rauat

e b,

formtmentf Thoracic and Hyperbaric Surgery, Graz, Austria

2007;

ovings shanagwas bcatioificaalysis

judgement ( p < 0.001), where the importance of trial and error learning, the possibility of being able to view a process and the simplicity ofthe model were particularly stressed. Conclusions: Computer simulation of chest trauma emergency treatment options is a safe and efficient

Graz and uses the e-learning system VMC Graz (VirtualMedical Campus Graz) [4,5]. In the present study we

European Journal of Cardio-thoracic Sueducation in chest trauma management should be providedto all physicians who might be involved in emergencytreatment. A fundamental understanding of the underlyingpathophysiological mechanisms and the rational choice ofappropriate measures should be delivered already duringundergraduate medical education.

Computer simulation models are particularly suitable fordemonstrating complex processes and functional relation-ships. Furthermore, simulation models facilitate interactive

undergraduate medical students.

2. Students and methods

2.1. Students

Forty-one students (29 females, 12 males) participated inthe study. The procedure had been approved by theinstitutional review board and all participants gave informedconsent. The students had finished their first year of humanmedicine and were at the beginning of their clinical years.Since e-learning is an integral part of medical education atthe Medical University of Graz, all students already had someexperience with e-learning.

The work was funded by grants from the Federal Ministry of Education,Science and Culture, Austria.* Corresponding author. Address: Institute for Medical Informatics, Statistics

and Documentation, Medical University of Graz, Billrothgasse 18a/7, A-8010Graz, Austria. Tel.: +43 316 385 72052; fax: +43 316 385 72059.

E-mail address: josef.smolle@meduni-graz.at (J. Smolle).

1010-7940/$ see front matter # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.doi:10.1016/j.ejcts.2007.06.042improving prognosis [1,2]. Since thoracic surgery specialistswill be available only in a minority of accidents, basic evaluated the effectiveness of the simulation model inImmediate and appropriate intervention is essential in# 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Keywords: Education; Learning aids; Trauma, blunt; Trauma, penetrating; Pneumothorax

1. Introduction

Trauma to the thorax with injury of the chest wall and/orthoracic organs is encountered in 5060% of all cases withpolytrauma. Besides head injuries, thoracic injuries are themost common cause of fatal outcome in these patients [1,2].

training of medical skills without putting patients at risk inservice of education [3]. Therefore, we created a simulationmodel demonstrating the consequences of various chesttrauma patterns and the effects of standard treatmentmodalities. This simulation model is part of the under-graduate medical curriculum of the Medical University oflearning approach in undergraduate medical education, which is highly appreciated by the students.Emergency treatment of chest tmodel for undergradu

Josef Smolle a,*, Gerhard PrausaMedical University of Graz, Institute of Medical In

bMedical University of Graz, DeparcMedical University of Graz, Department o

Received 17 April 2007; received in revised form 26 June

Abstract

Objective: Appropriate emergency measures are essential in imprbackground and basic principles of emergency treatment decisioneffectiveness of a computer simulation model on thoracic trauma min this pre-test/post-test self-controlled study. Learning experiencemechanisms of thoracic injuries and facilitating the interactive appliresults were 72.2% (66.977.5) correct answers, which increased signspent 30 min (2336) with the interactive learning object. Content anaccepted 28 June 2007; Available online 15 August 2007

the outcome of patients with thoracic injuries. Pathophysiologicalould be already taught in undergraduate medical curricula. Theement was evaluated. Methods: Forty-one students were enrolledased on a complex computer simulation model demonstrating basicn of various emergency measures. Results: Pre-test multiple-choicently to 86.5% (82.690.4) in the post-test ( p < 0.001). The studentsof open-ended feedback revealed a highly significant overall positivema an e-learning simulatione medical students

Freyja-Maria Smolle-Juttner c

atics, Statistics and Documentation, Graz, Austriaof Anaesthesiology, Graz, Austria

www.elsevier.com/locate/ejctsrgery 32 (2007) 644647

Phase 2: Simulation. The students did their training using

StatiststatisticaSunnyvale

J. Smolle et al. / European Journal of Cardio-thoracic Surgery 32 (2007) 644647 6452.2. Simulation model

The simulation model consisted of a schematic drawing ofthe upper airways and the main bronchi, the lung, the chestwall, the heart and thediaphragm. Fig. 1 showsa screenshot ofthe simulation model. Five patterns of injury were simulated:perforation of the thoracic wall without valve effect,perforation of the thoracic wall with valve effect, air leakageof the lung surface, air leakageof thecentral tracheobronchialsystem, and combined perforating injury of the thoracic walland of the lung surface. Therewere four emergency treatmentoptions available: intubation with positive airway pressure,chest drainage without suction, chest drainage with contin-uous suction and occlusive taping of the chest wall injury. Themodel is animated and shows the excursion of the thoracicwall, the diaphragm, the lung, the heart, and eventually of theventilator. To enhance pathophysiologic understanding, therespective pressure within the pleural cavity and, in case ofartificial ventilation, the inspiratory pressure is demonstrated.

The functionality of the model can be accessed in fourdifferent modes. In the first mode, the physiologic conditions

Fig. 1. Chest trauma emergency treatment. Simulation screenshot of basicthoracic physiology, patterns of injury and emergency treatment option.of normalthoracic wdemonstrtreatmencan be emodalitierandomlythe approreacts actreatmenpositivepresencethe result

2.3. Stud

The st

Phase 1:respiration as well as the effect of removal of theall and of positive pressure respirator treatment isated. In the secondmode, one can examine the fourt modalities. In the third mode, the injury patternsxamined and the effects of various treatments are studied. In the fourth mode, injuries arepresented and the student is encouraged to choosepriate treatment. In each situation, the systemcording to the type of injury and the chosent modalities. For example, choosing intubation andpressure ventilation without chest drainage inof a pulmonary air-leak will immediately showof tension pneumothorax with mediastinal shift.

y design

udy consisted of four phases:

Pre-test. Pre-simulation multiple choice (MC) teston chest trauma emergency management. Nine MC

post-simutest forsamples,test and s

Powerincreaseleast 10%deviationsuffice.

3. Result

Forty o29 femalconfidencsimulatios

ne students participated in this study. There werees and 12 males. They required 30 20 min (95%e interval 2436) min for performing the entiren.ce.analysis [6] was based on the aim to detect anbetween pre- and post-simulation MC tests of at. With alpha = 0.05 and beta = 0.1, and a standardof 14%, a minimum number of 17 students wouldof less thasignificanpropriate. The difference of pre-simulation andlation test results was examined by Students t-paired values. Students t-test for independentSpearmans rank correlation test, Fishers exactign test were applied where appropriate. A p valuen 0.05 was considered to indicate statisticalstandard dwhere apstics

ical analysis was performed using the SPSS 13.0l software package for social sciences (SPSS Inc.,, USA). Absolute and relative frequency, mean,eviation, and 95% confidence interval were usedthe computer simulation. Along with the learningobject, they received detailed instructions on howto handle the simulation. They were encouraged tofollow the instructions, but there was no super-vision as to what degree they really did. The timeeach student spent on the simulation was recorded.

Phase 3: Post-simulation MC test. Each student performed atest of nine randomly selected MC questions on thetopic of chest trauma emergency treatment. Thequestions were different from those of the pre-simulation MC test. The percentage of correctanswers was recorded.

Phase 4: Each student was encouraged to give full-text,open-ended feedback concerning the overall valueof the simulation, the personal learning experienceand the potential utility of the instruction. Theopen-ended feedback was explored by manualcontent analysis.

The primary end point was the difference in the MC testresults before and after the students had undergone thesimulation. Additional outcome measures were the timespent with the simulation, the frequency of various contentanalysis categories and the statistical relationship of thevariables.

Furthermore, utilization of the electronic learning objectsin undergraduate teaching was recorded.

2.4. Statiquestions had been randomly selected from a poolof 18 MC questions for the pre-simulation test. Theremaining nine questions were used for the post-simulation test. The percentage of correct answerswas recorded. There was no specific introductionon chest trauma prior to the pre-test.

The results of the MC tests are summarized in Table 1. Inthe pre-simulation test, the students had 72 17% (95%confidence interval 6778%) correct answers, after perform-

The feedback judgements did not correlate with sex

J. Smolle et al. / European Journal of Cardio-thoracic Surgery 32 (2007) 644647646

Table 1Chest trauma emergency treatment

Parameter Mean 95% confidenceinterval

Pre-simulation CBT results (%) 72.2 66.977.5Time spent with simulation (min) 30 2336Post-simulation CBT results (%) 86.5a 82.690.4Difference of pre- andpost-simulation CBT results (%)

14.3 10.218.4

Results of e-learning using a computer simulation model obtained with 41students (29 females, 12 males). Students performed a pre-test using acomputer-based training (CBT) learning object, then worked on the simulationmodel, and finally performed a post-test on the same topic with differentquestions.

a There was a highly significant difference in the results before and afterperforming the simulation (t-test for paired samples: t = 7.05, p < 0.001).

Importance of trial and error 7 17.1ing the simulation they achieved 86 12% (8390%) correctanswers (Fig. 2). The individual difference was 13 14% (817%). This difference was highly significant (t-test for pairedsamples: t = 7.05, p < 0.001). This significant improvementwas encountered in the subgroup of females as well as in thesubgroup of males ( p < 0.01 and p < 0.05, respectively).There was no significant gender-specific difference as to theresults in the MC tests. There was a highly significantcorrelation between the pre-simulation and post-simulationresults (r = 0.647, p < 0.001).

The time spent with the simulation did not correlate withthe post-simulation test results. There was, however, asignificant negative relationship between the time spent withthe simulation and the individual difference between thepre- and post-simulation tests (Spearmans rank correlationtest: r = 0.47, p > 0.01).

Concerning feedback, 83% gave an overall positive voting,in contrast to an overall negative statement in 5% (Table 2).This is a highly significant result in favour of a positivejudgement (sign test: z = 5.48, p < 0.001). Twenty percentparticularly emphasized the importance of being able toview a process, and 17% claimed the usefulness of theFig. 2. Chest trauma emergency treatment. Pre- and post-simulation multiplechoice test results (% correct answers).simulation to acquire understanding. Also 17% expressedthe importance of the possibility of trial and error, which theyconsidered rather helpful. Ten percent stated that thesimulation was strikingly better than a textbook. Fifteenpercent emphasized the simplicity of the simulation. Thedesign, which placed the comments always into the samewindow as the simulation, was valued by 7%. There wereambiguous results concerning the importance of theinstruction. Nineteen (46%) considered it helpful, while 21(51%) found it superfluous. 12 students (29%) claimed that thefont size of the explanatory text in the simulation was toosmall and reported difficulties in reading. The two registeredoverall negative statements referred to e-learning in general(no alternative to an attendance class) and one studentnoted that the animated movements of the heart and thethoracic wall were bothering.

There was no relationship between the judgement of thewritten instruction (positive or negative) and the MC testresults (t-test for paired values: p > 0.05). The onlyrelationship between feedback statements and results wasfound for the post-simulation MC test results. These weresignificantly higher (91 12%) for students who consideredthe written instruction as superfluous, compared to thosewho found it valuable (82 11%; t-test: p < 0.05). Thosewhofound the written instruction valuable showed a tendency tospend less time with the simulation than others (24 12 mincompared to 36 24 min; t-test: t = 1.986, p = 0.056).

Particular enhancement of understanding 7 17.1Superior to a textbook 4 9.8Straightforwardness of the simulation 6 14.6Font size too small 12 29.2Instruction considered to be of value 19 46.3Instruction considered to be superfluous 21 51.2

Results of e-learning using a computer simulation model obtained with 41students (29 females, 12 males). Content analysis of feedback statements.

a There is a highly significant difference in favour of a positive judgement(sign test: z = 5.48, p < 0001).Table 2Chest trauma emergency treatment

Content analysis category n (%)

Overall positive evaluation 34 82.9a

Overall negative evaluation 2 4.9Importance of being able to view a process 8 19.5except that a negative rating of the instruction was morecommon in females (62%) than in males (25%; Fishers exacttest: p < 0.05).

As far as the overall utilization of the simulation approachis concerned, from October 2005 to January 2007, students ofthe undergraduate medical curriculum paid 2509 visits to theelectronic learning unit on chest trauma emergency manage-ment.

4. Discussion

Our study shows that a computer-based model of thoracicemergency situations illustrating the related pathophysiolo-gical and therapeutic effects significantly increases theperformance of students in MC tests on the same topic. The

overall time spent with the simulation of about half an hour israther short for studying the subject of thoracic injury,related pathophysiology and emergency treatment mea-sures. The fact that the results of the pre-simulation andpost-simulation MC tests showed a highly significant improve-ment underscores the gain of knowledge associated with thesimulation model. The relatively high performance already inthe pre-test might be due to the fact that several aspects ofchest trauma can be explained by application of pre-clinicalknowledge alone. Gain of knowledge was noted similarly in

evaluated. Finally, the pre-test itself might be helpful inincreasing knowledge on chest trauma, even though differentquestions were used for pre- and post-test.

In conclusion, a computer simulation model of thoracicinjuries and emergency treatment modalities seems to be aneffective tool in increasing students understanding of thesubject. Besides the gain of knowledge, the overallacceptance of the didactic approach is high. This model,or similar ones, may be considered as an additionaleducational tool in pre- and postgraduate thoracic surgery

[12] Cook DA, Thompson WG, Thomas KG, Thomas MR, Pankratz PS. Impact ofself-assessment questions and learning styles in web-based learning: a

J. Smolle et al. / European Journal of Cardio-thoracic Surgery 32 (2007) 644647 647female and male participants and did not seem to favoureither of both groups. Therefore, gender-specific differencesin computer literacy [7] do not seem to play a role in ourstudy.

It is remarkable that the time spent with the simulationcorrelated negatively with the difference between the pre-and post-simulation results. Obviously the gain of knowledgedid not depend on the time spent with the simulation.Probably high performers are able to deal with the simulationin a more efficient and less time-consuming way.

The overwhelming positive feedback of most studentsshowed a high level of acceptance of the simulationapproach. The aspects the students valued most is in goodagreement with previous reports: interactivity, the possibi-lity to learn by trial and error, and the advantage of seeing adynamic process happen [8,9]. The fact that the simplicityof the model was mentioned several times is in agreementwith a statement of Grunwald, that more sophisticatedlearning objects are by no means the more effective ones[10]. Hoernlein, in particular, pointed out that reducing thecomplexity of the user interface increases acceptance [11].

It is interesting that a detailed instruction is valued byabout half of the students, while the others consider itsuperfluous. Obviously some enjoy the possibilities onexploring a model on their own, while others are gratefulwhen being offered a stringent learning path. One mayspeculate that these two groups correspond to the sequen-tial-versus-global learning styles according to Solomonsindex of learning styles [12]. Since those who worked withoutthe instruction performed better in the subsequent test, themodel seems to favour active instead of reflective learners.

Utilization statistics from the undergraduate curriculumreveal that the model also has a high acceptance by thestudents in everyday learning.

There are several drawbacks of the study, which should betaken into account. First, the model is highly schematic andsimplified. Second, the number of participants was rathersmall. Furthermore, the gain in knowledge was only assessedby MC test results. Change of student behaviour in realemergency situations, for example, has not yet been randomized, controlled, cross-over trial. Acad Med 2006;81:2318.and emergency medicine education.

Acknowledgement

Mrs Pamela Bauer is kindly thanked for data administra-tion. Mr Gottfried Schipfer and Mr Michael Eisner are kindlythanked for programming assistance.

References

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[4] Smolle J, Staber R, Jamer E, Reibnegger G. Aufbau eines universitats-weiten Lern- Informationssystems parallel zur Entwicklung innovativerCurricula zeitliche Entwicklung und Synergieeffekte. In: TavangarianD, Nolting K, editors. Auf zu neuen Ufern- E-Learning heute und morgen.Waxmann: Munster New York Munchen Berlin; 2005. p. 21726.

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[6] Hulser J, Zimmermann H. Statistische Prinzipien fur medizinische Pro-jekte. Huber: Bern; 2001.

[7] Link TM, Marz R. Computer literacy and attitudes towards e-learningamong first year medical students. BMC Med Educ 2006;6:34.

[8] Weller JM. Simulation in undergraduate medical education: bridging thegap between theory and practice. Med Educ 2004;38:328.

[9] Quinn F, Keogh P, McDonald A, Hussey D. A pilot study comparing theeffectiveness of conventional training and virtual reality simulation in theskills acquisition of junior dental students. Eur J Dent Educ 2003;7:139.

[10] Grunwald T, Corsbie-Massay C. Guidelines for cognitively efficient multi-media learning tools: educational strategies, cognitive load, and inter-face design. Acad Med 2006;81:21323.

[11] Hornlein A, Puppe F. Reduzierung der Komplexitat der Benutzerober-flache von Trainingssystemen. GMS Medizinische Informatik. Biometrieund Epidemiologie 2006;2(3). Doc19.

Emergency treatment of chest trauma - an e-learning simulation model for undergraduate medical studentsIntroductionStudents and methodsStudentsSimulation modelStudy designStatistics

ResultsDiscussionAcknowledgementReferences