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Understanding the potential of mixed reality simulation training for the management of ‘can’t intubate–can’t oxygenate’ emergencies
  1. John Sandars1,
  2. Peter Groom2,
  3. Jeremy Brown1,
  4. Peter Vangorp3,
  5. Tamryn Miller4,
  6. Thomas Miller2
  1. 1Health Research Institute, Edge Hill University, Ormskirk, UK
  2. 2Department of Anaesthesia, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
  3. 3Department of Computer Science, Edge Hill University, Ormskirk, UK
  4. 4Department of Anaesthesia, Alder Hey Children’s Hospital, Liverpool, UK
  1. Correspondence to Professor John Sandars, Health Research Institute, Edge Hill University, Ormskirk L39 4QP, UK; john.sandars{at}

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The management of an unanticipated difficult airway resulting in a ‘can’t intubate–can’t oxygenate’ (CICO) emergency is a rare time-critical and life-threatening emergency that is highly stressful, and the associated stress can impair the performance of the whole multidisciplinary team.

We are interested in supporting anaesthetic trainees in managing CICO emergencies, especially by developing their non-technical skills for dealing with this situation. Simulation training supports learners to develop clinical skills in a safe learning environment that shares many features of a real environment. Our challenge was to create simulation training that had sufficient fidelity so as to evoke the stress of managing CICO emergencies.

The fidelity of a simulation is essential for evoking stress during a performance and is determined by (1) the level of immersion, with a sense of presence in which the individual has the perception that they are engaged in a real experience1 and (2) the level of authenticity, which is the extent to which the learner considers the simulation represents a real environment.2

We describe a feasibility study to ensure that the components of an intervention are appropriate to produce the intended outcomes and to identify any changes that may be required for a future larger study. Previous studies suggest that six participants can identify the extent to which the components are appropriate.3

Developing the training simulation

We developed a …

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  • Contributors JS, PG, PV and JB designed the study and intervention. PV operated the CAVE virtual environment and PG, TM and TRM were scenario facilitators. JS collected the data and JS and JB analysed the data. All authors contributed to writing the draft manuscript and its critical revision, approval of the final version and are accountable for all aspects of the work.

  • Funding The study was funded with a grant from an Impact and Knowledge Exchange (IKEF) Award at Edge Hill University.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Faculty Research Ethics Committee at Edge Hill University (FREC IPP5/2018) and the NHS HRA (Project 249844 19/HRA/0264).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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