We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
On the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the record...
We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
On the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the recorded video the HME filter was used to sealed the ETT that indicated the non-use of stylet. Hence, the authors did not show us the ability of intubation without stylet. In addition, some recommend care when removing the stylet or bougie to avoid spreading contamination.
References
1. Ahmed OMA, Belkhair AOM, Adel E Ahmed Ganaw AEA et al. Anaesthesia simulation training during coronavirus pandemic: an experience to share. BMJ Stel .(2020-04-30).10.1136/bmjstel-2020-000643.
2. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020 Mar 27. doi: 10.1111/anae.15054. [Epub ahead of print].
3. DJ. The GlideScope video laryngoscope. Anaesthesia. 2005;60 :414-5.
4. Turkstra TP, Harle CC, Armstrong KP et al. The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use. Can J Anaesth. 2007 ;54:891-6.
5. van Zundert A, Maassen R, Lee R, Willems R, Timmerman M, Siemonsma M, Buise M, Wiepking M. A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. Anesth Analg. 2009;109:825-31.
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
Notwithstanding the tragic human toll of Covid-19, necessity can give birth to invention. Harnessing new teaching and assessment tools borne out of this crisis have the capability to both save lives and sustain the educational needs of students worldwide.
References
1. Li L, Lin M, Wang X, et al. Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China. BMJ Simulation and Technology Enhanced Learning Published Online First: 11 March 2020. doi: 10.1136/bmjstel-2020-000609
2. Pottle J1. Virtual reality and the transformation of medical education. Future Healthc J. 2019;6(3):181-185.
3. Smith P, Wigmore S, Paisley A et al. Distance Learning Improves Attainment of Professional Milestones in the Early Years of Surgical Training Ann Surg. 2013; 258(5): 838–843.
We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...
We congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficult delivery.9 In force training studies that demonstrate a clinical impact on shoulder dystocia-associated brachial plexus injury, providers were allowed to proceed with the delivery and were critiqued afterward. Often they went far beyond 100 N of traction. Gurewitsch Allen et al allowed trainees to prospectively estimate increasing levels of traction using a fetal head attached to a force measuring system; the trainees became better at estimating their own traction with repeated rehearsals.8
In still other studies where a decrease in brachial plexus injury incidence was observed after introducing a simulation-based intervention, a specific protocol was taught. Inglis et al. reduced their brachial plexus injury incidence by 2/3 after introducing a mandatory protocol (Code D) for all shoulder dystocia deliveries that began with a hands off period, a call for help, identifying fetal shoulder position and a rotation of the shoulders into the oblique pelvic diameter.10 These initial steps were considered mandatory before allowing for clinical judgement to be used concerning which additional shoulder dystocia maneuvers to employ. We previously demonstrated that rotation of fetal shoulders is mechanically advantageous over McRoberts;11 this is likely why Inglis et al were successful. Grobman, et al. was able to reduce brachial plexus incidence by a more than 80% introducing a team-based shoulder dystocia protocol, utilizing low-fidelity simulation (i.e., without force-training) and requiring prospective tracking of time elapsed during the head-to-body delivery interval.12
A systematic review of simulation-based training for shoulder dystocia identifies strengths and gaps in curricular content of differing training programs.13 We believe variation in clinical outcomes associated shoulder dystocia training programs is likely reflective of the differences in the curricular elements of each simulation program. The key is finding the simulation program that is most cost-effective and provides the best clinical outcome.
We again congratulate the important gains achieved by Kim et al in creating a training system that raises awareness of shoulder dystocia and recognition of the complication. Their lack of favorable impact on brachial plexus injuries should not discourage their continuing efforts.
References
1. Kim T, Vogel RI, Das K. Simulation in shoulder dystocia: does it change outcomes?. BMJ Simulation and Technology Enhanced Learning. 2018 Mar 29:bmjstel-2017.
2. van de Ven J, van Deursen FJ, van Runnard Heimel PJ, Mol BW, Oei SG. Effectiveness of team training in managing shoulder dystocia: a retrospective study. The Journal of Maternal-Fetal & Neonatal Medicine. 2016 Oct 1;29(19):3167-71.
3. Nguyen T, Fox NS, Friedman Jr F, Sandler R, Rebarber A. The sequential effect of computerized delivery charting and simulation training on shoulder dystocia documentation. The Journal of Maternal-Fetal & Neonatal Medicine. 2011 Nov 1;24(11):1357-61
4. Spong CY, Beall M, Rodrigues D, Ross MG. An objective definition of shoulder dystocia: Prolonged head-to-body delivery intervals and/or the use of ancillary obstetric maneuvers. Obstet Gynecol. 1995 September 01;86(3):433-6
5. Beall MH, Spong C, McKay J, Ross MG. Objective definition of shoulder dystocia: A prospective evaluation. Obstet Gynecol. 1998 October 01;179(4):934-7.
6. Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112(1):14-20.
7. Crofts JF, Lenguerrand E, Bentham GL, Tawfik S, Claireaux HA, Odd D, et al. Prevention of brachial plexus injury-12 years of shoulder dystocia training: An interrupted time-series study. Brit J Obstet Gynaec. 2015;123(1):111-8.
8. Gurewitsch Allen ED, Brown Will SE. Improving shoulder dystocia management and outcomes with a targeted quality assurance program. Am J Perinatol. 2017;34:1088-96.
9. Creasy RK, Resnik R, Iams JD. Maternal-fetal medicine: Principles and practice. In: 5th ed. Philadelphia: W.B. Saunders Company; 2004. p.671,677, 678.
10 Gurewitsch ED, Kim EJ, Yang JH, Outland KE, McDonald MK, Allen RH. Comparing McRoberts' and Rubin's maneuvers for initial management of shoulder dystocia: an objective evaluation. Am J Obstet Gynecol. 2005 Jan 1;192(1):153-60.
11. Inglis SR, Feier N, Chetiyaar JB, Naylor MH, Sumersille M, Cervellione KL, Predanic M. Effects of shoulder dystocia training on the incidence of brachial plexus injury. American journal of obstetrics and gynecology. 2011 Apr 1;204(4):322-e1.
12. Grobman WA, Miller D, Burke C, Hornbogen A, Tam K, Costello R. Outcomes associated with introduction of a shoulder dystocia protocol. Obstet Gynecol. 2011;205(6):513-7.
13. Gurewitsch Allen ED. Simulation of Shoulder Dystocia for Skill Acquisition and Competency Assessment: A Systematic Review and Gap Analysis. Simulat Healthc. 2018 Aug 1;13(4):268-83.
We read with interest the report by Ahmed et al1. "Anaesthesia simulation training during coronavirus pandemic: an experience to share". The authors developed A metric-based checklist steps of induction of GA, tracheal intubation, intraoperative management, tracheal extubation and patient recovery in the context of treating patient with covid-19. A supplemental video was used as learning method for the involved health workers. Although the investigators initiate that their clinicians improved their performance during simulation training, they could not consistently addressing all concerns. 1) it is not clear at what flow rate O2/min that preoxygenation should be delivered. Defining such flow is crucial to minimize viral transmission2. 2) the preparation/management between two cases of COVID19, ( e.g soda-lime canister changes; the necessary time pause between cases…),was not notified in their training sessions. Adding such guidance to the checklist would ensure more supplementary protective measures.
Show MoreOn the other hand, the video showed nicely all training steps, including the using of the glidescope as videolarungoscope (GVL) tool for endotrachel intubation. It is well known that due to the curvature of the GVL blade, a stylet must be used to position the endotrachel tube (ETT) tip at the glottic opening especially in suspected difficult airway3,4. The using of stylet facilitate a quick-pass first-attempt tracheal instrumentation5 .However, in the record...
We read with interest the article, Preparing and responding to 2019 novel coronavirus with simulation and technology-enhanced learning for healthcare professionals: challenges and opportunities in China (1) echoing the old adage ‘necessity is the mother of invention’ in relation to remote-site clinical education. Disruption to all levels of education have sparked initiatives as described by Li et al and have exposed the stark lack of a global coordinated mitigation plan. Lessons learned during the current crisis will re-shape our view of traditional clinical teaching theory and delivery. Distance learning is likely to become the norm in the post Covid-19 era and innovative simulation tools are set to enhance these platforms (2).
Our experiences in ophthalmology reinforce the notion that pedagogy follows technology in producing robust, validated and clinically relevant higher level education in the surgical specialties (3). We foresee a growing global imperative to ensure continued development of cost-effective, accessible, high quality alternatives to on-campus face to face clinical learning to supplement, and in some cases supplant current programmes. These are likely to include asynchronous discussion boards, reflective e-portfolios, remote site assessments and developing home microsurgical simulators (personal communication, Brennan P). Covid-19 has revealed, on a global scale, both our human frailties and resilience.
Notwithstanding the tragic human tol...
Show MoreWe congratulate Kim et al on developing a shoulder dystocia training program that included video instruction, a didactic portion and a simulation training session including force measurement, followed by a study aimed at evaluating the impact of the training on actual clinical outcomes.1 Their observed two-fold increase in shoulder dystocia incidence is consistent with some other studies,2, 3 and more in line with prospective clinical studies that report an incidence of ~ 4% among term vaginal deliveries.4, 5 It further suggests improved recognition of shoulder impaction in the final stages of delivery in the clinical setting following simulation-based training.
Ultimately, the patient safety goal of shoulder dystocia simulation training for should be the reduction in shoulder dystocia-associated brachial plexus injuries. We would be interested to learn if there was a higher correlation between brachial plexus injuries and shoulder dystocia after training than before.
Compared to other force training studies, Kim et al did not find a similar decrease in brachial plexus injuries.6-8 We offer a hypothesis as to why that might be.
We believe that demonstrating what 100 N feels during simulation, even with admonishing the trainee not to use that much traction, is not effective at reducing injury. One reason is that memory of that much traction once experienced is short-lived, and clinicians tend to underestimate the traction they apply during a difficu...
Show More