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Technology to Fast-Track Learning in

Regional AnesthesiaEdward R. Mariano, M.D., M.A.S.

Professor of Anesthesiology, Perioperative & Pain MedicineStanford University School of Medicine

Chief, Anesthesiology and Perioperative CareVeterans Affairs Palo Alto Health Care System

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Financial Disclosures

• Halyard Health, B Braun – Unrestricted educational program funding paid to my institution

The contents of the following presentation are solely the responsibility of the speaker without input from any of the above companies.

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Overview

• The “learning curve” • Technology for teaching and learning• Technology for assessment

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Overview

• The “learning curve” • Technology for teaching and learning• Technology for assessment

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How Hard Can It Be?

NYSORA.COM -

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The “10,000 Hours Rule”

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Deliberate Practice

Ericsson. Acad Emerg Med 2008;15:988

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Regional Anesthesia “Learning Curve”

Reg Anesth. 1996;21:182

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Learning Curve for UGRA

RAPM 2004;29:544

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Novice Behavior

• 520 ultrasound-guided nerve block captured on video and reviewed– 7 errors: needle not visualized, inadequate

equipment preparation, poor ergonomics, target malpositioning on screen, unintentional probe movement, awkward hand position on needle, and excessive visual focus on hands

• By the 60th block, still 2.8 errors per block

Sites, et al. RAPM 2007;32:107

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Barrington, et al. RAPM 2012;37:334

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Udani & Mariano, et al. RAPM 2016;41:151

Avg 7 (2–22 min)for the control group vs. 48 (29–65 min) for the DP group (p<0.001).

No other differences!

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Predictors of Learning UGRA

Shafqat, et al. Anesth 2015;123:1188

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Predictors of Learning UGRA

Shafqat, et al. Anesth 2015;123:1188

Maybe we are not all the same!

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Overview

• The “learning curve” • Technology for teaching and learning• Technology for assessment

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

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What Is “Simulation”?

79 articles involving simulation were reviewed:1. Simulation-based educational interventions

(14)2. Novel simulator design (18)3. Use of a simulated environment as an

experimental setting (11)4. Other/outside scope of review (36)

Udani & Mariano, et al. Local Reg Anesth 2015;8:33

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

Studies of Simulation Interventions

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

Studies of Simulator Design

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

Inorganic Simulator

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

Organic Simulator

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“Hybrid” Simulator

Udani & Mariano, et al. Local Reg Anesth 2015;8:33

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Ramlogan R, et al. RAPM 2017;42: 217http://www.pie.med.utoronto.ca/VSpine/index.htm

NEW!

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Udani & Mariano, et al. Local Reg Anesth 2015;8:33

Studies Using a Simulation Setting

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Anesthesiology-DirectedAdvancedProcedural Training

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Lectures,

Scanning

Iterative Practice,Simulatio

n

8 Hour Program

Mariano, et al. JUM 2015;34:1883

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Mariano, et al. JUM 2015;34:1883

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Echogenic Technology

Mariano, et al. JUM 2014;33:905

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Needle Guidance Systems

McVicar, et al. RAPM 2015;40:150

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Overview

• The “learning curve” • Technology for teaching and learning• Technology for assessment

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AssessmentCategory Description Points Procedural Time (min) Starting when US probe touches skin and ending when

placement needle is removed 2 (≤5 min) 1 (6-10 min) 0 (>10 min)

Needle Passes (#) Withdrawal of the placement needle >1 cm with readvancement 2 (1) 1 (2) 0 (>2)

Procedural Performance

Needle visualization during advancement 2 (All the time) 1 (Part of the time) 0 (None of the time)

Equipment preparation (e.g., probe selection, machine settings) 2 (Excellent) 1 (Good) 0 (Poor)

Target positioning (eg, able to see target and feasible needle trajectory)

2 (All the time) 1 (Part of the time) 0 (None of the time)

Probe stability (eg, no unintentional movement) 2 (All the time) 1 (Part of the time) 0 (None of the time)

Needle manipulation (eg, comfortable grip on needle and catheter)

2 (All the time) 1 (Part of the time) 0 (None of the time)

Visual focus (eg, appropriately focused on machine and not hands during procedure)

2 (All the time) 1 (Part of the time) 0 (None of the time)

Confirmation of proper injectate spread 2 (Excellent) 1 (Good) 0 (Poor)

Confirmation of proper catheter tip position 2 (Excellent) 1 (Good) 0 (Poor)

Ergonomic Factors Positioning of ultrasound machine 2 (Excellent) 1 (Good) 0 (Poor)

No thoracolumbar flexion (≥45 ) 2 (All the time) 1 (Part of the time) 0 (None of the time)

No head/neck rotation (≥45 ) 2 (All the time) 1 (Part of the time) 0 (None of the time)

No lateral shoulder tilt (≥30 ) 2 (All the time) 1 (Part of the time) 0 (None of the time)

No crossing sterile field to non-dominant side 2 (All the time) 1 (Part of the time) 0 (None of the time)

Mariano, et al. JUM 2015;34:1883

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DOPS

Wragg, et al. Clin Med 2003;3:131Watson, et al. Anaesth 2014;69:604Chuan, et al. Anaesth Int Care 2016;44:2

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DOPS

Wragg, et al. Clin Med 2003;3:131Watson, et al. Anaesth 2014;69:604Chuan, et al. Anaesth Int Care 2016;44:2

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Global Rating Scale

Cheung, et al. RAPM 2012;37: 329Wong, et al. RAPM 2014;39:399

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Video Recording and Review

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Hand Motion Analysis

Chin, et al. RAPM 2011;36:213

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Eye Tracking

Harrison & Mariano, et al. J Anesth 2015;30:530

The Expert94 sec

1.85 fixations/sec

The Novice257 sec

0.86 fixations/sec

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J Anesth 2015;30:530

How Does Expertise Look?

Can We Quantify It?

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Borg & Mariano, et al. Submitted

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Summary

We discussed:• The “learning curve” • Technology for teaching and learning• Technology for assessment

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“Regional anesthesia is a vital skill for any anesthesiologist and ultrasound-guided techniques have enhanced our ability to achieve effective and consistent blocks. It is important that we ensure our graduating residents have the requisite skills to perform basic regional techniques in a safe and effective manner in order to disseminate the benefits of regional anesthesia to the broader surgical population.”

McCartney & Mariano. RAPM 2016;41:663.

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April 19–21, 2018New York Marriott

MarquisNew York City, USA

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