Miriam Ruesseler

Arthroscopy or ultrasound in undergraduate anatomy education: a randomized cross-over controlled trial

BackgroundThe exponential growth of image-based diagnostic and minimally invasive interventions requires a detailed three-dimensional anatomical knowledge and increases the demand towards the undergraduate anatomical curriculum. This randomized controlled trial investigates whether musculoskeletal ultrasound (MSUS) or arthroscopic methods can increase the anatomical knowledge uptake.MethodsSecond-year medical students were randomly allocated to three groups. In addition to the compulsory dissection course, the ultrasound group (MSUS) was taught by eight, didactically and professionally trained, experienced student-teachers and the arthroscopy group (ASK) was taught by eight experienced physicians. The control group (CON) acquired the anatomical knowledge only via the dissection course. Exposure (MSUS and ASK) took place in two separate lessons (75 minutes each, shoulder and knee joint) and introduced standard scan planes using a 10-MHz ultrasound system as well as arthroscopy tutorials at a simulator combined with video tutorials. The theoretical anatomic learning outcomes were tested using a multiple-choice questionnaire (MCQ), and after cross-over an objective structured clinical examination (OSCE). Differences in student’s perceptions were evaluated using Likert scale-based items.ResultsThe ASK-group (n = 70, age 23.4 (20–36) yrs.) performed moderately better in the anatomical MC exam in comparison to the MSUS-group (n = 84, age 24.2 (20–53) yrs.) and the CON-group (n = 88, 22.8 (20–33) yrs.; p = 0.019). After an additional arthroscopy teaching 1% of students failed the MC exam, in contrast to 10% in the MSUS- or CON-group, respectively. The benefit of the ASK module was limited to the shoulder area (p < 0.001). The final examination (OSCE) showed no significant differences between any of the groups with good overall performances. In the evaluation, the students certified the arthroscopic tutorial a greater advantage concerning anatomical skills with higher spatial imagination in comparison to the ultrasound tutorial (p = 0.002; p < 0.001).ConclusionsThe additional implementation of arthroscopy tutorials to the dissection course during the undergraduate anatomy training is profitable and attractive to students with respect to complex joint anatomy. Simultaneous teaching of basic-skills in musculoskeletal ultrasound should be performed by medical experts, but seems to be inferior to the arthroscopic 2D-3D-transformation, and is regarded by students as more difficult to learn. Although arthroscopy and ultrasound teaching do not have a major effect on learning joint anatomy, they have the potency to raise the interest in surgery.

Peri-resuscitation echocardiography: Training the novice practitioner☆

AIMS Echocardiography performed in an ALS-compliant manner provides a tool whereby some of the potentially reversible causes of cardiac arrest can be diagnosed in real time by minimally trained practitioners. One of the major concerns this raises is how to deliver effective training to the required standard. The objective of this study was to determine the effectiveness of number of different educational methods used teach echocardiography to novices. This involved assessment of cognitive, psychomotor skills and affective aspects in five key areas. METHODS The study population was a convenience sample from participants attending standardised structured one-day training courses in peri-resuscitation echocardiography (n=204). Subjects were assessed for five learning outcomes including knowledge and image interpretation, practical performance of echocardiography including time taken to obtain a diagnostic view, integration into the ALS algorithm and overall compliance with established resuscitation guidelines. RESULTS There was a significant improvement in knowledge and interpretation of echocardiographic images before and after completion of the one-day course (pre 62%, post 78%, p<0.01). Skills acquisition resulted in 100% of participants being able to obtain a subcostal view of diagnostic quality by the end of the course, and 86% with a mean time to acquisition of <10s. On completion of the training programme, incorporation of echocardiography into current resuscitation practice did not compromise ALS-compliance. CONCLUSION Novice echocardiographers can obtain knowledge and skills relevant to ALS-compliant peri-resuscitation echocardiography using a range of educational techniques. In addition to the standard one-day training courses available, continued mentored practice and didactic adherence to ALS algorithms is required.

Emergency Airway Management in Trauma Patients Using Laryngeal Tube Suction

Abstract Background. Endotracheal intubation (ETI) is considered to be the “gold standard” of prehospital airway management of trauma patients. However, ETI requires substantial technical skills and ongoing experience. Because failed prehospital ETI is common and associated with a higher mortality, reliable airway devices are needed to be used by rescuers who are less experienced in ETI. Objective. To prospectively evaluate the feasibility of the use of laryngeal tubes by paramedics and emergency physicians for out-of-hospital airway management in trauma patients. Methods. During a 40-month period, data for all cases of prehospital use of the laryngeal tube suction disposable (LTS-D) within a large metropolitan area were recorded by a standardized questionnaire. We determined indications for laryngeal tube use, placement success, number of placement attempts, placement time, and personal level of experience. All patients admitted to our institution also underwent in-hospital follow-up. Results. Fifty-six of 57 prehospital intubations attempts with the LTS-D were successfully performed by paramedics (n = 19) or emergency physicians (n = 37) within one (n = 50) or two (n = 6) placement attempts. The device was used as initial airway (n = 27) or rescue device after failed ETI (n = 30). The placement time was ≤45 seconds (n = 42), 46–90 seconds (n = 13), and >90 seconds (n = 1). The majority of users (n = 44) were relative novices with no more than 10 previous laryngeal tube placements on actual patients. Of 33 patients eligible for follow-up, one underwent urgent LTS-D removal and subsequent ETI upon hospital admission, six underwent ETI after primary survey, and 26 underwent both primary and secondary survey or even damage-control surgery with the LTS-D. Conclusion. The LTS-D represents a promising alternative to ETI in the hands of both paramedics and emergency physicians. It can be used as an initial tool to secure the airway until ETI is prepared, as a definitive airway by rescuers less experienced in ETI, or as a rescue device when ETI has failed.

Increased authenticity in practical assessment using emergency case OSCE stations

In case of an emergency, a fast and structured patient management is crucial for patient’s outcome. The competencies needed should be acquired and assessed during medical education. The objective structured clinical examination (OSCE) is a valid and reliable assessment format to evaluate practical skills. However, traditional OSCE stations examine isolated skills or components of a clinical algorithm and thereby lack a valid representation of clinical reality. We developed emergency case OSCE stations (ECOS), where students have to manage complete emergency situations from initial assessment to medical treatment and consideration of further procedures. Our aim was to increase the authenticity and validity in the assessment of students’ capability to cope with emergency patients. 45 students participated in a 10-station OSCE with 6 ECOS and 4 traditional OSCE stations. They were assessed using a case-specific checklist. An inter-station and post-OSCE-questionnaire was completed by each student to evaluate both ECOS and traditional OSCE. In this study, we were able to demonstrate that ECOS are feasible as time-limited OSCE stations. There was a high acceptance on both students and examiners side. They rated ECOS to be more realistic in comparison to the traditional OSCE scenarios. The reliability estimated via Crohnbach’s α for the 6 ECOS is high (0.793). ECOS offer a feasible alternative to the traditional OSCE stations with adequate reliability to assess students’ capabilities to cope with an acute emergency in a realistic encounter.

Prehospital and Emergency Department Ultrasound in Blunt Abdominal Trauma

Blunt abdominal trauma is a challenging aspect of trauma management. Early detection has a major impact on patient outcome. In contrast to physical examination, computed tomography is known to be a sensitive and specific test for blunt abdominal injuries. However, it is time-consuming and thus contraindicated in hemodynamically unstable patients. Therefore, focused assessment with sonography for trauma (FAST) offers a fast and easily applicable screening method to identify patients for urgent laparotomy without any further diagnostics. FAST detects, with high sensitivity, intraperitoneal fluid that accumulates in dependent areas indicating blunt abdominal trauma. FAST has been established as a gold standard early screening method for blunt abdominal trauma when performing trauma management in the emergency department (ED) based on the Advanced Trauma Life Support® algorithm. The development of hand-held ultrasound devices facilitated the introduction of FAST into prehospital trauma management. It was demonstrated that prehospital FAST (p-FAST) can be performed with high sensitivity and specificity, and can lead to significant changes in prehospital trauma therapy and management. Standardized training with both theoretical and hands-on modules is mandatory in order to gain the skills required to perform FAST or p-FAST well.

Teaching in daily clinical practice: how to teach in a clinical setting

Teaching in the clinical setting is challenging; however, it is the location where students apply their learned facts and learn skills and attitudes most effectively. In order to improve clinical teaching, it is important to know and implement the principles of adult learning. The clinical teacher should know or assess the learners’ prior knowledge and skills, as well as their stage of learning, before starting a new teaching session. The learners should be actively involved in the clinical processes. Questions to probe students’ deeper understanding and capability to analyze, synthesize, and apply medical knowledge should be an important part of clinical teaching. Regular structured feedback is an important part of any learning experience.

Incidental findings in patients with multiple injuries: how to proceed?

BACKGROUND Multislice computed tomography (MSCT) is the diagnostic criterion standard for the initial evaluation of patients with suspected multiple injuries. Besides scanning for injuries directly related to the initial trauma, MSCT scans can reveal pathologies unrelated to the trauma of clinical relevance. The aim of the present study was to determine the frequency and follow-up course of incidental findings in patients with multiple injuries. METHODS This is a retrospective analysis of prospectively collected data on 2,242 patients with suspected multiple injuries at a Level I trauma center from 2006 to 2010. The MSCT reports were retrospectively reviewed regarding abnormal findings not related to trauma. These incidental findings were classified on a four-point level scoring system with respect to clinical importance and urgency for further diagnostic and therapeutic procedures. RESULTS During initial trauma center evaluation in the emergency department, 2,246 patients met our inclusion criteria. A total of 2,036 patients (90.7%) underwent MSCT; 1,142 (50.9%) of the patients had one or more incidental findings. A total of 2,844 incidental findings were detected. Overall, 349 tumor findings were noted (12.3% of all incidental findings); 113 findings were suspicious for malignant processes or metastasis. According to our classification, 168 (5.9%) of the incidental findings required urgent follow-up (Level 4), and 527 (18.5%) of the incidental findings required a follow-up before discharge (Level 3). CONCLUSION MSCT in patients with multiple injuries reveals one or more incidental findings in more than one of two patients. A scoring system classifying for relevance of incidental findings was introduced and could be applied in routine trauma care in the future. LEVEL OF EVIDENCE Epidemiologic study, level III.

Impact of peer feedback on the performance of lecturers in emergency medicine: a prospective observational study

BackgroundAlthough it is often criticised, the lecture remains a fundamental part of medical training because it is an economical and efficient method for teaching both factual and experimental knowledge. However, if administered incorrectly, it can be boring and useless.Feedback from peers is increasingly recognized as an effective method of encouraging self-reflection and continuing professional development. The aim of this observational study is to analyse the impact of written peer feedback on the performance of lecturers in an emergency medicine lecture series for undergraduate students.MethodsIn this prospective study, 13 lecturers in 15 lectures on emergency medicine for undergraduate medical students were videotaped and analysed by trained peer reviewers using a 21-item assessment instrument. The lecturers received their written feedback prior to the beginning of the next years’ lecture series and were assessed in the same way.ResultsIn this study, we demonstrated a significant improvement in the lecturers’ scores in the categories ‘content and organisation’ and ‘visualisation’ in response to written feedback. The highest and most significant improvements after written peer feedback were detected in the items ‘provides a brief outline’, ‘provides a conclusion for the talk’ and ‘clearly states goal of the talk’.ConclusionThis study demonstrates the significant impact of a single standardized written peer feedback on a lecturer’s performance.

Examiner effect on the objective structured clinical exam - a study at five medical schools

BackgroundThe Objective Structured Clinical Examination (OSCE) is increasingly used at medical schools to assess practical competencies. To compare the outcomes of students at different medical schools, we introduced standardized OSCE stations with identical checklists.MethodsWe investigated examiner bias at standardized OSCE stations for knee- and shoulder-joint examinations, which were implemented into the surgical OSCE at five different medical schools. The checklists for the assessment consisted of part A for knowledge and performance of the skill and part B for communication and interaction with the patient. At each medical faculty, one reference examiner also scored independently to the local examiner. The scores from both examiners were compared and analysed for inter-rater reliability and correlation with the level of clinical experience. Possible gender bias was also evaluated.ResultsIn part A of the checklist, local examiners graded students higher compared to the reference examiner; in part B of the checklist, there was no trend to the findings. The inter-rater reliability was weak, and the scoring correlated only weakly with the examiner’s level of experience. Female examiners rated generally higher, but male examiners scored significantly higher if the examinee was female.ConclusionsThese findings of examiner effects, even in standardized situations, may influence outcome even when students perform equally well. Examiners need to be made aware of these biases prior to examining.

Lehrzielkatalog im Pflicht- und Wahlbereich des Praktischen Jahres für die Inhalte des Faches „Orthopädie und Unfallchirurgie“

INTRODUCTION Practical training on clinical cases and work with patients is one of the most important steps within the educational programme of undergraduates. Until now a general programme with specific learning targets for undergraduate training in orthopedic and trauma surgery is lacking. MATERIAL AND METHOD In this article we present an educational skills programme developed by a national committee composed of specialists in the field of orthopaedic and trauma surgery. This programme is based on existing guidelines of German medical universities. RESULTS The facultative and obligatory guidelines developed by the national committee are presented. CONCLUSION The presented learning programme contains chapters regarding the increasing requirements within the field of orthopaedic and trauma surgery and provides reproducible contents with the possibility for learning control.