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005 APDS SPRING MEETING

uccessful Collaborative Model for Traumakills Training of Surgical and Emergencyedicine Residents in a Laboratory Setting

avid A. Berg, MD,* Richard E. Milner,† Dawn Demangone, MD,§ Jacob W. Ufberg, MD,§rica McKernan, MD,§ Carol A. Fisher,† John P. Gaughan, PhD,� Harsh Grewal, MD,‡aniel T. Dempsey, MD,* and Amy J. Goldberg, MD*

Department of Surgery, Temple University Hospital; †Department of Surgery, Temple University School ofedicine; ‡Department of Surgery, Temple University Children’s Medical Center; §Emergency Medicine,

emple University Hospital; and �Epidemiology and Biostatistics, Temple University School of Medicine,

hiladelphia, Pennsylvania

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BJECTIVES: To determine whether interdepartmental edu-ational and technical resources could be combined to success-ully train surgery and emergency medicine residents in com-on diagnostic and therapeutic trauma skills outside the

raditional hospital setting.

ESIGN: Curriculum improvement survey.

ETTING: Surgical Skills Laboratory, Temple Universitychool of Medicine, Philadelphia, Pennsylvania.

ARTICIPANTS: A total of 35 surgery residents (PGY 1 to 5)nd 26 emergency medicine residents (PGY 1 to 3).

ETHODS: Emergency medicine attendings used humanolunteers to train surgery residents in Focused Assessmentith Sonography in Trauma (FAST). Trauma surgery attend-

ngs used a porcine model to teach emergency medicine resi-ents tracheostomy, peripheral venous cutdown, diagnosticeritoneal lavage, tube thoracostomy, and bilateral thoracot-my. Upon completion of the courses, all residents were sur-eyed using a 5-point Likert scale to assess this teaching model.

ESULTS: The percentage of residents reporting an improve-ent in knowledge levels after the course increased significantly

p � 0.003) for all skill modules (FAST, 14% vs 73%; trache-stomy, 20% vs 64%; peripheral venous cutdown, 25% vs1%; diagnostic peritoneal lavage, 16% vs 60%; tube thoracos-omy, 42% vs 92%; thoracotomy, 15% vs 42%). A significantp � 0.05) increase in comfort levels during performance of therocedures in the clinical setting was also anticipated for all

orrespondence: Inquiries to David A. Berg, MD, Temple University Hospital, Depart-ent of Surgery, 3401 North Broad Street, Fourth Floor, Parkinson Pavilion, Philadel-

hia, PA 19140; fax: (215) 707-8432; e-mail: dberg@temple.edu

vPresented at the annual meeting of the Association of Program Directors in Surgery,arch 31–April 2, 2005, New York, NY.

URRENT SURGERY • © 2005 by the Association of Program Directors inPublished by Elsevier Inc.

kills modules (FAST, 11% vs 60%; tracheostomy, 12% vs0%; peripheral venous cutdown, 15% vs 31%; diagnosticeritoneal lavage, 12% vs 58%; tube thoracostomy, 35% vs3%; thoracotomy, 0% vs 15%). PGY 1 to 4 surgery residentsnd PGY 1 and 2 emergency medicine residents perceived thereatest benefit (p � 0.05) from their respective courses. Theverwhelming majority (89% to 100%) of surgery and emer-ency medicine residents felt the course was valuable and trans-erable to the clinical trauma setting.

ONCLUSIONS: Interdepartmental collaboration betweenhe Department of Surgery and Department of Emergency

edicine offered a unique training relationship that was a pos-tive educational experience for all residents. (Curr Surg 62:57-663. © 2005 by the Association of Program Directors inurgery.)

EY WORDS: skills laboratory, trauma skills, Focused Assess-ent with Sonography in Trauma (FAST), animate model,

uman model, collaborative training

NTRODUCTION

he care of the trauma patient involves a highly disciplined andystematic approach. To address the need for uniformity inelivering trauma care, the American College of Surgeonsommittee on Trauma, in 1979, adopted the Advancedrauma Life Support (ATLS) course.1 All physicians directly

nvolved with providing resuscitative care to a trauma patient,ncluding emergency room physicians and surgeons, are re-uired to be ATLS-certified. When evaluating any injured pa-ient, one must rely on the simultaneous application of physicalxamination skills, critical decision-making skills, and both in-

asive and noninvasive procedural skills. The proper implemen-

Surgery 0149-7944/05/$30.00doi:10.1016/j.cursur.2005.08.006

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ation of procedural skills could mean the difference betweenife and death for the trauma patient.

Surgery and emergency medicine are procedure-oriented dis-iplines that often work side-by-side in the trauma bay. Masterynd knowledge of the skills taught in the ATLS course is essen-ial for any surgeon or emergency room physician involved inhe care of a trauma patient. In addition to the invasive proce-ures taught in ATLS, Focused Assessment with Sonographyor Trauma (FAST)2 has become an essential diagnostic tool inhe armamentarium of the trauma practitioner. Ultrasound ex-mination of the traumatized abdomen has been shown to beapid, noninvasive, reliable, and effectively administered byonradiologists.3,4 FAST is becoming a standard procedure inhe assessment of trauma victims and has been deemed a neces-ary aspect of residency training by both the American College ofurgeons and the American College of Emergency Physicians.5

Recent Accreditation Council for Graduate Medical Educa-ion (ACGME)-mandated restrictions on resident work hours,6

imited availability of funds for residency training programs,nd concerns about learning potentially harmful, invasive pro-edures for the first time on patients have prompted physicianducators to seek venues for resident education outside of theraditional hospital setting. The Temple University Hospitalepartment of Surgery and Department of Emergency Medi-

ine sought to determine whether combining interdepartmen-al educational and technical resources in a laboratory settingould benefit resident education. Specifically, our goal was to

ncrease the knowledge and understanding of trauma proce-ures for surgery and emergency medicine residents and raiseheir confidence levels during performance of these skills. It wasccomplished by means of an ultrasound course for surgeryesidents and an animate trauma skills course for emergencyedicine residents. A resident survey assessed the effectiveness

f this teaching model.

ATERIALS AND METHODS

tudy Population

he ultrasound course was offered to Temple University Hos-ital Department of Surgery residents of all PGY levels (1 to 5),nd the animate trauma skills laboratory was offered to Templeniversity Hospital Department of Emergency Medicine resi-ents of all PGY levels (1 to 3). For the 2004/2005 academicear, at the time of this course, the Department of Surgerymployed 48 residents, and the Department of Emergency

edicine employed 27 residents. Thirty-five surgery residentsPGY 1 � 12, PGY 2 � 7, PGY 3 � 6, PGY 4 � 6, and PGY� 4) took the ultrasound course, and 26 emergency medicine

esidents (PGY 1 � 10, PGY 2 � 8, and PGY 3 � 8) partici-ated in the animate trauma skills course.

ltrasound Course

he ultrasound course began with a didactic session, in lecture

ormat, conducted by an emergency medicine attending. The w

58 CURRENT

ecture covered the physics, equipment, and terminology ofltrasound; the indications, limitations, and technique ofAST; and the application of FAST to clinical pathways inrauma. In addition, the lecture included an introduction to these of ultrasound-guided central venous cannulation. The lec-ure was followed by a hands-on ultrasound laboratory thatsed healthy human volunteers to demonstrate normal abdom-

nal, thoracic, and neck anatomy. Peritoneal dialysis patientsere used as models by the residents to simulate free intra-

bdominal fluid.All participating surgery residents attended a 2-hour ultra-

ound laboratory session. The laboratory consisted of 5 stationsith ultrasound equipment for each station. Participants were

aught a 6-view FAST examination. The 6 views included theight upper quadrant, pelvis, left upper quadrant, pericardialegion, and both hemithoraces. In addition, residents were in-tructed on locating and differentiating the central venous anat-my of the neck (carotid artery and jugular vein). Emergencyedicine attendings certified in performance of FAST were

tationed at each module and provided instruction and super-ision to surgery residents, as well as immediate feedback onheir performance.

rauma Skills Course

he Temple University School of Medicine Surgical Skills Lab-ratory served as the setting for a porcine trauma skills labora-ory for emergency medicine residents. This laboratory housesn operating facility that has been approved for both researchnd teaching purposes by the Institutional Animal Care andse Committee (IACUC) of Temple University. Approval for

he trauma skills course teaching protocol was obtained fromhe Temple University IACUC. Briefly, mixed-sex Yorkshirewine (25 to 30 kg) were fasted 18 hours before surgery, sedatedith Telazol (4.4 mg/kg intramuscularly), and transported to

he Surgical Skills Laboratory. Inhalational anesthesia (isoflou-ane, 3% to 4% induction, 1% to 2% maintenance) was ad-inistered via facemask. Heart rate and blood oxygen level

%SpO2) were measured continuously with a noninvasiveonitor. Establishment of an adequate level of anesthesia was

etermined by decreased heart rate and lack of response toainful stimuli (ie, pinch of coronary band of hoof). At thisoint, the tracheostomy module of the trauma skills session waserformed. A 6-0 endotracheal tube was inserted and delivery ofnesthesia was switched to a volume-cycle ventilator. The re-aining skills sets were then performed as described.Emergency medicine residents were divided into groups of 6

o 8 residents per laboratory session. There were a total of 4essions over a period of 4 consecutive weeks. Each session wascheduled for a 3-hour time period and used 2 pigs. All sessionsere instructed and supervised by 1 of 4 trauma staff surgeons

rom the Temple University Hospital Department of Surgery,ection of Trauma and Critical Care. Before attending the lab-ratory session, all emergency medicine residents were given a

ritten instruction manual developed from the 1997 ATLS

SURGERY • Volume 62/Number 6 • November/December 2005

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anual1 that outlined each procedure to be taught. This man-al also included literature describing the indications for, andteps involved with, an emergency room thoracotomy.7 Duringach laboratory session, the trauma surgeon led a brief didacticeriod, discussing both the indications for and the methods oferforming each procedure. The procedures taught were tra-heostomy, peripheral venous cutdown, diagnostic peritonealavage, tube thoracostomy, and bilateral thoracotomy with aor-ic cross-clamping. Tracheostomy was performed instead of thetandard ATLS procedure, cricothyroidotomy, because of theifficulty involved with identifying the cricothyroid membranef the pig.

urriculum Improvement Survey

t the completion of the respective courses, all residents of bothurgery and emergency medicine were asked to complete aemple University Institutional Review Board-approved “cur-

iculum improvement” survey. A survey specific to the ultra-ound course and the porcine trauma skills course was given tohe surgery and emergency medicine residents, respectively. Allurveys were voluntary, anonymous, and confidential. Resi-ents were identified by PGY level only. Survey data were re-orded, and the database was analyzed on a password-protectedomputer in the Surgical Skills Lab. Survey response rate was00% for both departments.The survey used a 5-point, subjective Likert scale.8 Residents

ere prompted to assess their levels of agreement with certaintatements (1 � disagree strongly, 2 � disagree slightly, 3 � nopinion, 4 � agree slightly, and 5 � agree strongly), levels ofifficulty of the procedures (1 � inappropriately simple, 2 �imple, 3 � appropriate, 4 � difficult, and 5 � inappropriatelyifficult), knowledge levels (1 � none, 2 � minimal, 3 �verage, 4 � slightly above average, and 5 � significantly aboveverage), and comfort levels (1 � extremely uncomfortable, 2

uncomfortable, 3 � neutral, 4 � comfortable, and 5 �xtremely comfortable).

Survey questions addressed the evaluation by the residents ofhe didactic and educational materials. Residents were ques-ioned on the transferability to the clinical venue of the proce-ures learned during the courses. The surveys also assessed theaseline clinical experience of residents with each procedureaught in the courses. They were asked to quantify the numberf times they had performed a procedure (observer, assistant,nassisted) before administration of the educational laboratory.he survey also assessed knowledge, difficulty, and comfort

evels before and after instruction. Residents were specificallysked to rate their expected comfort level with performing thearticular procedure in general and in the clinical setting.The final section of the surveys consisted of an overall eval-

ation of the course. Residents were asked to assess whether (1)he course was a valuable use of time, (2) the skills learned wereransferable to the clinical setting, (3) the course should beffered again, (4) they were comfortable being taught by an

ttending of another specialty, (5) the course should be com- r

URRENT SURGERY • Volume 62/Number 6 • November/December 20

ined for attendance by both specialties, and (6) the surgery andmergency medicine departments should continue to collabo-ate for educational purposes.

tatistical Analysis

he 5 Likert responses were placed into 3 groups for statisticalnalysis. Responses 1 and 2 were considered “negative.” Re-ponse 3 was considered “neutral.” Responses 4 and 5 wereonsidered “positive.” For each question, the chi-square test forqual proportions was used to determine whether the frequencyf responses was distributed evenly. The Fisher exact test waspplied to determine whether responses differed by PGY levelnd for comparison of pre- and post-course responses. A p-valuef less than 0.05 was considered statistically significant for allnalyses.

ESULTS

or FAST as well as ultrasound-guided location of central ve-ous neck anatomy, tracheostomy, peripheral venous cutdown,iagnostic peritoneal lavage, and thoracotomy, there were noifferences by PGY level in the number of times a resident haderformed the skill in the clinical setting before participating inhe ultrasound and trauma skills laboratory. PGY 1 and 2 emer-ency medicine residents, however, placed significantly lessp � 0.05) chest tubes before the laboratory course than PGY 3mergency medicine residents.

Table 1 summarizes the pre- and post-course knowledge andomfort levels for the ultrasound (FAST and location of centralenous neck anatomy) and trauma skill modules (tracheos-omy, peripheral venous cutdown, diagnostic peritoneal lavage,ube thoracostomy, and thoracotomy). Although an increase innowledge level was observed for FAST and all trauma skillodules, this was most evident for FAST (� � 59%) and least

vident for thoracotomy (� � 27%). All other skill moduleshowed an average net change in knowledge levels of 45%.imilarly, the increase in comfort level for FAST (� � 49%)as greatest. Thoracotomy (� � 15%) and peripheral venous

utdown (� � 16%) showed only a modest increase. Perceivedomfort performing neck ultrasound increased, but not signif-cantly. Despite these increases in comfort levels, the total per-entage of residents who actually would feel comfortable per-orming the ultrasound procedures in the clinical setting rangedrom 50% (neck ultrasound) to 60% (FAST), and for therauma skills, ranged from as low as 15% (thoracotomy) to asigh as only 73% (tube thoracostomy). Table 1 also depicts theGY levels for which significant increases in knowledge or com-

ort levels were reported. PGY 1 to 4 surgery residents reportedignificant increases in either knowledge or comfort levels forAST and PGY 1 and 2 emergency medicine residents reportedimilar trends for all trauma skill modules.

Table 2 summarizes the emergency medicine resident evalu-tion of the trauma skill modules. Most emergency medicine

esidents reported that all skill modules were realistic, should

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emain in the curriculum, and would transfer to the clinicaletting. Despite reporting very high difficulty levels for tubehoracostomy (73%) and thoracotomy (85%), the overwhelm-ng majority of emergency medicine residents (92% to 100%)elt these skill modules were realistic, should remain in theurriculum, and were transferable to the clinical setting.

Table 3 summarizes the overall evaluation of the ultrasoundnd trauma skills courses by surgery and emergency medicineesidents, respectively. Most surgery residents and all emer-ency medicine residents reported that their respective coursesere a valuable use of time, should be offered again, and that the

kills learned could be transferable to the clinical setting. Bothroups of residents felt comfortable being taught by the attend-ng of the other specialty, were in favor of continued educa-ional collaboration between departments, and felt the coursehould be combined for residents of both specialties.

ISCUSSION

he objective of our study was to combine the technical andducational resources of the Department of Surgery and De-artment of Emergency Medicine to increase knowledge, com-ort, and understanding of trauma procedures by residents.hese goals were accomplished by educating surgery and emer-ency medicine residents in the laboratory setting, using liveuman models for an ultrasound course, and an animate modelor a trauma skills course. Resident surveys revealed that after

ABLE 1. Reported Pre- and Post-Course Knowledge and Comf

Skill Module

Knowledge

Pre Post

AST 14 73†1,

eck ultrasound — —racheostomy 20 64†1

eripheral venous cutdown 25 71†1,

iagnostic peritoneal lavage 16 60†1

ube thoracostomy 42 92†1,

horacotomy 15 42†1

,2,3,4denote PGY level for which p � 0.05, post vs. pre.�% post � % pre.*% positive responses (Likert responses 4 or 5).†p � 0.05 post vs. pre for all residents.

ABLE 2. Evaluation of Trauma Skill Modules by Emergency M

Skill Module

DifficultyLevel(%)*

R

racheostomy 50eripheral venous cutdown 56iagnostic peritoneal lavage 54ube thoracostomy 73horacotomy 85

% positive responses (Likert responses 4 or 5).

60 CURRENT

aking the ultrasound and trauma skills courses, both knowl-dge and comfort levels for all procedures subjectively in-reased. Although these increases were reported, the total per-entage of residents who actually felt comfortable witherforming the ultrasound and trauma skills was well below00%.FAST is rapidly becoming a standard procedure in the assess-ent of the trauma victim. To be credentialed in FAST, themerican College of Surgeons states that the minimum amountf training required to learn the FAST procedure is 8 hours: 4ours of theoretical instruction and 4 hours of practical instruc-ion. The minimum number of supervised patient examina-ions should be 200.2 It would be impractical to expect allurgical residents to be fully credentialed in FAST before grad-ating a general surgery residency program, but all surgicalesidents should, at least, be able to demonstrate proficiency inhis procedure. Our teaching model, and those of others, rep-esents an effective way of incorporating FAST training into theurgical curriculum.3-5,9,10

Despite participating in trauma rotations before taking theltrasound course, surgical residents were neither knowledge-ble of FAST nor appropriately comfortable performing therocedure clinically. After taking the course, most surgery res-dents of all levels except PGY 5 significantly increased theiromfort levels with performing FAST clinically. The fact thaturgery PGY 1 to 4 perceived a greater benefit than PGY 5esidents could be explained by the greater overall clinical expe-

els for Ultrasound and Trauma Skill Modules

Comfort Performing in ClinicalSetting (%)*

� Pre Post �

59 11 60†1,2,3,4 49— 29 50 2144 12 50†1,2 3846 15 31†1 1644 12 58†1,2 4650 35 73†1 3827 0 15†1 15

e Residents

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(%)*

100 9296 8892 88

100 10092 96

ort Lev

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2

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ience of the senior residents. Given these findings, our FASTourse should either be offered more frequently or for a largerime block per the American College of Surgeons 8-hour train-ng guideline,2 especially for PGY 1 to 4 residents.

Central venous cannulation is an essential part of patientanagement in a variety of clinical settings. The complications

f cannulation may be as high as 10% and include arterialuncture, pneumothorax, hemothorax, cardiac tamponade, he-atoma, malposition of catheter, nerve injury, and death. The

tandard technique for placement of central venous catheters isy use of a blinded, external landmark-guided technique. Ul-rasound use in general surgery for placement of central venousatheters has been gaining popularity.11-13 The results of ourtudy suggest a need for a greater familiarity with locating cen-ral venous neck anatomy with ultrasound guidance to safelylace central venous catheters with this method.Analysis of survey data collected from emergency medicine

esidents after participation in the animate trauma skills courseevealed that, except for the tube thoracostomy module, emer-ency medicine residents may not be very comfortable perform-ng these procedures in the clinical setting. Statistically signifi-ant increases in reported comfort levels for all skill modulesonfirms the usefulness of this course, and the low percentage ofesidents that reported being comfortable with the proceduresnderscores the importance of continuing the course. The re-lity of the dynamics of a large urban trauma center, such asemple University Hospital, is that most procedures in the

rauma bay are likely to be performed by surgical residentsnd/or attendings. Therefore, emergency medicine residentsay not have many opportunities to perform these procedures

n a trauma setting. Indeed, this was confirmed by the lack of

ABLE 3. Overall Ultrasound and Trauma Skills Coursevaluation

Survey Item

SurgeryResidents(n � 35)

(%)*

EMResidents(n � 26)

(%)*

urgery and emergencymedicine residents shouldtake course together 80 69omfortable taught byattending of anotherspecialty 89 96ourse should be offeredagain 97 100ourse was a valuable use oftime 91 100

kills learned are transferableto clinical setting 91 100

urgery and emergencymedicine departmentsshould continueeducational collaboration 89 96

% positive responses (Likert responses 4 or 5).

eported experience with the trauma skill sets before the course. l

URRENT SURGERY • Volume 62/Number 6 • November/December 20

espite this result, emergency medicine residents should attainroficiency in trauma skills. Emergency room physicians areart of the resuscitation team in the trauma bay and could easilye called on to assist or perform any procedure depending onhe availability of surgical staff. In addition, the ability of anmergency medicine physician to perform these skills couldake a difference in the survival of a patient in the community

r rural setting.Some procedures taught in this course are applicable to the

on-trauma setting as well. A peripheral venous cutdown maye required as a last resort to obtain intravenous access in aritical patient. Chest tubes are indicated for various nontrau-atic origins such as malignant pleural effusion and spontane-

us pneumothorax. Any patient may need to have an urgentricothyroidotomy performed if repeated attempts at intuba-ion have been unsuccessful.

Further analysis of emergency medicine resident survey dataevealed that statistically significant increases in knowledge andomfort levels were observed for PGY 1 and 2 residents in allkills modules (tracheostomy, peripheral venous cutdown, di-gnostic peritoneal lavage, tube thoracostomy, and thoracot-my), which suggests that junior emergency medicine residentsenefited to a greater extent than their senior colleagues. Thisesult, as for surgery residents, is likely from the longer exposuref senior residents to the clinical venue.

Our teaching model was well received by most residents fromoth specialties. Importantly, over 90% of residents perceivedransferability to the clinical setting of the skills learned in theaboratory modules. This perception, coupled with a strongesire by the residents to continue the course (97% surgery,00% emergency medicine), confirms the benefit of our collab-rative model.

The logistics of scheduling educational laboratories for largeroups of residents without disrupting clinical duties can behallenging. Weekly 4- to 5-hour blocks of time devoted toandatory educational activities and conferences are part of

oth surgery and emergency medicine residency programs atemple University Hospital. At any given time, surgery and

mergency medicine residents are rotating at Temple Univer-ity Hospital or any of its affiliates. Incorporating the ultra-ound and trauma skills course into an established block of timelready devoted to surgery and emergency medicine residentducation afforded the greatest potential for a high level ofttendance without disrupting regular clinical responsibilities.

It has been shown that procedural skills of residents canmprove after education in the laboratory setting.14-19 Perform-ng and learning new skills on simulators is becoming an in-reasingly common aspect of graduate medical education, espe-ially concerning prevention of medical errors. It has beenuggested that simulation must have priority in training curric-la and should be built into the credentialing process for deter-ining who participates in the program and performs certain

rocedures. Simulation will lead to fewer errors and shorten the

earning curve for new procedural advances.20

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ONCLUSIONS

ur study is limited by the lack of objective measures of theffectiveness of our teaching model. Although junior surgerynd emergency medicine residents clearly reported a perceivedenefit from learning the exercises in the laboratory, we did notbserve performance or measure outcomes of the learned skillsn the clinical setting. In the future we will need to add objectivessessments to our model and prospectively evaluate transfer-bility to the clinical setting. Ideally, patient outcomes in therauma bay need to be correlated with residents’ experiences inhe laboratory. Nevertheless, our results suggest that our collab-rative teaching models were successful. The results of our sur-ey allowed us to plan for adjustments in the laboratory curric-lum. Junior residents would benefit from increased frequencyf laboratory sessions throughout the academic year, with theoal of increasing knowledge and comfort to approach 100%.n the current environment of restricted clinical hours, limitedducational resources, and the need to assess physician compe-ency, the laboratory is an effective venue for teaching surgerynd emergency medicine residents skills essential to the deliveryf safe and effective care to the injured patient.

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1. American College of Surgeons Committee on Trauma.Advanced Trauma Life Support for Doctors: Student CourseManual. 6th ed. Chicago, IL: American College of Sur-geons Committee on Trauma; 1997.

2. Scalea TM, Rodriguez A, Chiu WC, et al. Focused Assess-ment with Sonography for Trauma (FAST): results froman international consensus conference. J Trauma. 1999;46(3):466-472.

3. Ali J, Campbell JP, Gana T, Burns PN, Ochsner MG Jr.Swine and dynamic ultrasound models for trauma ultra-sound testing of surgical residents. J Surg Res. 1998;76(1):17-21.

4. Ali J, Rozycki GS, Campbell JP, Boulanger BR, WaddellJP, Gana TJ. Trauma ultrasound workshop improvesphysician detection of peritoneal and pericardial fluid.J Surg Res. 1996;63(1):275-279.

5. Salen P, O’Connor R, Passarello B, et al. Fast education: acomparison of teaching models for trauma sonography.J Emerg Med. 2001;20(4):421-425.

6. Accreditation Council for Graduate Medical Education(ACGME). Available at: http://www.acgme.org/acWeb-site/dutyHours/dh_Lang703.pdf.

7. Feliciano DV, Mattox KL. Indications, technique, andpitfalls of emergency center thoracotomy. Surg Rounds.

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62 CURRENT

8. Likert R. A technique for the measurement of attitudes.Arch Psychol. 1932;140:5-55.

9. Knudson MM, Sisley AC. Training residents using simu-lation technology: experience with ultrasound for trauma.J Trauma. 2000;48(4):659-665.

0. Sisley AC, Johnson SB, Erickson W, Fortune JB. Use ofan Objective Structured Clinical Examination (OSCE)for the assessment of physician performance in the ultra-sound evaluation of trauma. J Trauma. 1999;47(4):627-631.

1. Gann M Jr, Sardi A. Improved results using ultrasoundguidance for central venous access. Am Surg. 2003;69(12):1104-1107.

2. Hind D, Calvert N, McWilliams R, et al. Ultrasonic lo-cating devices for central venous cannulation: meta-anal-ysis. BMJ. 2003;327(7411):361.

3. Keenan SP. Use of ultrasound to place central lines. J CritCare. 2002;17(2):126-137.

4. Matsumoto ED, Hamstra SJ, Radomski SB, CusimanoMD. A novel approach to endourological training: train-ing at the Surgical Skills Center. J Urol. 2001;166(4):1261-1266.

5. Adrales GL, Chu UB, Hoskins JD, Witzke DB, Park AE.Development of a valid, cost-effective laparoscopic train-ing program. Am J Surg. 2004;187(2):157-163.

6. Grober ED, Hamstra SJ, Wanzel KR, et al. The educa-tional impact of bench model fidelity on the acquisition oftechnical skill: the use of clinically relevant outcome mea-sures. Ann Surg. 2004;240(2):374-381.

7. Steixner B, Milner RE, Jensen A, Goldberg AJ, Grewal H.Teaching laparoscopic skills to residents: can it be done inthe laboratory? (abstract). Presented at The Society of Lapa-roendoscopic Surgeons 13th International Congress and EndoExpo 2004. September 29–October 2, 2004.

8. Jensen A, Grewal H, Milner RE, Gaughan J, Rolandelli R.Does postgraduate year level (PGY) affect basic laparo-scopic skill acquisition in the laboratory? Pediatr EndosurgInnov Tech. 2003;7(1):98.

9. Jensen A, Milner RE, Grewal H. An ex-vivo porcine lapa-roscopic nissen fundoplication training model: A usefultool for resident education (abstract). Poster Presentation atthe 13th Annual Congress for Endosurgery in Children(IPEG). May 6-8, 2004, Maui, HI.

0. Daly JM. Surgical simulation: Beyond “to be or not to

be.” Contemp Surg. 2004;60(12):552.

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