The American Journal of Surgery (2016) 211, 350-354
Association for Surgical Education
An early surgical training module for compartment pressure measurement Tayler M. Schwartz, B.S.a,*, Kristopher M. Day, M.D.b, David T. Harrington, M.D., F.A.C.S.b a
The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02903, USA; bDepartment of Surgery, Rhode Island Hospital, Providence, RI, USA KEYWORDS: Surgical education; Structured resident education; Compartment syndrome; Compartment pressure
Abstract BACKGROUND: We test a novel simulated teaching module’s ability to educate junior residents in the assessment of compartment syndrome (CS) and compartment pressure measurement (CPM). METHODS: Twenty-two postgraduate year 1 and postgraduate year 2 surgical residents received a 2hour didactic and practical teaching module on CS assessment and CPM using a simulated model. A structured teaching session by a postgraduate year 5 surgical resident was assessed by carefully constructed pretest, post-test, and delayed retention tests and a practical testing session by 2 boardcertified general surgeons. RESULTS: Analysis of variance demonstrated significant difference between pretest (6.1/10), posttest (7.9/10), and retention test (8.2/10) scores [F (2,49) 5 9.24, P , .01], with no difference in post-test to retention test comparison (P 5 .90). Mean CPM scores were 8.5/10 for preparation, 9.0/10 for performance, and 8.5/10 for management components, which did not differ [F (2,57) 5 .46, P 5 .63]. CONCLUSIONS: We demonstrate an efficient simulated CS and CPM teaching module for the education of junior surgical residents using a synthetic model. Ó 2016 Elsevier Inc. All rights reserved.
The timely diagnosis and treatment of compartment syndrome (CS) are crucial to prevent the morbidity associated with its sequelae, such as renal failure and limb loss.1–3 Despite the benefits of early identification, CS poses a challenge to clinicians as diagnosis relies largely on clinical judgment.1,4,5 We identified a need for increased early exposure to the diagnosis and management of CS in a surgical training curriculum. This report describes a didactic and practical, synthetic model–based, simulated The Brown University Summer Assistantship supported this study, but played no role in the formulation of this study or the publication of this manuscript. * Corresponding author. Tel.: 11 (202) 669-8576; fax: 401-444-6681. E-mail address: [email protected] Manuscript received May 28, 2015; revised manuscript August 13, 2015 0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.08.035
teaching module to improve junior surgical residents’ ability to diagnose and manage CS. Technical proficiency in compartment pressure measurement (CPM) is a vital aspect of care; however, the diagnostic utility of the intracompartmental pressure monitor relies on the clinician’s technical proficiency. One study describes a 35% false positive rate for intracompartmental pressure monitors in the diagnosis of CS.6 The timely and accurate identification and treatment of CS are crucial to preserve limb function, quality of life, and reduce the morbidity associated with unnecessary fasciotomy.4,7–9 We postulate that an educational module targeted toward junior surgical residents may increase the knowledge base and technical proficiency of CS diagnosis. Many studies encourage simulated teaching modules in surgical education10–14 and have documented the efficacy
T.M. Schwartz et al.
Surgical training module: compartment pressure measurement
of CS evaluation15–17 and CS teaching modules18 through animal models. However, the value of a simulated CS teaching module for junior surgical residents using a synthetic model has not been directly investigated previously. We describe the impact of a novel synthetic model, simulated teaching module on junior surgical residents’ knowledge base and technical proficiency in the diagnosis and management of CS. Quantitative measures include multiple-choice testing before, immediately after, and 1 month after administration of the teaching module, and practical testing by board-certified acute care surgeons. We offer this novel simulated teaching module for to aid in the training of junior surgical residents in CS management.
Methods Participants This project was conducted in accordance with institutional standards of ethics and was granted exemption from institutional review board review per federal regulation 45 Code of Federal Regulations 64.101(b)(2) for educational studies. This instructional module was administered during the course of an established training curriculum provided for incoming junior surgical residents at a level I trauma center. Twenty-two junior surgical residents gave informed consent and participated. All participants completed the pretest, 21 participants completed the post-test, and 12 participants completed the retention test.
Equipment We used intracompartmental pressure monitors (295000-000, Stryker Corporation; Kalamazoo, MI) and CS leg models (ERP #1519-6 and #1703-217, Sawbones; Pacific Research Laboratories Inc., Vashon Island, WA). The pretest and knowledge retention test were administered using Qualtrics Survey Software (Provo, UT).
Teaching module Junior surgical residents received a 60-minute didactic and 90-minute practical session on the clinical assessment and performance of CPM for the diagnosis and management of CS. The sequence of module components is outlined in Fig. 1. Participant proficiency was measured
Figure 1
351
with a carefully constructed pretest and post-test multiple-choice examination after the didactic teaching session, as well as a knowledge retention test 1 month after module administration.
Written assessment A panel of 40 written test questions were developed to address principles of CS diagnosis, management, and treatment based on existing literature.1–4,17,19–29 We administered these 40 questions to 14 senior residents. Based on the number of correct responses, the questions were categorized by difficulty level: easy (n 5 13, R90% correct), medium (n 5 4, R80% correct), hard (n 5 4, R70% correct), and very hard (n 5 19, %70% correct). Using this information, we created 3 unique 10-question tests of equal difficulty and comparable content based on senior resident performance (pretest score 6.9/10, post-test score 6.7/10, and retention test score 6.8/10, which did not differ significantly by 1-way within-subjects analysis of variance [ANOVA; F (2,27) 5 .01, P 5 .99]). Ten questions were discarded to maintain equivalent question categories and difficulty across tests. Subjects were notified by an email containing a link to a confidential online survey containing the pretest, which was administered within 5 days before the administration of the teaching module. A PowerPoint presentation consisting of a case presentation and summary of fundamental concepts for the involved anatomy, physiology, diagnosis, and treatment of CS was presented with audience participation that was concluded with a question-and-answer session. This presentation included video examples of CPM technique and a demonstration of the Stryker intracompartmental monitor and Sawbones simulated lower extremity model. After the initial demonstration, the intracompartmental pressure monitor was distributed to each participant for the opportunity to establish familiarity with the device, and a member of the audience then demonstrated performance of the technique. Each resident had the same exposure to the intracompartmental pressure monitor beforehand and had no further practice before the practical examination. The post-test was administered after completion of the didactic portion. Participants were then directed immediately to the practical component. The knowledge retention test was administered 1 month after the teaching module via emailed link to a confidential online survey to evaluate the maintenance of learned information.
Sequence of module components.
352
The American Journal of Surgery, Vol 211, No 2, February 2016
Practical assessment Two board-certified general surgeons with specialization in acute care surgery administered a practical examination for CS measurement and clinical assessment. The examination was developed using the Stryker intracompartmental pressure monitor manufacturer’s instructions, taking into account known caveats that lead to incorrect CS measurement (Fig. 2). Subjects attempted to demonstrate proficiency in preparation, performance, and management components of suspected CS, each of which was graded out of 10 points. First, the examiner described a clinical scenario in which it would be necessary to measure compartment pressure. Participants then prepared the Stryker intracompartmental pressure monitor by assembling and calibrating the device as depicted in Fig. 2 and then used the SawBones simulated leg model. The model displayed different colored lights on a feedback unit when a needle was inserted into each of 4 compartments (Fig. 3). Participants were then supplied with intracompartmental pressure measurements, with which they formulated a treatment plan.
Results A 1-way within-subjects ANOVA demonstrated significant difference between pretest (n 5 22), post-test (n 5
Figure 2
Figure 3
Sawbones leg compartment syndrome model.
21), and retention test (n 5 12) scores [F (2,49) 5 9.29, P , .01]. Participants showed significant improvement in written test performance after module completion, with mean pretest and post-test scores of 6.1/10 and 7.9/10,
Intracompartmental pressure monitor grading criteria.
T.M. Schwartz et al.
Surgical training module: compartment pressure measurement
respectively (P , .01). Retention test scores (mean 8/10) trended higher though were not significantly different from post-test scores (mean 7.9/10; P 5 .90). Participants scored significantly higher overall on test questions pertaining to CS recognition and diagnosis (mean 85.2%), compared with questions pertaining to CS treatment and management (mean 77.4; P 5 .21). On ‘‘easy’’ questions, participants scored an average of 86.7% overall (75.7% on pretest, 92.1% on post-test, and 90.0% on retention test). The average score on ‘‘medium’’ questions was 82.9% (63.6% on pretest, 92.5% on posttest). On ‘‘hard’’ questions, the average score was 76.1% (70.5% on pretest, 80.0% on post-test, and 83.3% on retention test). The average score 58.9% on ‘‘very hard’’ questions (43.2% on pretest, 66.9% on post-test, and 66.7% on retention test). The overall scores across difficulty designations were significantly different by 1-way ANOVA [F (3,26) 5 5.46, P 5 .005]. Students successfully demonstrated practical skill ability with average CPM practical performance scores of 8.5/10 for preparation components, 9.0/10 for performance components, and 8.5/10 for management components, which did not statistically differ by 1-way within-subjects ANOVA [F (2,52) 5 .46, P 5 .63]. Skills test scores were not statistically different between evaluators (P 5 .83).
Comments We report the first reproducible teaching module for the education of junior surgical residents in CS management and CPM technique. We demonstrate retained improvement in knowledge base and technical proficiency. This replicable didactic and practical teaching module uses a durable, synthetic, simulated lower extremity model. It not only provides an opportunity for residents to gain experience before encountering patients experiencing a potential surgical emergency but also enables technical and clinical knowledge competency testing. Synthetic simulated teaching modules have not been previously described for CS. Other studies have used animal15–17 or fresh cadaver30 limbs in the evaluation of lower extremity CS and in education modules targeted toward junior residents,18 but none have used synthetic models as a teaching paradigm. Although no model allows for exact anatomic replication or the rapport of a real patient encounter, simulated modules represent effective surgical teaching methods.31–38 The synthetic lower extremity CS model used in this study is durable, reusable, does not require climate-controlled storage, and replicates essential anatomy, including bony landmarks and a distinctive ‘‘pop’’ on entry into each fascial compartment. Simulated CS teaching modules for junior surgical residents may serve as a powerful learning tool. A simulated module for CPM skill development with the Stryker intracompartmental monitor aimed toward orthopedic residents using cadaveric and porcine modules demonstrated
353
improved technique and measurement accuracy, as well as 9-month skill retention.18 Similar resident educational modules with simulation and didactic components have shown higher multiple-choice test scores39 and higher resident comfort level with procedures40 than a didactic lecture alone. Other studies using simulation for resident education demonstrate learned technical proficiency,31 improved clinical test scores32 and provide an objective assessment tool.33–35 Participants in our study similarly demonstrated technical skill competency, enhanced knowledge base, and knowledge retention at 1 month. This study has several limitations. The CS lower leg model did not allow for a quantitative measurement of compartmental pressure; however, the instructor supplied this information. In addition, several participants who were lost to follow-up did not take the knowledge retention test. Those who excelled in the module may have been more likely to complete the retention test, rendering the retention data subject to selection bias. Although we identified the need for increased early exposure of the management of suspected CS, meaningful exposure to clinical CS scenarios will vary between institutions. Future iterations of this module should evaluate how increased knowledge of CS affects patient outcomes. We believe this educational intervention may lead to more prompt and proficient management of CS and improved patient safety. It would be beneficial to include a control group consisting of those who did not participate in the module and to evaluate interspecialty variation in junior surgical resident performance. Future research could also evaluate how junior surgical resident CS management confidence correlates with proficiency and whether CPM technical skills are retained long term.
Conclusion This teaching module demonstrates a mechanism for the efficient education of junior surgical residents in the clinical assessment of CS and CPM technique using a synthetic model. This educational approach may have widespread applicability across surgical training programs and could potentially improve CS patient outcomes.
Acknowledgments The authors thank Dr. Jaswin Sawhney and Katherine Deegan for their indispensible aid in carrying out the module.
References 1. Shadgan B, Menon M, O’Brien PJ, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma 2008;22:581–7. 2. Wall CJ, Lynch J, Harris IA, et al. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma. ANZ J Surg 2010;80:151–6.
354 3. Tiwari A, Haq AI, Myint F, et al. Acute compartment syndromes. Br J Surg 2002;89:397–412. 4. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002;16:572–7. 5. Oprel PP, Eversdijk MG, Vlot J, et al. The acute compartment syndrome of the lower leg: a difficult diagnosis? Open Orthop J 2010;4: 115–9. 6. Whitney A, O’Toole RV, Hui E, et al. Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome? J Trauma Acute Care Surg 2014;76:479–83. 7. Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World J Surg 2003;27:744–7. 8. Giannoudis PV, Nicolopoulos C, Dinopoulos H, et al. The impact of lower leg compartment syndrome on health related quality of life. Injury 2002;33:117–21. 9. Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690–3. 10. Whitson BA, Hoang CD, Jie T, et al. Technology-enhanced interactive surgical education. J Surg Res 2006;136:13–8. 11. Scott DJ, Cendan JC, Pugh CM, et al. The changing face of surgical education: simulation as the new paradigm. J Surg Res 2008;147: 189–93. 12. Reznick RK, MacRae H. Teaching surgical skillsdchanges in the wind. New Engl J Med 2006;355:2664–9. 13. Stovall TG, Ling FW, Lipscomb GH, et al. A model for resident surgical training in laparoscopic sterilization. Obstet Gynecol 1994;83: 470–2. 14. Brewster LP, Risucci DA, Joehl RJ, et al. Management of adverse surgical events: a structured education module for residents. Am J Surg 2005;190:687–90. 15. Kalns J, Cox J, Baskin J, et al. Threshold model for extremity compartment syndrome in swine. J Surg Res 2011;167:e13–9. 16. McGill R, Jones E, Robinson B, et al. Correlation of altitude and compartment pressures in porcine hind limbs. J Surg Orthop Adv 2011;20:30–3. 17. Daly KA, Wolf M, Johnson SA, et al. A rabbit model of peripheral compartment syndrome with associated rhabdomyolysis and a regenerative medicine approach for treatment. Tissue Eng Part C Methods 2011;17:631–40. 18. Morris MR, Harper BL, Hetzel S, et al. The effect of focused instruction on orthopaedic surgery residents’ ability to objectively measure intracompartmental pressures in a compartment syndrome model. J Bone Jt Surg Am 2014;96:e171. 19. Balogh Z, McKinley BA, Holcomb JB, et al. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma 2003;54:848–59. 20. Doro CJ, Sitzman TJ, O’Toole RV. Can intramuscular glucose levels diagnose compartment syndrome? J Trauma Acute Care Surg 2014; 76:474–8. 21. Gourgiotis S, Villias C, Germanos S, et al. Acute limb compartment syndrome: a review. J Surg Educ 2007;64:178–86. 22. Hunt L, Frost SA, Hillman K, et al. Management of intra-abdominal hypertension and abdominal compartment syndrome: a review. J Trauma Manag Outcomes 2014;8:2.
The American Journal of Surgery, Vol 211, No 2, February 2016 23. Janzing HM, Broos PL. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment! Injury 2001; 32:415–21. 24. Leppaniemi AK, Hienonen PA, Siren JE, et al. Treatment of abdominal compartment syndrome with subcutaneous anterior abdominal fasciotomy in severe acute pancreatitis. World J Surg 2006;30:1922–4. 25. Mitas P, Vejrazka M, Hruby J, et al. Prediction of compartment syndrome based on analysis of biochemical parameters. Ann Vasc Surg 2014;28:170–7. 26. O’Toole RV, Whitney A, Merchant N, et al. Variation in diagnosis of compartment syndrome by surgeons treating tibial shaft fractures. J Trauma 2009;67:735–41. 27. Uliasz A, Ishida JT, Fleming JK, et al. Comparing the methods of measuring compartment pressures in acute compartment syndrome. Am J Emerg Med 2003;21:143–5. 28. Van der Wal WA, Heesterbeek PJ, Van den Brand JG, et al. The natural course of chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc 2015;23:2136–41. 29. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices. J Bone Jt Surg Am 2005;87:2415–22. 30. Messina FC, Cooper D, Huffman G, et al. A human cadaver fascial compartment pressure measurement model. The J Emerg Med 2013; 45:e127–31. 31. Cohen ER, Barsuk JH, Moazed F, et al. Making July safer: simulationbased mastery learning during intern boot cAMP. Acad Med 2013;88: 233–9. 32. 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. 33. Zendejas B, Cook DA, Bingener J, et al. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial. Ann Surg 2011;254:502–9. 34. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin 2007;25:225–36. 35. Mashaud LB, Castellvi AO, Hollett LA, et al. Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance. Surgery 2010;148:194–201. 36. Edelman DA, Mattos MA, Bouwman DL. FLS skill retention (learning) in first year surgery residents. J Surg Res 2010;163:24–8. 37. Stefanidis D, Acker C, Heniford BT. Proficiency-based laparoscopic simulator training leads to improved operating room skill that is resistant to decay. Surg Innov 2008;15:69–73. 38. Castellvi AO, Hollett LA, Minhajuddin A, et al. Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents. Surgery 2009;146: 387–93. 39. Ramsingh D, Alexander B, Le K, et al. Comparison of the didactic lecture with the simulation/model approach for the teaching of a novel perioperative ultrasound curriculum to anesthesiology residents. J Clin Anesth 2014;26:443–54. 40. Wang CL, Schopp JG, Petscavage JM, et al. Prospective randomized comparison of standard didactic lecture versus high-fidelity simulation for radiology resident contrast reaction management training. AJR Am J Roentgenol 2011;196:1288–95.
Association for Surgical Education
An early surgical training module for compartment pressure measurement Tayler M. Schwartz, B.S.a,*, Kristopher M. Day, M.D.b, David T. Harrington, M.D., F.A.C.S.b a
The Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI, 02903, USA; bDepartment of Surgery, Rhode Island Hospital, Providence, RI, USA KEYWORDS: Surgical education; Structured resident education; Compartment syndrome; Compartment pressure
Abstract BACKGROUND: We test a novel simulated teaching module’s ability to educate junior residents in the assessment of compartment syndrome (CS) and compartment pressure measurement (CPM). METHODS: Twenty-two postgraduate year 1 and postgraduate year 2 surgical residents received a 2hour didactic and practical teaching module on CS assessment and CPM using a simulated model. A structured teaching session by a postgraduate year 5 surgical resident was assessed by carefully constructed pretest, post-test, and delayed retention tests and a practical testing session by 2 boardcertified general surgeons. RESULTS: Analysis of variance demonstrated significant difference between pretest (6.1/10), posttest (7.9/10), and retention test (8.2/10) scores [F (2,49) 5 9.24, P , .01], with no difference in post-test to retention test comparison (P 5 .90). Mean CPM scores were 8.5/10 for preparation, 9.0/10 for performance, and 8.5/10 for management components, which did not differ [F (2,57) 5 .46, P 5 .63]. CONCLUSIONS: We demonstrate an efficient simulated CS and CPM teaching module for the education of junior surgical residents using a synthetic model. Ó 2016 Elsevier Inc. All rights reserved.
The timely diagnosis and treatment of compartment syndrome (CS) are crucial to prevent the morbidity associated with its sequelae, such as renal failure and limb loss.1–3 Despite the benefits of early identification, CS poses a challenge to clinicians as diagnosis relies largely on clinical judgment.1,4,5 We identified a need for increased early exposure to the diagnosis and management of CS in a surgical training curriculum. This report describes a didactic and practical, synthetic model–based, simulated The Brown University Summer Assistantship supported this study, but played no role in the formulation of this study or the publication of this manuscript. * Corresponding author. Tel.: 11 (202) 669-8576; fax: 401-444-6681. E-mail address: [email protected] Manuscript received May 28, 2015; revised manuscript August 13, 2015 0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.08.035
teaching module to improve junior surgical residents’ ability to diagnose and manage CS. Technical proficiency in compartment pressure measurement (CPM) is a vital aspect of care; however, the diagnostic utility of the intracompartmental pressure monitor relies on the clinician’s technical proficiency. One study describes a 35% false positive rate for intracompartmental pressure monitors in the diagnosis of CS.6 The timely and accurate identification and treatment of CS are crucial to preserve limb function, quality of life, and reduce the morbidity associated with unnecessary fasciotomy.4,7–9 We postulate that an educational module targeted toward junior surgical residents may increase the knowledge base and technical proficiency of CS diagnosis. Many studies encourage simulated teaching modules in surgical education10–14 and have documented the efficacy
T.M. Schwartz et al.
Surgical training module: compartment pressure measurement
of CS evaluation15–17 and CS teaching modules18 through animal models. However, the value of a simulated CS teaching module for junior surgical residents using a synthetic model has not been directly investigated previously. We describe the impact of a novel synthetic model, simulated teaching module on junior surgical residents’ knowledge base and technical proficiency in the diagnosis and management of CS. Quantitative measures include multiple-choice testing before, immediately after, and 1 month after administration of the teaching module, and practical testing by board-certified acute care surgeons. We offer this novel simulated teaching module for to aid in the training of junior surgical residents in CS management.
Methods Participants This project was conducted in accordance with institutional standards of ethics and was granted exemption from institutional review board review per federal regulation 45 Code of Federal Regulations 64.101(b)(2) for educational studies. This instructional module was administered during the course of an established training curriculum provided for incoming junior surgical residents at a level I trauma center. Twenty-two junior surgical residents gave informed consent and participated. All participants completed the pretest, 21 participants completed the post-test, and 12 participants completed the retention test.
Equipment We used intracompartmental pressure monitors (295000-000, Stryker Corporation; Kalamazoo, MI) and CS leg models (ERP #1519-6 and #1703-217, Sawbones; Pacific Research Laboratories Inc., Vashon Island, WA). The pretest and knowledge retention test were administered using Qualtrics Survey Software (Provo, UT).
Teaching module Junior surgical residents received a 60-minute didactic and 90-minute practical session on the clinical assessment and performance of CPM for the diagnosis and management of CS. The sequence of module components is outlined in Fig. 1. Participant proficiency was measured
Figure 1
351
with a carefully constructed pretest and post-test multiple-choice examination after the didactic teaching session, as well as a knowledge retention test 1 month after module administration.
Written assessment A panel of 40 written test questions were developed to address principles of CS diagnosis, management, and treatment based on existing literature.1–4,17,19–29 We administered these 40 questions to 14 senior residents. Based on the number of correct responses, the questions were categorized by difficulty level: easy (n 5 13, R90% correct), medium (n 5 4, R80% correct), hard (n 5 4, R70% correct), and very hard (n 5 19, %70% correct). Using this information, we created 3 unique 10-question tests of equal difficulty and comparable content based on senior resident performance (pretest score 6.9/10, post-test score 6.7/10, and retention test score 6.8/10, which did not differ significantly by 1-way within-subjects analysis of variance [ANOVA; F (2,27) 5 .01, P 5 .99]). Ten questions were discarded to maintain equivalent question categories and difficulty across tests. Subjects were notified by an email containing a link to a confidential online survey containing the pretest, which was administered within 5 days before the administration of the teaching module. A PowerPoint presentation consisting of a case presentation and summary of fundamental concepts for the involved anatomy, physiology, diagnosis, and treatment of CS was presented with audience participation that was concluded with a question-and-answer session. This presentation included video examples of CPM technique and a demonstration of the Stryker intracompartmental monitor and Sawbones simulated lower extremity model. After the initial demonstration, the intracompartmental pressure monitor was distributed to each participant for the opportunity to establish familiarity with the device, and a member of the audience then demonstrated performance of the technique. Each resident had the same exposure to the intracompartmental pressure monitor beforehand and had no further practice before the practical examination. The post-test was administered after completion of the didactic portion. Participants were then directed immediately to the practical component. The knowledge retention test was administered 1 month after the teaching module via emailed link to a confidential online survey to evaluate the maintenance of learned information.
Sequence of module components.
352
The American Journal of Surgery, Vol 211, No 2, February 2016
Practical assessment Two board-certified general surgeons with specialization in acute care surgery administered a practical examination for CS measurement and clinical assessment. The examination was developed using the Stryker intracompartmental pressure monitor manufacturer’s instructions, taking into account known caveats that lead to incorrect CS measurement (Fig. 2). Subjects attempted to demonstrate proficiency in preparation, performance, and management components of suspected CS, each of which was graded out of 10 points. First, the examiner described a clinical scenario in which it would be necessary to measure compartment pressure. Participants then prepared the Stryker intracompartmental pressure monitor by assembling and calibrating the device as depicted in Fig. 2 and then used the SawBones simulated leg model. The model displayed different colored lights on a feedback unit when a needle was inserted into each of 4 compartments (Fig. 3). Participants were then supplied with intracompartmental pressure measurements, with which they formulated a treatment plan.
Results A 1-way within-subjects ANOVA demonstrated significant difference between pretest (n 5 22), post-test (n 5
Figure 2
Figure 3
Sawbones leg compartment syndrome model.
21), and retention test (n 5 12) scores [F (2,49) 5 9.29, P , .01]. Participants showed significant improvement in written test performance after module completion, with mean pretest and post-test scores of 6.1/10 and 7.9/10,
Intracompartmental pressure monitor grading criteria.
T.M. Schwartz et al.
Surgical training module: compartment pressure measurement
respectively (P , .01). Retention test scores (mean 8/10) trended higher though were not significantly different from post-test scores (mean 7.9/10; P 5 .90). Participants scored significantly higher overall on test questions pertaining to CS recognition and diagnosis (mean 85.2%), compared with questions pertaining to CS treatment and management (mean 77.4; P 5 .21). On ‘‘easy’’ questions, participants scored an average of 86.7% overall (75.7% on pretest, 92.1% on post-test, and 90.0% on retention test). The average score on ‘‘medium’’ questions was 82.9% (63.6% on pretest, 92.5% on posttest). On ‘‘hard’’ questions, the average score was 76.1% (70.5% on pretest, 80.0% on post-test, and 83.3% on retention test). The average score 58.9% on ‘‘very hard’’ questions (43.2% on pretest, 66.9% on post-test, and 66.7% on retention test). The overall scores across difficulty designations were significantly different by 1-way ANOVA [F (3,26) 5 5.46, P 5 .005]. Students successfully demonstrated practical skill ability with average CPM practical performance scores of 8.5/10 for preparation components, 9.0/10 for performance components, and 8.5/10 for management components, which did not statistically differ by 1-way within-subjects ANOVA [F (2,52) 5 .46, P 5 .63]. Skills test scores were not statistically different between evaluators (P 5 .83).
Comments We report the first reproducible teaching module for the education of junior surgical residents in CS management and CPM technique. We demonstrate retained improvement in knowledge base and technical proficiency. This replicable didactic and practical teaching module uses a durable, synthetic, simulated lower extremity model. It not only provides an opportunity for residents to gain experience before encountering patients experiencing a potential surgical emergency but also enables technical and clinical knowledge competency testing. Synthetic simulated teaching modules have not been previously described for CS. Other studies have used animal15–17 or fresh cadaver30 limbs in the evaluation of lower extremity CS and in education modules targeted toward junior residents,18 but none have used synthetic models as a teaching paradigm. Although no model allows for exact anatomic replication or the rapport of a real patient encounter, simulated modules represent effective surgical teaching methods.31–38 The synthetic lower extremity CS model used in this study is durable, reusable, does not require climate-controlled storage, and replicates essential anatomy, including bony landmarks and a distinctive ‘‘pop’’ on entry into each fascial compartment. Simulated CS teaching modules for junior surgical residents may serve as a powerful learning tool. A simulated module for CPM skill development with the Stryker intracompartmental monitor aimed toward orthopedic residents using cadaveric and porcine modules demonstrated
353
improved technique and measurement accuracy, as well as 9-month skill retention.18 Similar resident educational modules with simulation and didactic components have shown higher multiple-choice test scores39 and higher resident comfort level with procedures40 than a didactic lecture alone. Other studies using simulation for resident education demonstrate learned technical proficiency,31 improved clinical test scores32 and provide an objective assessment tool.33–35 Participants in our study similarly demonstrated technical skill competency, enhanced knowledge base, and knowledge retention at 1 month. This study has several limitations. The CS lower leg model did not allow for a quantitative measurement of compartmental pressure; however, the instructor supplied this information. In addition, several participants who were lost to follow-up did not take the knowledge retention test. Those who excelled in the module may have been more likely to complete the retention test, rendering the retention data subject to selection bias. Although we identified the need for increased early exposure of the management of suspected CS, meaningful exposure to clinical CS scenarios will vary between institutions. Future iterations of this module should evaluate how increased knowledge of CS affects patient outcomes. We believe this educational intervention may lead to more prompt and proficient management of CS and improved patient safety. It would be beneficial to include a control group consisting of those who did not participate in the module and to evaluate interspecialty variation in junior surgical resident performance. Future research could also evaluate how junior surgical resident CS management confidence correlates with proficiency and whether CPM technical skills are retained long term.
Conclusion This teaching module demonstrates a mechanism for the efficient education of junior surgical residents in the clinical assessment of CS and CPM technique using a synthetic model. This educational approach may have widespread applicability across surgical training programs and could potentially improve CS patient outcomes.
Acknowledgments The authors thank Dr. Jaswin Sawhney and Katherine Deegan for their indispensible aid in carrying out the module.
References 1. Shadgan B, Menon M, O’Brien PJ, et al. Diagnostic techniques in acute compartment syndrome of the leg. J Orthop Trauma 2008;22:581–7. 2. Wall CJ, Lynch J, Harris IA, et al. Clinical practice guidelines for the management of acute limb compartment syndrome following trauma. ANZ J Surg 2010;80:151–6.
354 3. Tiwari A, Haq AI, Myint F, et al. Acute compartment syndromes. Br J Surg 2002;89:397–412. 4. Ulmer T. The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder? J Orthop Trauma 2002;16:572–7. 5. Oprel PP, Eversdijk MG, Vlot J, et al. The acute compartment syndrome of the lower leg: a difficult diagnosis? Open Orthop J 2010;4: 115–9. 6. Whitney A, O’Toole RV, Hui E, et al. Do one-time intracompartmental pressure measurements have a high false-positive rate in diagnosing compartment syndrome? J Trauma Acute Care Surg 2014;76:479–83. 7. Heemskerk J, Kitslaar P. Acute compartment syndrome of the lower leg: retrospective study on prevalence, technique, and outcome of fasciotomies. World J Surg 2003;27:744–7. 8. Giannoudis PV, Nicolopoulos C, Dinopoulos H, et al. The impact of lower leg compartment syndrome on health related quality of life. Injury 2002;33:117–21. 9. Fitzgerald AM, Gaston P, Wilson Y, et al. Long-term sequelae of fasciotomy wounds. Br J Plast Surg 2000;53:690–3. 10. Whitson BA, Hoang CD, Jie T, et al. Technology-enhanced interactive surgical education. J Surg Res 2006;136:13–8. 11. Scott DJ, Cendan JC, Pugh CM, et al. The changing face of surgical education: simulation as the new paradigm. J Surg Res 2008;147: 189–93. 12. Reznick RK, MacRae H. Teaching surgical skillsdchanges in the wind. New Engl J Med 2006;355:2664–9. 13. Stovall TG, Ling FW, Lipscomb GH, et al. A model for resident surgical training in laparoscopic sterilization. Obstet Gynecol 1994;83: 470–2. 14. Brewster LP, Risucci DA, Joehl RJ, et al. Management of adverse surgical events: a structured education module for residents. Am J Surg 2005;190:687–90. 15. Kalns J, Cox J, Baskin J, et al. Threshold model for extremity compartment syndrome in swine. J Surg Res 2011;167:e13–9. 16. McGill R, Jones E, Robinson B, et al. Correlation of altitude and compartment pressures in porcine hind limbs. J Surg Orthop Adv 2011;20:30–3. 17. Daly KA, Wolf M, Johnson SA, et al. A rabbit model of peripheral compartment syndrome with associated rhabdomyolysis and a regenerative medicine approach for treatment. Tissue Eng Part C Methods 2011;17:631–40. 18. Morris MR, Harper BL, Hetzel S, et al. The effect of focused instruction on orthopaedic surgery residents’ ability to objectively measure intracompartmental pressures in a compartment syndrome model. J Bone Jt Surg Am 2014;96:e171. 19. Balogh Z, McKinley BA, Holcomb JB, et al. Both primary and secondary abdominal compartment syndrome can be predicted early and are harbingers of multiple organ failure. J Trauma 2003;54:848–59. 20. Doro CJ, Sitzman TJ, O’Toole RV. Can intramuscular glucose levels diagnose compartment syndrome? J Trauma Acute Care Surg 2014; 76:474–8. 21. Gourgiotis S, Villias C, Germanos S, et al. Acute limb compartment syndrome: a review. J Surg Educ 2007;64:178–86. 22. Hunt L, Frost SA, Hillman K, et al. Management of intra-abdominal hypertension and abdominal compartment syndrome: a review. J Trauma Manag Outcomes 2014;8:2.
The American Journal of Surgery, Vol 211, No 2, February 2016 23. Janzing HM, Broos PL. Routine monitoring of compartment pressure in patients with tibial fractures: beware of overtreatment! Injury 2001; 32:415–21. 24. Leppaniemi AK, Hienonen PA, Siren JE, et al. Treatment of abdominal compartment syndrome with subcutaneous anterior abdominal fasciotomy in severe acute pancreatitis. World J Surg 2006;30:1922–4. 25. Mitas P, Vejrazka M, Hruby J, et al. Prediction of compartment syndrome based on analysis of biochemical parameters. Ann Vasc Surg 2014;28:170–7. 26. O’Toole RV, Whitney A, Merchant N, et al. Variation in diagnosis of compartment syndrome by surgeons treating tibial shaft fractures. J Trauma 2009;67:735–41. 27. Uliasz A, Ishida JT, Fleming JK, et al. Comparing the methods of measuring compartment pressures in acute compartment syndrome. Am J Emerg Med 2003;21:143–5. 28. Van der Wal WA, Heesterbeek PJ, Van den Brand JG, et al. The natural course of chronic exertional compartment syndrome of the lower leg. Knee Surg Sports Traumatol Arthrosc 2015;23:2136–41. 29. Boody AR, Wongworawat MD. Accuracy in the measurement of compartment pressures: a comparison of three commonly used devices. J Bone Jt Surg Am 2005;87:2415–22. 30. Messina FC, Cooper D, Huffman G, et al. A human cadaver fascial compartment pressure measurement model. The J Emerg Med 2013; 45:e127–31. 31. Cohen ER, Barsuk JH, Moazed F, et al. Making July safer: simulationbased mastery learning during intern boot cAMP. Acad Med 2013;88: 233–9. 32. 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. 33. Zendejas B, Cook DA, Bingener J, et al. Simulation-based mastery learning improves patient outcomes in laparoscopic inguinal hernia repair: a randomized controlled trial. Ann Surg 2011;254:502–9. 34. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin 2007;25:225–36. 35. Mashaud LB, Castellvi AO, Hollett LA, et al. Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance. Surgery 2010;148:194–201. 36. Edelman DA, Mattos MA, Bouwman DL. FLS skill retention (learning) in first year surgery residents. J Surg Res 2010;163:24–8. 37. Stefanidis D, Acker C, Heniford BT. Proficiency-based laparoscopic simulator training leads to improved operating room skill that is resistant to decay. Surg Innov 2008;15:69–73. 38. Castellvi AO, Hollett LA, Minhajuddin A, et al. Maintaining proficiency after fundamentals of laparoscopic surgery training: a 1-year analysis of skill retention for surgery residents. Surgery 2009;146: 387–93. 39. Ramsingh D, Alexander B, Le K, et al. Comparison of the didactic lecture with the simulation/model approach for the teaching of a novel perioperative ultrasound curriculum to anesthesiology residents. J Clin Anesth 2014;26:443–54. 40. Wang CL, Schopp JG, Petscavage JM, et al. Prospective randomized comparison of standard didactic lecture versus high-fidelity simulation for radiology resident contrast reaction management training. AJR Am J Roentgenol 2011;196:1288–95.
