5/5/14

Evaluation of Tube Thoracostomy Teaching Models: An Argument forDeveloping Low-Fidelity SimulatorsAzmath Mohammed, MD; Christina Jenkins, MD; Jimmi Mangla, MD; James Robbins, MD

INTRODUCTIONTube thoracostomy (TT) is a common surgical procedure performed in both acute and non-acute settings. Often, it is performed in trauma setting which can be life-saving to patients. With the recent resident work hour restrictions, there may be a deficit of TT placement skills in junior residents. In addition, there are avoidable risks associated among inexperienced operators. Several simulation models for TT placement have been described in the American College of Surgeons skills curriculum. The models allow feedback to the trainees with regards to anatomic knowledge and also their technique in placing chest tubes.Our purpose is to evaluate three different models for simulating chest tube placement: low-fidelity rib model (LFRM), TraumaMan® and cadaver. We would further evaluate each model's validity, effectiveness, costs and make an argument for cost-effective low-fidelity rib model.

MATERIALS & METHODSResidents and attending physicians were selected to complete our TT module which consisted of a pre-test. This assesses knowledge of indications, pre-procedure timeout elements, and pertinent anatomy. A TT instructional video performed by an expert is shown to the trainees as well. The hands-on skills lab consists of three models: low-fidelity rib model (LFRM), TraumaMan® and cadaver. Each trainee performed chest tube placement on each model. Upon completion, a post-test was given. The final task consisted of the trainees evaluating four categories in each model: •Set-up confidence•Performance confidence•Ability to apply procedural skills•Realism

RESULTSFigure 1. Number of TT Performed by Trainees Prior to Module

0–4 5–9 10–14 15–19 20+0

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2

3

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8

9

10

Num

ber o

f Tra

inee

s

Pre-Test Post-Test

Percent Percent

2 Correct Answers 5.56 5.56

3 Correct Answers 16.67 22.22

4 Correct Answers 55.56 33.33

5 Correct Answers 22.22 38.89

Table 1. Pre-test and Post-test Results

Table 2. Improvement in Overall Confidence After Module

Rib Model TraumaMan® Cadaver0

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4

6

8

10

12

NeutralAgreeStrongly Agree

Num

ber

of R

espo

nses

Table 3. Confidence in Applying Proper Steps and Technique After Module

Rib Model TraumaMan® Cadaver0

2

4

6

8

10

12

NeutralAgreeStrongly Agree

Nu

mb

er

of

Re

spo

nse

s

Table 3. Model Which Felt Most Realistic

Rib Model TraumaMan® Cadaver0

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2

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4

5

6

7

8

9

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NeutralAgreeStrongly Agree

Num

ber

of R

espo

nses

Cost Analysis

Cadaver: $3,000 - $4,000 per body

TraumaMan®: $23,500 purchase; lease for $100-$150 per student

Low Fidelity Rib Model: $35 per student

Both experts and novices rated cadaver model the highest in all categories.However, LFRM had better results compared to TraumaMan®.Most common reason for low scores was absence of realistic subcutaneous tissue.In addition, comparing the vast difference in cost of the three models, this study supports that Low Fidelity Rib Model is a cost effective simulation model for tube thoracostomies.

CONCLUSIONS

A cadaver may be ideal with regards to face and content validity for tube thoracostomy simulation but is often cost prohibitive. The LFRM appears to provide effective training in TT placement in an economic fashion. Further correlative work using larger cohorts is required to establish use of this technique.

REFERENCES1. McDougall EM, Corica FA, Boker JR, et al. Construct Validity Testing of a Laparoscopic

Surgical Simulator. American College of Surgeons. 2006;202:779-787.2. Lyons C, Goldfarb D, Jones SL, et al. Which Skills Really Matter? Proving Face,

Content, and Construct Validity for a Commercial Robotic Simulator. Surg Endosc. 2013;27: 2020-2030.

3. Vick LR, Vick KD, Borman KR, et al. Face, Content, and Construct Validities of Inanimate Intestinal Anastomosis Simulation. Journal of Surgical Education. 2007;64:365-368.