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Novel Otolaryngology Simulation for the Management of Emergent Oropharyngeal Hemorrhage

Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068 1 of 6
Archives of Otorhinolaryngology-Head & Neck Surgery
Novel Otolaryngology Simulation for the
Management of Emergent Oropharyngeal
Joshua Feintuch, BA1; Jeremy Feintuch, BA1; Emily Kaplan MPA, EMTP2;
Merona Hollingsworth, BS3; Christina Yang, MD4; Marc J. Gibber, MD4*
1New York University School of Medicine, New York, New York, USA
2Monteore-Einstein Center for Innovation in Simulation, Bronx, New York, USA
3Mary and Michael Jaharis Simulation Center, College of Physicians and Surgeons, Columbia University, New York, New York, USA
4Department of Otorhinolaryngology - Head & Neck Surgery, Albert Einstein College of Medicine, Bronx, New York, USA
Oropharyngeal hemorrhage is a rare but life-threatening complication of
oropharyngeal tumors [1]. They can occur quickly, and with or without
stimulation of the tumor. Bleeding episodes such as these can quickly
lead to airway obstruction, aspiration and can result in asphyxiation [1].
Oropharyngeal bleeds are associated with these dangerous outcomes
and also have a high mortality rate because safe management of these
cases can be rather complex [1]. Nascent otolaryngology residents who
have recently graduated medical school are “expected to triage and man-
age airway [and] bleeding with little prior experience [2].” Further, due
to the emergent nature of these bleeds, the approach to rapid patient
stabilization likely involves providers from dierent specialties working
side by side to manage this life-threatening condition. This can make
for a stressful setting in which conicting medical opinions pertaining
to management may arise. With all of this in mind, we created a sim-
ulation scenario in which our junior residents learned to properly and
safely manage a patient with an oropharyngeal bleed while also learning
to properly interact and communicate with fellow healthcare providers in
a tense, emergent situation. The goals of the study were to apply airway
management and leadership skills in the context of a clinical team as well
as to identify and adapt to clinical changes in real time.
This scenario was designed for the training of rst year residents (in-
terns), however it can be used for residents at any level of training. In
order to benet most from this scenario, the participating intern/resident
should have a background of the basic anatomy of the oropharynx pri-
Introduction: Oropharyngeal hemorrhage is a rare but life-threatening complication of oropharyngeal tumors. Bleeding episodes such as these
can quickly lead to airway obstruction, aspiration and can result in asphyxiation. Nascent otolaryngology residents who have recently graduated
medical school are expected to manage this situation with scant amount of prior experience. Simulation oers the unique opportunity to learn
procedural skills to a resident/trainee in a safe, controlled environment designed to have specic, obtainable educational goals without any risk
to the patient.
Methods: In this study, we created a simulation scenario in which junior otolaryngology residents learned to properly and safely manage a patient
with an oropharyngeal bleed while also learning to properly interact and communicate with fellow healthcare providers in a tense, emergent
Results: A 5-point Likert scale survey was utilized to assess realism and benet from the simulation. An average score of 4.7 points was obtained
for this simulation.
Conclusion: We developed an eective and realistic oropharyngeal bleeding mass scenario that was well received by participants in preparing
them for real life scenarios.
Table 1. Materials/Equipment Required for Mannequin Setup and
Scenario Management
Mannequin Setup Scenario Management
Laerdal ALS Mannequin® Mouth guards
Simulated patient monitor Mac blade, laryngoscope
handle, extra batteries
Instructor computer Fiberoptic scope
Link box Camera and tower
External compressor for chest rise
and fall
Portable light source
3L bag of pre-Mixed blood per learner Trachestomy tray
Administrator extension set 10 gtt/ml Tracheostomy tubes
30” IV extension tubing Scalpels
Absorbent disposable u underpads
6.5 ETT tube
60cc syringe
3-way stopcock
Magill forceps
or to running through the simulation. Table 1 shows a list of equipment
needed for both the mannequin setup and for the oropharyngeal bleed
Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068
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Mannequin Setup
Our oropharyngeal tumor simulator was created to train our Otolaryn-
gology junior residents on management of oropharyngeal bleeding. Re-
alism is enhanced through the specic, novel, selection of the manikin
for modication. We used the electronic simulator Laerdal ALS Manne-
quin. The mannequin breathes, has lung sounds, heart sounds, talks and
has the capacity to display vital signs. To set up for this simulation, the
abdominal bag was removed and padded with absorbent disposable
u underpads (chucks) to absorb any residual uids that ran along the
pharynx into the mannequin (Figure 1). The chest skin was also removed,
and the internal mechanics were covered with a towel and chucks (ab-
sorbable side up) to capture any residual uids. We then disconnected
the esophagus from the mannequin’s abdomen (Figure 2) and placed the
bottom of the esophagus into a plastic bag to prevent uid from damag-
ing the innards of the mannequin. IV tubing, attached to a pre-mixed 3L
bag of articial blood, and extension tubing, was then threaded through
the esophagus into the oropharynx (Figure 3). The cu of a 6.5 ET tube
was inated, and the ET tube tip was cut o. A portion of the proximal
end of the ETT tube was also removed with a scissor. The inated balloon
was then covered with HY-Tape®to make the mass look more realis-
tic (Figure 4). The IV tubing from the oropharynx (that was threaded up
the esophagus) was then pulled up using Magill forceps and threaded
through the inverted ET tube (Figure 5), letting the opening of IV tubing
to sit right at the inated balloon of the ET tube. The inverted tube, with
the IV tubing still inside was then placed into the oropharynx using Magill
forceps, allowing the balloon to sit in the oropharynx (Figure 6), and the
superior part of the tube to go down the pharynx.
In order to facilitate bleeding (Figure 7), we used two dierent, but equal-
ly eective techniques.
Figure 1. Preparation of the mannequin for simulation step 1.
Figure 2. Preparation of the mannequin for simulation step 2.
Version 1
An Alaris 8015 pump tubing is connected to the extension tubing with a
3L bag of pre-mixed articial blood. To express minimal continual blood-
ow, the pump was set to express 500 ml in 10 minutes. Greater blood
ow is achieved by increasing the rate of the pump. Up to 1 liter of blood
should be aimed to be expressed per learner. The pump is positioned
behind the mannequin. This version requires manual changes of pump
setting to increase blood ow.
Figure 3. Intravenous tube placement.
Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068 3 of 6
Figure 4. Construction of the oropharyngeal mass.
Figure 5. Preparation of the oropharyngeal mass for bleeding.
Figure 7. Bleeding from the oropharyngeal mass.
Figure 6. Placement of the oropharyngeal mass.
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Version 2
To express greater blood volume and force associated with emergent
bleeding cases, a manual hand pump is utilized. A three-way stop-cock
is attached to the extension IV tubing. A 60 CC syringe is connected to
one port. The remaining port is attached to a pre-mixed 3L bag of blood
via an Administrator Extension set and IV tubing (Figure 8). The Simula-
tion Technician is positioned behind the bed, out of the learner’s line of
sight. Using the 60 CC syringe and three way stop cock, blood is drawn up
into the syringe from the 3-liter reservoir bag. After the syringe is com-
pletely full, the stopcock is then switched to allow blood to be expressed
from the syringe into the patient’s oropharynx. Blood is then expressed
from the syringe, at the desired rate, to cause oropharyngeal bleeding.
The process is repeated continuously throughout the scenario. After the
mannequin setup is complete, the learner can then manage the oropha-
ryngeal bleeding as directed by the instructor/scenario.
The intern/learner is paged to the intensive care unit (ICU) for a 69-year-old
male with history of oropharyngeal cancer complaining of oral bleeding.
The ICU attending is at the bedside. Table 2 shows the vital sign setting.
The intern/learner assesses the patient who complains of diculty
breathing as he/she is coughing up blood. The ICU attending urges the
intern/learner to help the patient. The intern/learner should rst attempt
to suction the airway and use a ber optic scope to establish the source of
the bleed. If scoped correctly, the source of the bleed should be identied
as the bleeding mass in the posterior oropharynx. As more time passes,
the patient’s oxygen saturation continues to drop, and he becomes in-
creasingly tachycardic. Seeing the dropping oxygen saturation, the ICU
attending questions the intern/learner if an orotracheal intubation could
be a good treatment option for this patient. The intern/learner should
explain to the ICU attending the risks associated with sedating a patient
with an oropharyngeal mass. As the patient’s oxygen saturation contin-
ues to drop, the intern/learner should assess the feasibility and safety
for an attempted nasotracheal intubation. If the intern/learner deems a
Table 2. Vital Signs Setup
General Patient is sitting in bed at 45 degrees, with blood
dripping from mouth. Patient is in mild distress
Head, Eyes, Ears,
Nose, Throat
Active bleeding from oropharynx
Pulmonary Clear to auscultation bilaterally
Cardiovascular Normal S1/S2. No murmurs
Extremities No cyanosis or clubbing noted
Heart Rate 118 Beats Per Minute
Blood Pressure 165/100 mmHg
Respiratory Rate 44 respirations per minute
Temperature 39.3 °C
Oxygen Saturation Starts at 93% O2 , rapidly dropping over 2 minutes
Figure 8. Bleeding equipment setup: version 2.
nasotracheal intubation safe, he/she should attempt to perform one. If
successfully placed, the patient’s oxygen saturation should increase, and
vitals should stabilize.
If the intern/learner is not able to perform a nasotracheal intubation,
or if the patient destabilizes at any point in the scenario, the intern/leaner
should perform a cricothyroidotomy. If the intern/learner is unsuccessful
in managing the scenario, the patient will continue to decompensate. If
at any point, the intern/learner sedates the patient, the patient should
decompensate. At the conclusion of the scenario, participants were then
asked to ll out a 5-point Likert score to assess realism and perceived
benet from the simulation.
To ensure benet from this scenario, a pre-training and post-training
assessment can be used as well.
Over the last 2 years, 8 interns completed this simulation. A 5-point Likert
scale survey was utilized to assess resident perceived realism and benet
from this simulation. An average score of 4.7 points was obtained for this
The expeditious transition from a senior medical student to a junior res-
ident can be a daunting, and overwhelming experience. Coming from a
sheltered and protected environment to one that is fraught with patient
encounters, situation- based decisions and technical skills can cause
much stress for a new intern [3]. In addition to the stress put on the resi-
dent, evidence has emerged that there is more incidence of physician er-
ror causing patient harm in the beginning of residency [4]. This situation
can be made even worse when entering a surgical and a procedure-lad-
en subspecialty such as otolaryngology, where the technical skills are so
specialized that some of them are not taught in medical school [5]. To
mitigate this issue, attempts have been made, through simulation and
boot camp training, to equip these novice residents with the skills needed
to succeed in their new role.
Simulation oers the opportunity to learn procedural and inter-
viewing skills to a resident/trainee in a safe, controlled environment that
is designed to have specic educational opportunities without serious
risk to the patient [3,6-11]. Just as it applies to the military, boot camp
style learning emphasizes teaching novices the basic skills necessary to
properly function in a real-world scenario. In otolaryngology, the ulti-
mate goal is to transition “undierentiated senior medical students to
dedicated otolaryngology residents [3].” With the advent of duty hour
restrictions and resource limitations, training a resident in a shorter pe-
riod of time and in a more modiable environment is being more heavily
favored than traditional teaching of only experiencing a medical emer-
gency in a real-life situation [2,3,7,12,13]. By putting these skills into a
boot camp style course, residents are given the opportunity to partici-
pate in intense-style training while still being taught in a safe, simulated
Archives of Otorhinolaryngology-Head & Neck Surgery. 2018;2(1):3 DOI: 10.24983/scitemed.aohns.2018.00068 5 of 6
Time and time again, simulation-based training has shown its eec-
tiveness in the medical eld, and specically in the eld of otolaryngol-
ogy [14-16]. A study in 2015 by Chin et al. found that “an otolaryngology
boot camp gives residents the chance to learn and practice emergency
skills before encountering the emergencies in everyday practice. Their
condence in multiple skill sets was signicantly improved after the
boot camp [7].” Other studies have also shown similar results in med-
icine and the eld of otolaryngology [17,18]. All of these studies have
consistently shown that through simulation and boot camp training,
residents began developing the appropriate knowledge, skill set and
self-condence [2,7] needed to succeed during residency and, more im-
portantly, that these skills transferred to real clinical situations/proce-
dures with real patients.
Due to the proven success of simulation-based learning, we have
created a scenario in which our residents can practice how to properly
manage an oropharyngeal bleed. Vascular erosion, causing a hemorrhag-
ic episode, can occur in all patients with advanced-stage tumors, recur-
rent tumors, infection and pharyngocutaneous stulas [1,19]. Addition-
ally, when chemotherapy and radiation are used in conjunction, without
surgical intervention, secondary adverse eects can arise, including “ero-
sion of skin and mucosa…. premature atherosclerosis with stenosis and
weakening of arterial walls due to adventitial brosis, fragmentation of
elastic laments, and destruction of vasa vasorum. Following chemora-
diation, therapy, spontaneous hemorrhage can result as a consequence
of weakened arterial walls [1].” This complication, especially in tumors
arising from the oropharynx can be particularly devastating.
These emergent situations must be recognized and cared for quickly
to prevent blood loss, aspiration and/or asphyxiation. However, caution
must be used when managing a patient like this, as a wrong step can put
the patient at serious risk. A patient with a bleeding oropharyngeal mass
who loses consciousness or is anesthetized, may lose the ability to protect
his/her own airway and the bleeding may continue to ow distally, caus-
ing asphyxiation [20]. Further, endotracheal intubation can irritate and
stimulate the bleeding lesion, thus exacerbating the bleeding and making
airway management even more dicult [20]. With these complications
in mind, nasotracheal intubation is seen as the safest and most eective
way of securing an airway in these patients. Our simulation allows our
residents to systematically work through the critical decision-making pro-
cess in a safe environment, in order to acquire the knowledge as well as
the manual dexterity to properly manage these patients.
As with other medical emergencies, managing an oropharyngeal
bleed can be stressful. Working with healthcare providers of a dierent
specialty can sometimes add to the stress, as there may be diering
opinions related to patient management. Junior residents can be more
susceptible to these stressors, as they may lack the experience and con-
dence needed to make a decision in the face of conict. While the leader
of the medical team is ultimately in charge of the decision-making during
a medical emergency, there may be times when a trainee from one spe-
cialty may not agree with a treatment decision made by an attending of
a dierent specialty. In this situation, we want to foster professionalism,
collaboration, leadership and communication skills between both medi-
cal providers from dierent training backgrounds. In a study performed
by Belyansky et al., it was found that “74-78% of trainees and attend-
ings recalled an incident where the trainee spoke up and prevented an
adverse event. While all attendings in this study reported that they en-
courage residents to question their intraoperative decision making, only
55% of residents agreed [21].” By being encouraged to voice concerns
during an emergency, trainees can act as partners in the reduction of
possible medical errors. Further, in a literature review by Ignacio et al.,
it was found that “excessive stress and/or anxiety in the clinical setting
have been shown to aect performance and could compromise patient
outcomes [22].” In and out of the eld of medicine, studies have “sug-
gested that stress training showed an improving trend in performance….
[and was a] valuable strategy for enhancing… thought process and im-
proving… performance in communication skills [22].” By presenting the
junior residents with a stressful situation in which an attending suggests
a management option that might not be appropriate for the patient, the
residents learn how to properly and respectfully suggest an alternate
treatment approach, while also learning the technical skills needed to
properly care for such a patient. This provides the resident with the tools
necessary to deal with such a situation, when it is appropriate, during res-
idency and beyond. Using this simulation, the learner is encouraged to
move from comprehension and application to synthesis and evaluation.
The novelty of this scenario comes from both the setup of the man-
nequin, and the use of the mannequin with the designed scenario. By
using this simulation, the intern/learner learns how to both utilize the
treatment algorithm for a bleeding oropharyngeal mass and work with
members of medical teams composed of members from dierent spe-
cialties and experience levels. This simulation facilitates the development
of technical, knowledge-based and interpersonal skills all within a suc-
cinct and collaborative educational environment.
Using a safe and controlled simulation environment, we were able to
develop an eective and realistic oropharyngeal bleeding mass scenario
that was well received by participants.
Article Information
*Correspondence: Marc J. Gibber, MD
Department of Otorhinolaryngology - Head & Neck Surgery, Albert
Einstein College of Medicine, Bronx, New York, USA.
Email: Mgibber@monte
Received: May 09 ,2018; Accepted: Jun. 20,2018; Published: Jul. 13, 2018
DOI: 10.24983/scitemed.aohns.2018.00068
Copyright © 2018 The Author (s). This is an open-access article distribut-
ed under the terms of the Creative Commons Attribution 4.0 Internation-
al License (CC-BY).
Funding: None
Conict of Interest: None
Hemorrhage; oropharyngeal; otolaryngology; simulation; training.
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Full-text available
Hemoptysis requires proper treatment to prevent blood aspiration and asphyxiation. If the patient loses consciousness or is anesthetized, the bleeding inside the trachea may continuously flow into the distal part, which may be fatal. Fatal damage resulting from hemoptysis is mainly caused by asphyxiation, and it is important to find the exact location of the bleeding in order to prevent it from spreading to both lungs. However, endotracheal intubation may increase the bleeding by stimulating the bleeding lesion in the respiratory track, and can make airway management more difficult. We report a successful case of airway management using the cuff and Murphy eye of the endotracheal tube in a patient with tracheal bleeding.
Full-text available
Background: It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year. Purpose: To systematically review studies describing the effects of trainee changeover on patient outcomes. Data sources: Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010. Study selection: Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator. Data extraction: Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported. Data synthesis: Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results. Limitations: The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data. Conclusion: Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic. Primary funding source: National Heart, Lung, and Blood Institute.
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The objective of this project was to develop a virtual temporal bone dissection system that would provide an enhanced educational experience for the training of otologic surgeons. A randomized, controlled, multi-institutional, single-blinded validation study. The project encompassed four areas of emphasis: structural data acquisition, integration of the system, dissemination of the system, and validation. Structural acquisition was performed on multiple imaging platforms. Integration achieved a cost-effective system. Dissemination was achieved on different levels including casual interest, downloading of software, and full involvement in development and validation studies. A validation study was performed at eight different training institutions across the country using a two-arm randomized trial where study subjects were randomized to a 2-week practice session using either the virtual temporal bone or standard cadaveric temporal bones. Eighty subjects were enrolled and randomized to one of the two treatment arms; 65 completed the study. There was no difference between the two groups using a blinded rating tool to assess performance after training. A virtual temporal bone dissection system has been developed and compared to cadaveric temporal bones for practice using a multicenter trial. There was no statistical difference between practice on the current simulator compared to practice on human cadaveric temporal bones. Further refinements in structural acquisition and interface design have been identified, which can be implemented prior to full incorporation into training programs and used for objective skills assessment.
The convergence of technology and medicine has led to many advances in surgical training. Novel surgical simulators have led to significantly improved skills of graduating surgeons, leading to decreased time to proficiency, improved efficiency, decreased errors, and improvement in patient safety. Endoscopic sinus surgery poses a steep learning curve given the complex 3-dimensional anatomy of the nasal and paranasal cavities, and the necessary visual-spatial motor skills and bimanual dexterity. This article focuses on surgical simulation in rhinological training and how innovative high-fidelity and low-fidelity simulators can maximize resident training and improve procedural skills before operating in the live environment.
Background: In otolaryngology, surgical emergencies can occur at any time. An annual surgical training camp (or 'boot camp') offers junior residents from across North America the opportunity to learn and practice these skills in a safe environment. The goals of this study were to describe the set-up and execution of a simulation-based otolaryngology boot camp and to determine participants' confidence in performing routine and emergency on-call procedures in stressful situations before and after the boot camp. Methods: There were three main components of the boot camp: task trainers, simulations and an interactive panel discussion. Surveys were given to participants before and after the boot camp, and their confidence in performing the different tasks was assessed via multiple t-tests. Results: Participants comprised 22 residents from 12 different universities; 10 of these completed both boot camp surveys. Of the nine tasks, the residents reported a significant improvement in confidence levels for six, including surgical airway and orbital haematoma management. Conclusion: An otolaryngology boot camp gives residents the chance to learn and practice emergency skills before encountering the emergencies in everyday practice. Their confidence in multiple skillsets was significantly improved after the boot camp. Given the shift towards competency-based learning in medical training, this study has implications for all surgical and procedural specialties.
The assessment and treatment of patients with ENT disorders requires significant specialist knowledge and skills not routinely taught during medical school or Foundation training. Furthermore, ENT emergencies can be rapidly life-threatening and may necessitate systematic and multidisciplinary management and resuscitation. We aimed to develop a practical and simulation-based intensive ‘boot camp’ to prepare junior doctors entering ENT jobs within the Eastern Deanery using emergency simulation methods previously validated by our group1. The term ‘boot camp’ originates from the United States military who use intensive training camps to prepare new recruits, though now the term has entered common usage to describe any concentrated period of focussed training. The ENT ‘boot camp’ concept is an evolution of traditional training, that has proved popular as an induction method for new residency (registrar) trainees2 and more senior faculty3 in the United States. However, it has not been used as a training method for Foundation or Core training grade doctors on short ENT rotations in the United Kingdom.This article is protected by copyright. All rights reserved.
Simulation has become a valuable tool in medical education, and several specialties accept or require simulation as a resource for resident training or assessment as well as for board certification or maintenance of certification. This study investigates current simulation resources and activities in US otolaryngology residency programs and examines interest in advancing simulation training and assessment within the specialty. Web-based survey. US otolaryngology residency training programs. An electronic web-based survey was disseminated to all US otolaryngology program directors to determine their respective institutional and departmental simulation resources, existing simulation activities, and interest in further simulation initiatives. Descriptive results are reported. Responses were received from 43 of 104 (43%) residency programs. Simulation capabilities and resources are available in most respondents' institutions (78.6% report onsite resources; 73.8% report availability of models, manikins, and devices). Most respondents (61%) report limited simulation activity within otolaryngology. Areas of simulation are broad, addressing technical and nontechnical skills related to clinical training (94%). Simulation is infrequently used for research, credentialing, or systems improvement. The majority of respondents (83.8%) expressed interest in participating in multicenter trials of simulation initiatives. Most respondents from otolaryngology residency programs have incorporated some simulation into their curriculum. Interest among program directors to participate in future multicenter trials appears high. Future research efforts in this area should aim to determine optimal simulators and simulation activities for training and assessment as well as how to best incorporate simulation into otolaryngology residency training programs. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.
Objectives/hypothesis: Medical students graduate with the knowledge and skills to be undifferentiated general physicians. Otolaryngology-head and neck surgery (OtoHNS) is an essential component of primary healthcare, but is disproportionately under-represented in undergraduate medical education (UME). Advances and innovations in educational technology may represent an exciting and creative solution to this important problem. Failure to meet this educational need will result in substantial downstream effects in primary healthcare delivery. The objectives of this study were to 1) demonstrate current deficits in OtoHNS teaching at the UME level; 2) develop, validate, and critically appraise educational innovations that may enrich OtoHNS teaching in medical school curricula; and 3) propose a process for standardization of learning objectives for OtoHNS in UME as it relates to development and deployment of such educational tools. Study design: A white paper, prepared as a Triological Society thesis, which consolidates a prospective 10-year investigation of the problem of and potential solutions for under-representation of OtoHNS in UME. Cited datasets include multicenter surveys, cohort studies, and prospective, randomized controlled trials. Methods: A series of published and unpublished data were synthesized that addresses the following: 1) the current state of OtoHNS teaching at the UME level with respect to content, volume, structure, and methods; and 2) educational innovations including e-learning and simulation with emphasis on validity and learning effectiveness. Educational innovations specific to postgraduate (residency) training were excluded. Results: Data support the observation that there is uniformly disproportionate under-representation of OtoHNS within UME curricula. Medical school graduates, especially those pursuing primary care specialties, report poor overall comfort levels in managing OtoHNS problems. A series of novel teaching methods were developed and validated using e-learning and simulation. Selected technologies may have a role in medical student teaching. It has been shown that e-learning has limited value in teaching complex spatial anatomy to novice learners, but good value in teaching basic clinical knowledge and selected technical skills. The role of simulation as it pertains to the novice learner is evolving. Important factors to consider during development of these tools include: 1) knowledge base and learning style of the learner, 2) complexity and nature of the learning objectives, 3) understanding the features and limitations of different technological genres, and 4) a team approach to module development. There remains a role for traditional teaching paradigms such as lectures, labs, and standardized patients; however, the choice of instructional genre should be fundamentally tailored to the nature of the learning outcomes. Conclusions: Enriching OtoHNS teaching in medical school is essential optimize primary care delivered to patients. Although e-learning and simulation are broadly accepted and desirable by today's medical students, these technologies should be woven into the fabric of UME pedagogical principles judiciously, and only after empiric assessment. Foundational to the development and implementation of these technologies is the framework of standardized competency-based learning objectives, common to all graduating medical students. Level of evidence: NA
Objectives This article has two objectives. Firstly, we critically review simulation-based mastery learning (SBML) research in medical education, evaluate its implementation and immediate results, and document measured downstream translational outcomes in terms of improved patient care practices, better patient outcomes and collateral effects. Secondly, we briefly address implementation science and its importance in the dissemination of innovations in medical education and health care. Methods This is a qualitative synthesis of SBML with translational (T) science research reports spanning a period of 7 years (2006–2013). We use the ‘critical review’ approach proposed by Norman and Eva to synthesise findings from 23 medical education studies that employ the mastery learning model and measure downstream translational outcomes. ResultsResearch in SBML in medical education has addressed a range of interpersonal and technical skills. Measured outcomes have been achieved in educational laboratories (T1), and as improved patient care practices (T2), patient outcomes (T3) and collateral effects (T4). Conclusions Simulation-based mastery learning in medical education can produce downstream results. Such results derive from integrated education and health services research programmes that are thematic, sustained and cumulative. The new discipline of implementation science holds promise to explain why medical education innovations are adopted slowly and how to accelerate innovation dissemination.
Importance: Knowledge of the risk factors for oropharyngeal hemorrhage after chemoradiation therapy will guide clinicians in monitoring high-risk patients in order to prevent a life-threatening complication. Objective: To determine risk factors for the development of oropharyngeal hemorrhage following chemoradiation therapy without surgery for oropharyngeal squamous cell carcinoma. Design: Retrospective review of medical records of patients treated during the period January 2005 through December 2010. Setting: University of Louisville Hospital. Participants: The study population comprised 139 patients with a diagnosis of oropharyngeal squamous cell carcinoma who were treated with chemoradiation therapy without surgery. All patients received primary treatment from our institution. Those with recurrent tumors or prior oropharyngeal resections, with the exception of tonsillectomy, were excluded from the study. Patients were divided into 2 groups: those who did not hemorrhage following treatment (n = 129) and those who developed oropharyngeal hemorrhage (n = 10), defined as hemorrhage necessitating procedural intervention. Main outcomes and measures: Four clinical variables were measured: T category, radiation therapy method, weight loss, and age. Results: Results from logistic regression analysis showed that significant risk factors for hemorrhage were advanced T category (odds ratio [OR], 8.40 [95% CI, 2.44-46.61]; P < .001), radiation therapy method (OR, 79.94 [95% CI, 2.64-<999.90]; P = .008), weight loss (OR, 0.89 [95% CI, 0.79-0.98]; P = .01), and increased age (OR, 0.93 [95% CI, 0.86-0.99]; P = .03). After multiple logistic regression analyses, only advanced T category remained statistically significant (adjusted OR, 6.6 [95% CI, 1.2-∞]; P = .02). Results from Kaplan-Meier survival analysis on all patients showed that those who hemorrhaged had significantly shorter survival time than those who did not (P = .04). However, after multivariate analysis with a Cox proportional hazards regression model, hemorrhage no longer remained a significant factor (P = .13). Conclusions: For patients with oropharyngeal squamous cell carcinoma treated with chemoradiation without surgery, advanced T category is the most important determinant of developing oropharyngeal hemorrhage; furthermore, hemorrhage occurs in the presence of either recurrent and/or persistent disease or radiation necrosis. Survival analysis indicates that development of hemorrhage is a poor prognostic marker for overall survival.