Use of a Human Patient Simulator for the Advanced Trauma Life Support Course

ERNEST F.J. BLOCK, M.D., F.A.C.S., F.C.C.M., LAWRENCE LOTTENBERG, M.D., F.A.C.S.,

LEWIS FLINT, M.D., F.A.C.S.,  JOELLE JAKOBSEN, M.D., DIANNA LIEBNITZKY, R.N.

From the Departments of Surgery, Orlando Regional Medical Center, Orlando; Memorial Regional Hospital, Hollywood; §Tampa General Hospital, Tampa; and the Florida Committee of Trauma, Jacksonville, Florida 

A highly anticipated and rewarding components of the Advanced Trauma Life Support (ATLS) program is the surgical skill station. Logistic, societal, and economic issues have resulted in development of human patient simulators (HPSs) as an alternative to the animal model. We studied initial student reaction to a simulator designed for this skill station. Fourteen participants in an ATLS Provider course completed the standard surgical skill stations and an experimental station using the Simulab TraumaMan HPS. After completion of the stations the students were asked to complete a 13-point satisfaction survey using a modified Likert scale (1 = strongly negative/dissatisfied, 5 = strongly positive/satisfied). Overall response was favorable. Students found the HPS to be superior to the animal model in teaching surgical airways [mean 3.64; standard deviation (SD) 0.93] and the management of pneumothorax (mean 3.86; SD 0.77). The students felt the HPS would be useful in ATLS and should be included as an option in training (mean 4.07; SD 0.92). Preliminary experience with an interactive HPS to teach the ATLS surgical skill station is well received by students when compared with standard methods. This strong acceptance supports inclusion of simulators in teaching ATLS skills.

The advanced Trauma Life Support (ATLS) course is a 2-day intensive training program that includes didactic lectures, group discussion problem-based sessions, and technical skill segments. A highly anticipated and rewarding component of ATLS Program is the surgical skill station, which is frequently performed on anesthetized animals. Logistic, societal, and economic issues have resulted in development of alternatives to the animal model included human patient simulators (HPSs).

Methods

Fourteen participants in an ATLS Provider course completed the surgical skill station and an experimental station using the Simulab TraumaMan HPS (www.simulab.com). The Simulab model is a life-sized human torso with thoracic and abdominal cavities and a simulated neck/trachea for teaching chest tube insertion, Pericardiocentesis, peritoneal lavage, and tracheostomy (Figs. 1-3). The torso is covered with a pliable elastomeric polymer that closely mimics the texture of human skin. The “thoracic cavity” has a palpable rhythmically contracting sac to simulate a lung and the “abdominal cavity” may be filled with red fluid to mimic a positive diagnostic peritoneal lavage. After completion of the stations the students were asked to complete a 13-point satisfaction survey (Table 1) using a modified Likert scale (1 = stongly negative/dissatisfied, 5 = strongly positive/satisfied). Questions included rating the HPS for teaching the aforementioned surgical skills as well as overall experience in teaching surgical skills. The Florida Committee on Trauma Chairman (L.L.) and the Chair of the American College of Surgeons Committee on Trauma ATLS Subcommittee approved the study.

Table 1. Survey Tool for ATLs Students

Results

All 14 participants completed the survey tool. The average age of the participants was 39 years, and only two were surgeons. The overall response was favorable (see Table 2). Students found the HPS to be superior to the animal model in teaching surgical airways [mean 3.64, standard deviation (SD) 0.93] and the management of pneumothrax (mean 3.43, SD 0.94). Overall the student felt the HPS would be useful in ATLs and should be included as an option in training (mean 4.07, SD 0.92). The students disagreed that there existed a significant learning curve to using the HPS. Institutional cost for purchase of 16 HPS “skins” was $2000 and previous cost of the animal facility was approximately $2400.

Table 2. Results of Likert Scale Survey of Students Reaction to Use of HPS in ATLS Surgical Skill Station

Discussion

HPSs are more widely accepted in surgical education because of advances in simulator technology. Juxtaposed with this progress is a documented decline in formal study of human anatomy in graduate medical education.²  Several factors are responsible for this change in curriculum including competing subject matter, redirection of teaching toward clinical sciences, and attrition in faculty members.

Surgical educators have turned to anatomic models to teach various surgical procedures including pelvic and laparoscopic surgery. ^{3, 4}   Although these computer-assisted mannequins are highly realistic institutions may be limited by their costs coupled with the concerns that the technology may rapidly be outdated.

The Simulab Trauma Torso is a realistic anatomic model with modest physiologic responses. Its simplicity allows for a cost-effective realistic model that may function as an alternative to animal or cadaver models. Animal models are limited to institutions that have a veterinary facility on the premises. Institutions with remote animal laboratories must either shuttle their students over long distances or restrict their ATLS offering to refresher courses that do not include the surgical skills station. Cadaveric models are permitted for the ATLS surgical skills station, but institutional and legal barriers may limit widespread applicability.^{3, 5, 6} 

Cost for animal and cadaver sessions is significant. Previous studies have centered on computer-assisted mannequins; these HPSs have initial facility costs in excess of $250,000 and annual maintenance costs of $10,000.⁴  These maintenance costs exclude training and salary of personnel to assist with the computer component. TraumaMan is provided on a per-use basis. Each student is provided with a replaceable “skin” for the torso. The costs noted previously are for an ATLS Provider course with 16 students; the mannequin shells are included in this cost. No special personnel are needed, although an initial training fee of $500 is in place. Because the ATLS surgical skills station is primarily anatomic rather than physiologic no computer responsiveness is necessary. Nevertheless tactile and visual feedback is provided heightening the sense of realism.

Although previous studies have examined the enhancement of surgical skills and confidence through use of HPS authors have not examined student experience and acceptance of this new teaching model.⁷ Previous studies have allowed for a “null scenario” to allow students to become familiar with the HPS before its use in formal teaching and testing.⁴  The current limited investigation indicates that students were able to easily adapt to a new learning tool without such precourse preparation. None of the students in this study had previous experience with HPS, which underscores the limited learning curve needed to beneft from the TraumaMan teaching tool.

Preliminary experience with an interactive HPS to teach the ATLS surgical skill station is well received by students when compared with standard methods. This strong acceptance supports inclusion of simulators in teaching ATLS skills. HPSs are now approved by the American College of Surgeons Committee on Trauma for use in ATLS courses based on this data.

Acknowledgment

We thank Irvene Hughes (Manager, ATLS Division) for her support and guidance in the performance of this study.

REFERENCES

1.   Issenberg SB, McCaghie WC, Hart IR, et al. Simulation technology for healthcare professional skills training and assessment. JAMA. 1999;282:861-86.

2.   Phillips LG Jr. Anatomy: How much or how little and taught by whom? Am Surg 1987;53:540-2.

3.   Cundiff GW, Weidner AC, Visco AG. Effectiveness of laparoscopic cadaveric dissection in enhancing resident comprehension of pelvic anatomy. J Am Coll Surg 2001;192:492-6.

4.   Marshall RL, Smith JS, Gorman PJ, et al. Use of a human patient simulator in the development of resident trauma management skills. J Trauma 2001;51:17-21.

5.   Eaton BD, Messent DO, Haywood IR. Animal cadaveric models for advanced trauma life support training. Ann R Coll Surg Engl 1990;72:135-9.

6.   Bennett JR, Bodenham AR, Berridge JC. Advanced Trauma Life Support: A time for reappraisal. Anaesthesia 1992;47:798-800.

7.   Gilbart MD, Hutchinson CR, Cusmano MD, et al. A computer-based trauma simulator for teaching trauma management skills. Am J Surg 2000;179:223-8.

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