Page 59 - Journal of Special Operations Medicine - Summer 2016

proximal extremity hemorrhage control; amputation Figure 1 Simulator models from more than 30
hemorrhage control (tourniquet placement); chest-seal manufacturers for the procedures under investigation.
placement for an open, sucking chest wound; needle
thoracostomy (NT); tube thoracostomy (TT); endotra-
cheal intubation (ETI); and cricothyrotomy.

The literature search was updated in November 2014
on completion of our research protocols. We reviewed
all relevant returned articles. Any articles that provided
insight into our key areas were included for comment
and discussion in this review. Due to the small number
of relevant articles and the exceedingly low number of
randomized controlled trials, studies were not excluded
based on metrics to assess the quality of each study.

Keywords searched for all procedures were the fol-
lowing: teaching, learning, instruction, education, skill
retention, skill decay, proficiency, learning curves, inani-
mate model, animate model, tissue model, cadaver, sim- There were more studies describing the use of simula-
ulation, simulator, mannequin, manikin, skill trainer, tor models than LT models. Only one study, which was
task trainer, military medicine, and combat. underpowered, compared the objective performance
of learners trained on a LT versus simulator model for
For hemorrhage control (to include both noncompress- TT and cricothyrotomy, using a cadaver as the testing
ible, proximal extremity hemorrhage and amputation- model. Some studies compared procedural training
23
related hemorrhage), we added the following terms: on synthetic models with each other or compared syn-
blood loss, bleed, hemostatic techniques, hemorrhage, thetic models to cadaver models. No studies compared
tourniquet, amputation, junctional wound, junctional LT models with each other. A number of studies were
hemorrhage, proximal extremity hemorrhage, noncom- based solely on reports of the trainee’s satisfaction, self-
pressible hemorrhage, and proximal extremity wound. confidence, or self-efficacy—at times after completing
For management of an open/sucking chest wound, the only one type of training—whereas other studies simply
following terms were added: Asherman, Bolin, 3-sided described how performance improved after one form
dressing, three-sided dressing, chest wound, chest seal, of training on one type of model or described a novel
penetrating chest wound dressing, sucking chest wound, model. 24–39 Information on learning curves and skill re-
and chest wound occlusive dressing. For NT, we added tention or decay was found only for TT and ETI.
the following search terms: needle decompression,
needle thoracostomy, pneumothorax, decompression. Overall, LT models appear to have face validity and ac-
For TT, the following search terms were added: chest ceptability; these models are routinely used for military
tube, thoracostomy, tube thoracostomy, hemothorax, training and assessment for the procedures investigated
and pneumothorax. For ETI with direct laryngoscopy, in this report, and are still used by some emergency med-
we added the following search terms: endotracheal in- icine and surgery residency programs. By nature, ca-
29
tubation, tracheal intubation, intubation, anesthesia, davers seem to have implicit face and content anatomic
laryngoscopy, direct laryngoscopy, and airway. For cri- validity as a human model; however, the use of cadavers
cothyrotomy, the following terms were added: cricothy- requires timely availability of donor bodies, affordabil-
rotomy and cricothyroidotomy. ity, and the facilities to manage them. Furthermore, if
needing to train for or assess effective hemorrhage con-
In addition, an Internet search of commercially available trol, a perfused cadaver would be required. Regarding
synthetic models was performed. The University of Minne- synthetic models, a few studies show acceptability and
sota institutional review board deemed this study exempt. aspects of construct validity for certain simulators to
teach four of our seven core procedures.
Results and Discussion
In Appendix 1 (available online), we collated the spe-
We identified 185 simulator models from more than 30 cifics from the literature informing our first question
manufacturers for the procedures under investigation regarding comparative efficacy of models and the litera-
(Figure 1). Adult, live animal models described include ture informing our second question regarding validity
goat (caprine), pig (porcine), dog (canine), and sheep for various models. Appendix 2 (available online) de-
(ovine) models. 18–22 tails the information gathered on learning curves, skill

Simulation Versus Live Tissue for Training Trauma Procedures 45