Introduction Cricothyrotomy is a rare but critical emergency procedure, making simulation-based training essential. Traditional methods, such as cadavers and synthetic models, provide hands-on experience but are limited by time and instructor availability. Virtual reality (VR) offers an immersive, low-risk environment for repeated practice, which is particularly valuable for high-acuity, low-frequency procedures. This study developed and evaluated a VR cricothyrotomy simulation to assess its educational value, realism, and usability. Methods The VR cricothyrotomy simulation and headset were provided by 8Chili, Inc. (Milpitas, CA, USA). The module was developed with input from a multidisciplinary team of healthcare professionals. Fifteen emergency medicine attendings and residents completed the stepwise, interactive module and then completed a survey to assess usability, face validity, content validity, and educational value. Results Participants rated the VR cricothyrotomy simulation as educationally valuable and effective for introducing procedural steps. However, usability fell below the acceptable threshold, with participants noting difficulties with hand control, depth perception, and feedback for correcting errors. The simulation was perceived as accurately representing all steps of a cricothyrotomy and providing clear instructional guidance. While patient tools were considered realistic, participants reported that the depth perception and control of the virtual hands were not fully realistic. Conclusions The VR simulation was designed to help novice learners build foundational knowledge before transitioning to physical training. Expert feedback suggests that the simulation offers educational value but could be enhanced through improvements to the user interface and haptics. As a low-risk method that does not require faculty guidance, this simulation has practical significance for early procedural training in medical education, particularly for high-acuity, low-frequency procedures.

BACKGROUND:There are limited opportunities to practice surgical skills and techniques in residency. Therefore, it is important to explore strategies which optimize surgical simulation experiences to enhance learning outcomes and skill retention. METHODS:Novice medical students (n = 29) were recruited to participate in a Fundamentals of Laparoscopic Surgery (FLS) peg transfer task training. Participants were randomly assigned to a control group, practicing the peg transfer task independently, or an experimental group, practicing with time pressure. Participant skill assessments were completed before the training, after the training, and 8-weeks after the training. Subjective and objective stress measurements were taken in the form of self-report surveys and heart rate variability data, respectively. RESULTS:For all the skill assessment measurements, there was no difference between groups in performance on the FLS task. Both groups showed improvement in performance after the training compared to before. The experimental group reported higher stress during and after the training period compared to the control group; however, there was no difference between groups on heart rate variability metrics. CONCLUSION:Time pressure while practicing an FLS task did not significantly impact learning acquisition or retention. However, the experimental group reported higher levels of stress. This preliminary study suggests time pressure does not confer an enhanced surgical skill learning experience for novices.

Background Suturing requires repeated practice with guidance to prevent skill deterioration; however, guidance is often limited by expert availability. There is evidence that augmented reality (AR) may assist procedural skill acquisition among learners. This study examines the use of an AR suture guidance application to assist the independent practice of suturing. Methodology A novel suture guidance application was designed for the Microsoft HoloLens. The guidance system included a calibration system and holograms that projected over a suture pad in a stepwise manner. To assess the application, 30 medical students were recruited and randomly assigned to two groups. The control group (n = 16) was given 30 minutes of independent suture practice, while the experimental group (n = 14) utilized the suture guidance application. Both groups completed a pre- and post-test wound closure assessment. After the post-test, the control group trialed the suture guidance application. All participants completed a feedback survey on the application. Statistical analysis was completed using Stata (StataCorp., College Station, TX, USA) with paired Student's t-tests and Welch's t-tests with a significance of 95%. Results Both groups demonstrated a significant improvement in total time and time per stitch during the post-test. Additionally, comparing pre- and post-test assessments in the experimental group revealed a significant improvement in the total number of stitches (p = 0.007), the ratio of bisecting stitches (p = 0.02), and the symmetry of stitch bite (p = 0.03). The feedback survey supported the application for guiding suture placement and spacing. Participants identified limitations in the hologram stability and neck positioning. Conclusions This study suggests the potential to use AR to facilitate the independent practice of wound closure within simulation environments.

Background Medical simulation allows clinicians to safely practice the procedural skill of endotracheal intubation. Applied force to oropharyngeal structures increases the risk of patient harm, and video laryngoscopy (VL) requires less force to obtain a glottic view. It is unknown how much force is required to obtain a glottic view using commercially available simulation manikins and if variability exists. This study compares laryngoscopy force for a modified Cormack-Lehane (CL) grade I view in both normal and difficult airway scenarios between three commercially available simulation manikins. Methods Experienced clinicians (≥2 years experience) were recruited to participate from critical care, emergency medicine, and anesthesia specialties. A C-MAC size 3 VL blade was equipped with five force resistor reading (FSR) sensors (four concave surfaces, one convex), measuring resistance (Ohms) in response to applied pressure (1-100 Newtons). The study occurred in a university simulation lab. Using a randomized sequence, 49 physicians performed intubations on three manikins (Laerdal SimMan 3GPlus, Gaumard Hal S3201, CAE Apollo) in normal and difficult airway scenarios. The outcomes were sensor mean pressure, peak force, and CL grade. Summary statistics were calculated. Generalized estimating equations (GEEs) conducted for both scenarios assessed changes in pressure measured in three manikins while accounting for correlated responses of individuals assigned in random order. Paired t-test assessed for the in-manikin difference between scenarios. STATA/BE v17 (R) was used for analysis; results interpreted at type I error alpha is 0.05. Results Participants included 49 experienced clinicians. Mean years' experience was 4(±6.6); median prior intubations were 80 (IQR 50-400). Mean individual sensor pressure varied within scenarios depending on manikin (p<0.001). Higher mean forces were used in difficult scenarios (603.4±128.9, 611.1±101.4, 467.5±72.4 FSR) than normal (462.5±121.9, 596.0±90.5, 290.6±63.2 FSR) for each manikin (p<0.001). All manikins required more peak force in the difficult scenario (p<0.03). The highest mean forces (Laerdal, CAE, difficult scenario) were associated with the higher frequency of grade 2A views (p<0.001). The Gaumard manikin was rated most realistic in terms of force required to intubate. Conclusion Commercially available high-fidelity manikins had significant variability in laryngoscopy force in both normal and difficult airway scenarios. In difficult airway scenarios, significant variability existed in CL grade between manikin brands. Experienced clinicians rated Gaumard Hal as the most realistic force applied during endotracheal intubation.

Background Point-of-care ultrasound is becoming a ubiquitous diagnostic tool, and there has been increasing interest to teach novice practitioners. One of the challenges is the scarcity of qualified instructors, and with COVID-19, another challenge is the difficulty with social distancing between learners and educators. The purpose of our study was to determine if ultrasound-naïve operators can learn ultrasound techniques and develop the psychomotor skills to acquire ultrasound images after reviewing SonoSim® online modules. Methods This was a prospective study evaluating first-year medical students. Medical students were asked to complete four SonoSim® online modules (aorta/IVC, cardiac, renal, and superficial). They were subsequently asked to perform ultrasound examinations on standardized patients utilizing the learned techniques/skills in the online modules. Emergency Ultrasound-trained physicians evaluated medical students’ sonographic skills in image acquisition quality, image acquisition difficulty, and overall performance. Data are presented as means and percentages with standard deviation. All P values are based on 2-tailed tests of significance. Results Total of 44 medical students participated in the study. All (100%) students completed the hands-on skills evaluation with a median score of 83.7% (IQR 76.7–88.4%). Thirty-three medical students completed all the online modules and quizzes with median score of 87.5% (IQR 83.8–91.3%). There was a positive association between module quiz performance and the hands-on skills performance (R-squared = 0.45; p < 0.001). There was no statistically significant association between module performance and hands-on performance for any of the four categories individually. In all four categories, the evaluators’ observation of the medical students’ difficulty obtaining views correlated with hands-on performance scores. Conclusions Our study findings suggest that ultrasound-naïve medical students can develop basic hands-on skills in image acquisition after reviewing online modules.

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment II (MP47)1 Apr 2020MP47-11 DEVELOPMENT OF A LOW-COST, HIGH-FIDELITY SIMULATOR FOR ULTRASOUND-GUIDED PERCUTANEOUS NEPHROLITHOTOMY (PCNL) TRAINING Marissa K. Lovett*, Michael C. Phung, David E. Biffar, Allan J. Hamilton, Benjamin R. Lee, and David T. Tzou Marissa K. Lovett*Marissa K. Lovett* More articles by this author , Michael C. PhungMichael C. Phung More articles by this author , David E. BiffarDavid E. Biffar More articles by this author , Allan J. HamiltonAllan J. Hamilton More articles by this author , Benjamin R. LeeBenjamin R. Lee More articles by this author , and David T. TzouDavid T. Tzou More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000902.011AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ultrasound-guided percutaneous nephrolithotomy (US-PCNL) has emerged as an attractive alternative to traditional fluoroscopic PCNL. With only a limited number of training programs teaching US-PCNL, there remains a need for tools to assist with teaching this technique. Currently, most simulation PCNL models are expensive and focus on mimicking fluoroscopic guided access, with few models tailored to practicing the skills specific to US-PCNL. This study aimed to report the cost and fidelity of a novel US-PCNL simulator and assess its ability to change procedural confidence in urologic trainees. METHODS: The time, materials, and cost to creation of this model were recorded over 5 iterative versions. Using a 5-point visual analog scale (1 – Least Realistic; 5 – Most Realistic), model fidelity was assessed by: University of Arizona urology residents (n=9), and international attending urologists experienced in US-PCNL (n=8) at the AUA 2019 conference. Procedural confidence among the 9 residents was assessed before and after simulation training with the model – (5-point Likert scale; 1 – Not Comfortable, 5 – Very Comfortable). Confidence data was analyzed using a paired, two-tailed Student’s t-test. RESULTS: The model (Figure 1) costs ∼$50 USD and takes ∼1.5 hours to create. Mean overall model fidelity was 4.2 + 0.8, with high fidelity appreciated amongst specific model features including: visualization of needle (4.4 + 1.1) and fluid return (4.4 + 0.9); echogenicity of cortex (4.2 + 0.7), stones (4.2 + 0.8), and target calyces (4.1 + 0.8). After training with the model, urology resident procedural confidence increased significantly across all operational tasks, including: ultrasound probe positioning (p<0.01); identification of individual renal landmarks - capsule, cortex, stone, and target calyx (p<0.05); locating the needle on ultrasound (p<0.05); advancing the needle into the target calyx (p<0.01); and confirming fluid return (p<0.01). CONCLUSIONS: This low-cost simulator provides a high-fidelity, affordable solution for teaching urologists how to perform US-PCNL. Given the associated improvement in procedural confidence, this model can be a helpful addition to the training of urologists learning US-PCNL. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e688-e688 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marissa K. Lovett* More articles by this author Michael C. Phung More articles by this author David E. Biffar More articles by this author Allan J. Hamilton More articles by this author Benjamin R. Lee More articles by this author David T. Tzou More articles by this author Expand All Advertisement PDF downloadLoading ...

This pilot study appraised traditional versus remote facilitation via telesimulation for an established interprofessional training at two geographically separate sites. Participant feedback was captured via 5- point Likert scale surveys. Results demonstrate learners supported the use of remote facilitation: to meet the interprofessional learning objectives, as an adequate replacement for live facilitation and to implement simulation education in low-resource or low-facilitator areas. Improvements were suggested for audio connectivity between participants. In conclusion, the program evaluation suggests that telesimulation, with remote and traditional facilitation, is an effective strategy to provide interprofessional simulation education. Improvements identified are to standardize the set-up of audio/visual technology and tailor participant orientation to encourage meaningful dialogue between sites.

Laparoscopic surgery relies on effective visualization of areas of interest and surrounding tissue. The limited field of view of traditional laparoscopes increases the risk of peripheral tissue injury. To address this limitation, a multiresolution foveated laparoscope (MRFL) was designed to enhance peripheral awareness while maintaining focus on the area of interest. Peripheral awareness and learner effect were evaluated with novices (n=13) and experts (n=8). These subjects completed a modified Fundamentals of Laparoscopy Surgery task using a traditional laparoscope, MRFL with autotracking (AT), and MRFL without autotracking (NoAT). Subjects using the traditional laparoscope performed better than MRFL AT and MRFL NoAT in task completion time and collision number. The learner effect was steeper with use of MRFL. In multiple tested parameters, MRFL NoAT performed as well as the traditional laparoscope while providing the added benefits of enhanced field of view and multiple viewing perspectives. These findings warrant further development of MRFL.

The changing landscape of healthcare education, delivery, and technology is placing new demands for significant inter-disciplinary and inter-professional training in medical simulation. New architectural concepts and building designs must ensure that large-scale healthcare simulation facilities offer customized training opportunities for nursing, medicine, public health, and pharmacy while allowing for maximal flexibility and adaptation across nearly fifty different user groups and stake holders. A novel concept of a larger, configurable "stage" design, more akin to a Hollywood production studio, with in-patient and outpatient suites seen as temporary or "standing" sets was created. The stage, called a "Sim Deck," can be easily dismantled while providing ample square footage for mass casualty scenarios. The facility required significant technological support to provide remote simulation training via existing and future telemedical technologies as well as remaining nimble enough to incorporate technologies in augmented and virtual reality, artificial intelligence, and large-scale learner management systems.

Introduction: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck presenting to emergency departments.(1) No commercial PTA task trainer exists for simulation training. Thus, resident physicians often perform their first PTA needle aspiration in the clinical setting, knowing that carotid artery puncture and hemorrhage are serious and devastating complications. Mile several low-fidelity PTA task trainers have been previously described, none allow for ultrasound image acquisition.(6-9) We sought to create a cost-effective and realistic task trainer that allows trainees to acquire both diagnostic ultrasound and needle aspiration skills while draining a peritonsillar abscess. Methods: We built the task trainer with low-cost, replaceable, and easily cleanable materials. A damaged airway headskin was repurposed to build the model. A mesh wire cylinder attached to a wooden base was fashioned to provide infrastructure. PTAs were simulated with a water and lotion solution inside a water balloon that was glued to the bottom of a paper cup. The balloon was fully submerged with ordnance gelatin to facilitate ultrasound image acquisition, and an asymmetric soft palate and deviated uvula were painted on top after setting. PTA cups were replaced after use. We spent eight hours constructing three task trainers and used 50 PTA cups for a total cost <$110. Results: Forty-six emergency medicine (EM) residents performed PTA needle aspirations using the task trainers and were asked to rate ultrasound image realism, task trainer realism, and trainer ease of use on a five-point visual analog scale, with five being very realistic and easy. Sixteen of 46 (35%) residents completed the survey and reported that ultrasound images were representative of real PTAs (mean 3.41). They found the model realistic (mean 3.73) and easy to use (mean 4.08). Residents rated their comfort with the drainage procedure as 2.07 before and 3.64 after practicing on the trainer. Conclusion: This low-cost, easy-to-construct simulator allows for ultrasound image acquisition while performing PTA needle aspirations and is the first reported of its kind. Educators from EM and otolaryngology can use this model to educate inexperienced trainees, thus ultimately improving patient safety in the clinical setting.

Objectives Emergency medicine (EM) residents are required to perform a cricothyrotomy during training as per the Accreditation Council for Graduate Medical Education (ACGME) guidelines. Cricothyrotomy is a rare procedure, comprising 0.45% of emergency department airway management procedures. Procedural competence in utilizing a realistic trainer is of utmost importance. We have developed a cricothyrotomy trainer using a fused deposition modeling (FDM) three-dimensional (3D) printer and innovative bleeding tissue to enhance fidelity. We aim to evaluate the trainer’s realism. Methods Implementation occurred during a difficult airway educational lab for EM residents in April 2018. Participants completed anonymous written surveys after performing a cricothyrotomy on the trainer. The survey evaluated the realism of the trainer and compared it to other available models by utilizing five-point visual analog scales (VAS). The participants rated their comfort level in performing the procedure pre- and post-educational lab on a five-point VAS. Demographic data included postgraduate year, prior clinical cricothyrotomy experience as a primary operator versus as an assistant, and previous trainer experience. The survey included open-response suggestions for trainer improvement. Results Forty-three EM residents completed the survey (82.7%, 43/52). The mean realism rating of the trainer was 3.81 (95% CI = 3.54-4.1). The participants reported previous training on cadaver (62.8%, 27/43), porcine (46.5%, 20/43), and manikin (67.4%, 29/43) models prior to using this trainer. The bleeding cricothyrotomy trainer was rated higher than other models (4.45, 95% CI = 4.28-4.63). Participants noted improved comfort with performing the cricothyrotomy after the educational lab (average improvement of 1.23±0.75). Participants specifically commented on the realism of the bleeding and skin texture; however, they also recommended a reduction in the size of the cricothyroid membrane space. Conclusion The innovative bleeding cricothyrotomy trainer has greater fidelity and reported superiority when compared to other commonly used nonbleeding models. This trainer provides a more advanced platform to teach an infrequent yet critical procedural skill to emergency medicine residents.

Limited clinical site availability and an increased need for clinical training experiences often make it difficult for prehospital health care providers to complete new and annual training requirements. Medical simulation provides an alternative learning environment that provides trainees the opportunity to acquire and perfect new clinical skills without compromising patient care. The following is a detailed description of an air medical transport simulation of a neonate with hypoxic ischemic encephalopathy requiring transport to a higher level of care. Patient parameters were altered during flight to simulate potential complications unique to air medical transport. Use of this training strategy is particularly beneficial for low-volume, high-risk patients, and these lessons can be applied across all age patient groups, making the experience broadly applicable.

BACKGROUND: Ultrasonography use is increasing in emergency departments, and ultrasound education is now recommended in resident training. Ultrasound phantoms are used in many institutions for training purposes. The purpose of this study is to describe an inexpensive and simple method to create ultrasound-imaging models for the purpose of education and practice using clear ballistic gel.METHODS: Clear ballistic gel is used to simulate tissue for firing practice and other military evaluations.RESULTS: The transparent and durable ultrasound phantom we produced was clear and contained four vessel lumens. The images obtained using the phantom were of high quality and compared well to normal sonographic anatomy.CONCLUSIONS: The clear ballistic brand gel is unique because it is inexpensive, does not dry out, does not decay, is odorless, and is reusable. The ultrasound images obtained using the phantom are realistic and useful for ultrasound education.

Background: An emergent open thoracotomy (OT) is a high-risk, low-frequency procedure uniquely suited for simulation training. We developed a cost-effective Cardiothoracic (CT) Surgery trainer and assessed its potential for improving technical and interprofessional skills during an emergent simulated OT.Materials and methods: We modified a commercially available mannequin torso with artificial tissue models to create a custom CT Surgery trainer. The trainer's feasibility for simulating emergent OT was tested using a multidisciplinary CT team in three consecutive in situ simulations. Five discretely observable milestones were identified as requisite steps in carrying out an emergent OT; namely (1) diagnosis and declaration of a code situation, (2) arrival of the code cart, (3) arrival of the thoracotomy tray, (4) initiation of the thoracotomy incision, and (5) defibrillation of a simulated heart. The time required for a team to achieve each discrete step was measured by an independent observer over the course of each OT simulation trial and compared.Results: Over the course of the three OT simulation trials conducted in the coronary care unit, there was an average reduction of 29.5% (P<0.05) in the times required to achieve the five critical milestones. The time required to complete the whole OT procedure improved by 7 min and 31 s from the initial to the final trialdan overall improvement of 40%.Conclusions: In our preliminary evaluation, the CT Surgery trainer appears to be useful for improving team performance during a simulated emergent bedside OT in the coronary care unit. (C) 2015 Elsevier Inc. All rights reserved.

Introduction: The objective of this study was to determine whether or not a navigation pointer (NP) integrated into a laparoscopic camera and projected onto a surgical display might allow instructors to more easily and precisely direct assistants' instruments to specific sites in a simulated laparoscopic field. Methods: Two hundred forty pins served as targets in a standard laparoscopic box trainer. An instructor guided 24 subjects to locate 5 randomly selected targets each, with verbal instructions alone, or with verbal instructions supplemented by either a navigation grid (NG) or the localizing NP. Each subject performed 15 trials alternating between use of the NP, NG and no navigation tool. The primary outcome measure was the time to target identification. Results: The mean time to identify each selected target was significantly shorter with the NP (4.53 ± 2.87 seconds) than with the NG (8.59 ± 4.35 seconds, P<0.001) or without any navigation tool (11.16 ± 5.39 seconds, P<0.001). Conclusion: The use of the NP appears to improve efficiency in guiding an instrument to randomly selected targets within a simulated laparoscopic field. The use of the NP may reduce the time required to move instruments to specific sites during laparoscopic surgery.

Initiation of extracorporeal membrane oxygenation (ECMO) is stressful, especially for inexperienced extracorporeal life support providers. The main objective of this study was to create a novel, reusable mannequin for high-fidelity simulation of ECMO initiation. We modified a Laerdal neonatal mannequin (SimNewB; Stavanger, Norway) so that it could be used to simulate an ECMO initiation. A simulation of a neonatal patient suffering from meconium aspiration was performed in the pediatric intensive care unit, and participants included new extracorporeal life support specialists in addition to the composition of the clinical ECMO team. A total of 17 individuals participated in the neonatal ECMO initiation simulation. Questionnaire results showed that 88% of participants felt better prepared to assist in an ECMO initiation after the simulation. All participants (100%) agreed that the modified mannequin and the environment were realistic and that this simulation helps teamwork and communication in future initiations of ECMO. Simulation can be used for the prevention, identification, and reduction of anxiety-related crisis situations that novice providers may infrequently encounter during routine clinical use of mechanical circulatory support. Use of a reusable, high-fidelity mannequin may be beneficial for effective team training of complex pediatric ECMO-related procedures.

The goal of this study was to determine whether video laryngoscopy (VL) provides any advantage over direct laryngoscopy (DL) in first-attempt intubations. This was a controlled, randomized study of 120 medical students. Students were randomly assigned to either of 2 intubation groups, which used (1) DL (n=64) or (2) VL (n=56) with the Karl Storz C-MAC® video laryngoscope. Each student attempted 1 endotracheal intubation on a Laerdal® Airway Management Trainer. The primary outcome measure was the time for successful endotracheal intubation. Secondary outcome measures included the incidence of esophageal intubation (EI), excess application of pressure on the maxillary incisor teeth (EMP), and first-time success rate. Mean time for endotracheal intubation was significantly faster in the VL group than in the DL group (101 ± 83 seconds vs. 180 ± 102.5 seconds; P<0.001). In the VL group, 3.6% of the students committed an EI versus 56.3% in the DL group (P<0.001). No significant difference was found in the incidence of EMP: 51.8% in the VL group versus 57.8% in the DL group (P=0.508). For medical students with little or no endotracheal intubation experience, VL facilitates success and decreases the number of EIs, at least in a simulated environment.

Introduction: The objective of this study was to determine whether or not a navigation grid (NG) with a coordinate system overlaid on a laparoscopic display might allow attending surgeons to more easily and precisely direct their assistants' instruments to specific sites in a simulated laparoscopic field. Materials and Methods: In this randomized, crossover study, we evaluated the impact of the NG on an individual's performance in a target identification task. One hundred thirty pins served as targets in a standard laparoscopic box trainer. An instructor guided 30 naive subjects to locate five randomly selected targets each, either with verbal instructions alone or with verbal instructions supplemented by a localizing NG. The NG appeared on both the instructor's and the participants' monitors, but the randomly selected targets were visible only to the instructor. Each participant performed 10 trials alternating between with and without the NG. The outcome measure was the interval (in seconds) from when the laparoscopic instrument was first visible in the field to when the subject grasped the correct target with forceps. Results: The mean time to identify each selected target was significantly shorter with the NG (9.150±3.43 seconds) than without (12.53±4.89 seconds) (P<.0001). This effect was sustained throughout the learning curve. Conclusions: The use of the NG appears to improve efficiency in guiding an instrument to randomly identified targets within a laparoscopic field. The use of an NG may reduce the time required to move instruments to specific sites during surgery.

BACKGROUND Telepresence is emerging in clinical and educational settings as a potential modality to provide expert guidance during remote airway management. This study aimed to compare the effectiveness of telepresent versus in-person supervision of tracheal intubation. MATERIALS AND METHODS A randomized, crossover study was performed in a university medical simulation center with 48 first- and second-year medical students with no formal procedural training in tracheal intubation. Each participant was assigned to receive each of four study arms in random sequence: (1) direct laryngoscopy (DL) with in-person supervision, (2) DL with telepresent supervision, (3) videolaryngoscopy (VL) with in-person supervision, and (4) VL with telepresent supervision. Telepresence was established with a smartphone (Apple [Cupertino, CA] iPhone(®)) via FaceTime(®) connection. The primary outcome measure was the time to successful intubation. Secondary outcome measures included first pass success rate and the number of blade and tube attempts. RESULTS There was no significant difference between in-person and telepresent supervision for any of the outcomes. The median difference (in-person versus telepresent) for time to intubation was -3 s (95% confidence interval [CI], -20 to 14 s). The odds ratio for first attempt success was 0.7 (95% CI, 0.3-1.3), and the rate ratio for extra number of blade attempts (i.e., attempts in addition to first) was 1.1 (95% CI, 0.7-1.7) and 1.4 (95% CI, 0.9-2.2) for extra number of tube attempts. CONCLUSIONS In this study population of procedurally naive medical students, telepresent supervision was as effective as in-person supervision for tracheal intubation.

The objective of this study was to determine whether or not a standard definition stereoscopic, 3D display could improve trainees' performance on a standard Fundamentals of Laparoscopy (FLS) task. Thirty-two procedurally naive volunteers were recruited for the study. Subjects were randomized to begin the trials on either the 3D or 2D display and performed 10 trials on a peg transfer task (SAGES). Subjects alternated between 3D and 2D displays for each trial. Time to completion of task, and the number of dropped objects were recorded for each trial, and a subjective evaluation of the subjects' preference in display monitor was collected. Mean time for peg transfer was significantly faster with the 3D monitor than the 2D monitor (114.22 s. versus 133.05 s.; SE: 3.82; P