in the non-dominant hand, stabilize the trachea
9. Apply upward traction on the inferior margin of the thyroid cartilage
10. Use the tip of the scalpel blade to create a horizontal incision through the cricoid membrane into the trachea
11. Use scalpel handle, gloved finger, or tracheal dilator to open the incision
12. Remove tracheal hook
13. Insert cuffed ETT until balloon had passed through the opening
14. Inflate ETT balloon and secure with occlusive dressing, then gauze
15. Assess breath sounds, hemodynamic, and ventilatory status
16. Document

Peripheral Intravenous Access on mannequin and peer was assessed using the following steps:

1. Gather equipment.
2. Assemble Appropriate IV solution, administration set, and extension tubing
3. Flush all air from IV tubing
4. Apply tourniquet to extremity
5. Select venous site and perform aseptic venipuncture
6. Attach reseal or IV tubing and confirm adequate flow
7. Observe for vital signs of infiltration
8. If no signs of infiltration notes, secure IV with vein-guard or tape
9. Document

Two-hand knot tying was performed as taught by the retired and current surgeons attending the course. Simple-interrupted suturing was performed as instructed in medical school.

Testing included stress response using vital signs, accuracy using checklist, and efficiency using time measurement. In addition to measuring the stress response with pre- and post-test vital signs and accuracy using the above mentioned checklists, efficiency was measured using time to complete skill.

Similar forms were used for each of the other skills excluding the two-hand knot tying and simple-interrupted suturing.

Results

Results comparing individual student pre- and post-week scores of each technical skill tested (chest tube thoracotomy, cricothyrotomy, peripheral IV access, and simple interrupted suturing) are shown in Figures 1-6. Results show a general trend improvement in all areas when compared to pre-test scores. Baseline heart rate trend for individual students is shown in Figure 7.

Graph 1: Results of the chest tube thoracostomy insertion on the mannequin

Graph 2: Results of the chest tube thoracostomy insertion on the “Cut-Suit”

Graph 3: Results of the surgical cricothyroidotomy insertion on the mannequin

Graph 4: Results of the surgical cricothyroidotomy insertion on the “Cut-Suit”

Graph 5: Results of the peripheral IV access on the mannequin initially and student peer at week’s end.

Graph 6: Results of the interrupted suture skills on skin slab

Graph 7: Results of the baseline heart rate at beginning and end of training course

The average pre-week baseline heart rate was 71.3 beats per minute (bpm) and the average post-week baseline heart rate was 68.6 bpm. Standard deviation for pre- and post-week bpm was 12.2 for both. This shows an average decrease of 2.7 bpm for our student population.

Table 1 shows the statistical results of all technical skill tested including average, median and standard deviation. Figure 8 depicts the improvement seen in all technical skills testing when comparing the pre- and post-test average scores in each technical field. The cricothyroidotomy skills evaluation on the mannequin shows the greatest improvement with an 80.9% differential between pre- and post-test scores.

Graph 8: Average improvement in percentile scores for all technical skills tested (CT = chest tube, Cric = cricothyroidotomy)

Conclusion

Students were given minimal instruction on each technique and were asked to perform under testing conditions. Initially, many students failed to meet satisfactory or proficient scores. Students were then expected to practice and teach each other throughout the week according to the handouts and instruction given regarding each technique. At the end of the week, participants were re-tested and results showed a 100% pass rate for every technical skill assessed. This demonstrates the successful application of the hyper-realistic training environment in improving and employing surgical and procedural techniques. It highlights the importance and usefulness of this type of training course in preparing students in the medical field for the clinical year’s experiences.

The results show variations between pre- to post-test score comparisons and, individually, between each technical skill assessed. This may indicate a level of rater bias or inconsistency between each technical skill assessment station as well as a disparity between each student’s technical backgrounds prior to this training course.

For example, the initial evaluation of the cricothyroidotomy performed on a mannequin displays the lowest average score. Whether this indicates a discrepancy in rater bias or a lack of student population experience in doing cricothyrotomies, specifically, is unknown. Also, each technical skill has a unique scoring sheet with raw scores that varied between 5 points to 16 points correlating with each skill having a varying degree of difficulty. The suturing technique has very minimal steps; therefore, it has the lowest percentile improvement (20%) between pre- and post-test average scores. The cricothyroidotomy has a 16 step scoring process and, thus, shows the largest margin of improvement (80.9%) when comparing pre- to post-week scores.

It would be difficult to find a solution to accommodate for the disparity in the step-wise scoring process because each technical skill has a varying degree of difficulty. Future studies, may find some benefit to standardizing the raters and ensuring that the original rater at the beginning of the week is the same rater at the final evaluation. Also, educating raters on each technical skill tested prior to the initial testing process may help standardize the evaluation process and reduce the variability between raters.

In addition to improved performance accuracy, participants’ baseline heart rate vitals also depict an average of 2.7 bpm decrease between pre- and post- training, indicating desensitization to stress and increased confidence in the assessment. This, again, infers the importance of training programs such as ISSC to adequately sensitize and prepare medical students for their endeavors in clinical situations.

About the Authors

Capt. Carissa Chalut DO, Capt. Nathan Low DO and Capt. Korey Leafblad DO are in the Medical Corps of the United States Army. Capt. Chalut is currently a second year Emergency Medicine resident at the Medical College of Georgia, Capt. Low is currently a first year Psychiatry resident at Tripler Medical Center and Capt. Leafblad is currently a transitional year intern at Walter Reed Medical Center.

Capt. Ashley Martin DO, Capt. Daniel Hansen DO and Capt. Karina Bostwick are in the Medical Corps of the United States Air Force. Capt. Martin is currently a second year General Surgery resident at University of Nevada School of Medicine, Capt. Hansen is currently a first year General Surgery resident at Keesler Medical Center and Capt. Bostwick is currently a first year Ophthalmology resident at San Antonio Medical Center.

Col. (USA Ret.) Alan Moloff DO, MPH is Board Certified in Aerospace, Undersea and Disaster Medicine, Fellow of the Aerospace Medical Association and American College of Preventive Medicine.

Col. (USA Ret) Anthony J. Laporta MD, FACS, Clinical Professor of Surgery, Rocky Vista University School of Osteopathic Medicine.

References

1. Kotsis, S. V, MPH, & Chung, K. C. MD, MS (2012). Application of the "see one, do one, teach one" concept in surgical training.Plastic and Reconstruction Surgery, 131(5), 1194-1201. Retrieved from

http://www.ncbi.nlm.nih.gov/pubmed/23629100

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2. Blair, A., MD, MScm FAAEM, FACEP (2013). Emergent surgical cricothyrotomy.Up-To-Date, Retrieved from

http://proxy.rockyvistauniversity.org:2058/contents/emergent-surgical-cricothyrotomy-cricothyroidotomy?source=search_result&search=cricothyroidotomy&selectedTitle=1~36

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2. Doelken, P, MD, FCCP (2012). Placement and management of thoracostomy tubes.Up-To-Date, Retrieved from 2.http://proxy.rockyvistauniversity.org:2058/contents/placement-and-management-of-thoracostomy-tubes?source=search_result&search=chest tube placement materials&selectedTitle=1~150.
3. Frank, R., MD, FACEP (2013). Peripheral venous access in adults.Up-To-Date, Retrieved from 1.http://proxy.rockyvistauniversity.org:2058/contents/peripheral-venous-access-in-adults?source=search_result&search=peripheral IV materials&selectedTitle=1~150