- Email: [email protected]
A review of clinically relevant human anatomy in emergency medicine
The Journal of Emergency Medicine, Vol. 29, No. 3, pp. 347–352, 2005 Copyright © 2005 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/05 $–see front matter
doi:10.1016/j.jemermed.2005.01.032
Education
A REVIEW OF CLINICALLY RELEVANT HUMAN ANATOMY IN EMERGENCY MEDICINE Lisa Marie Campanella,
MD,*
Helen Bloch, MD,† Maureen Gang, and Victoria Ort, PhD储
MD,‡
William Rennie,
MD,†§
*Emergency Medical Associates, Livingston, New Jersey, †Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York, ‡Department of Emergency Medicine, Bellevue Hospital-NYU School of Medicine, New York, New York, §Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New York, and 储Department of Cell Biology, NYU School of Medicine, Division of Anatomy, New York, New York Reprint Address: Lisa Campanella, MD, 651 West Mt. Pleasant Road, Livingston, New Jersey
e Abstract—The objectives of this project were to establish a practical model for the review of clinical anatomy relevant to the assessment and care of the ill and injured patient, and to design practice models for invasive procedures using human cadaver, porcine cadaver, and plastic model material. A practical course based on the human gross anatomy of the face, neck, thorax, airway, arm, and leg was designed. Regional anesthesia techniques, arthrocentesis, saphenous vein cutdown, central venous and arterial cannulation, surgical airway, thoracostomy tube placement and thoracotomy were integrated into the appropriate practice stations. A syllabus was developed. A clinically relevant, online anatomy atlas demonstrating all of the above was developed. In conclusion, an anatomy review course combining clinically relevant, human, gross anatomy and procedure practice stations was established. © 2005 Elsevier Inc.
cate that “a majority of the residency programs report that gross anatomy is either extremely important or very important to mastery of their discipline . . . [and] . . . 57% of the residency program directors felt that residents need a refresher in gross anatomy upon their arrival” (1). Procedure classes and practice sessions on animal or plastic models are becoming more popular during residency training, however, they are not always good substitutes for practicing on the human body (2). In 1993, Nelson et al. reported that only four out of 60 U.S. medical schools surveyed offered procedure courses that included more than basic phlebotomy skills (3). Six years later, Hao et al. described their department’s development of a clinical skills laboratory on manikins for third year medical students (4). In 2002, Van der Vlugt et al. described their medical student procedure skills elective that includes practice on plastic models and fresh frozen cadavers (5). Several surgical specialties are using simulator models to instruct residents in procedures as well as practice of the focused abdominal sonography in trauma (FAST) examination and advanced trauma life support (ATLS) techniques (6,7). These articles clearly demonstrate that laboratories using cadaver material, animal products, and plastic models are becoming the preferred method for teaching procedures to residents and
e Keywords—anatomy; cadaver; procedures; emergency medicine; education
INTRODUCTION The optimal method and timing for teaching invasive procedures to medical students and residents has been the subject of a growing body of literature for the last 10 years. In 1999, Cottam reported survey results that indi-
Education is coordinated by Stephen R. Hayden, Diego, California
RECEIVED: 10 March 2004; FINAL ACCEPTED: 26 January 2005
SUBMISSION RECEIVED:
MD,
of the University of California San Diego Medical Center, San
13 December 2004; 347
348
L. M. Campanella et al.
Table 1. Suggested Daily Rotation Schedule for Three Groups of Students Day 1
Session 1 Session 2 Session 3
Day 2
Chest
Face
Arm
Airway
Neck
Leg
Group 1 Group 2 Group 3
Group 2 Group 3 Group 1
Group 3 Group 1 Group 2
Group 1 Group 2 Group 3
Group 2 Group 3 Group 1
Group 3 Group 1 Group 2
medical students (3–5,8 –10). Unfortunately, due to the limitations of the models, procedure laboratories often focus on the technical details of performing the procedure without thoroughly reviewing the pertinent human anatomy. In 1985, Hamilton and Nagy introduced the concept of incorporating an Emergency Medicine (EM) residents’ anatomy curriculum into their training. They created a course that involved review of anatomy, dissections, and some discussion of clinical correlation (11). In 1990, William Rennie and Helen Bloch established a clinically relevant Anatomy Review Course for a group of Emergency Medicine Residents at the Albert Einstein School of Medicine. In 1991, the same group sponsored a booth at the American College of Emergency Physicians to evaluate the anatomy knowledge base of clinicians. Over the last decade their course has been used as an example by other institutions, including our own, wishing to implement a clinically relevant anatomy review course. Thomas revisited this concept in the context of procedure education during the Society of Academic Emergency Medicine (SAEM) 1993 conference at which he outlined the “principles involved in teaching adult learners the critical procedure skills . . . in the practice of emergency medicine . . . [which] . . . include: 1) a review of pertinent anatomic structures, 2) the indications for the procedure, 3) supervised practice of the procedure on models, 4) the contraindications to the procedure, and 5) the possible complications from the procedure” (12). Maclean and colleagues revisited this topic in 1996 with a detailed description of an updated 5-day course that combined in-depth anatomy review with clinical correlation discussions, procedure practice, and radiology correlations (13). In collaboration with the Department of Anatomy at New York University (NYU) School of Medicine, a course, based on a similar program at Albert Einstein Medical School, was established incorporating a review of clinically relevant human gross anatomy on predissected cadavers and an integrated practical procedure laboratory. The course was limited to 8 h so that it could be provided to the entire residency program during protected conference time. The curriculum included a review of dissected structures of the face, neck, arm, leg,
airway, and thorax, as well as procedure stations pertinent to the Emergency Physician’s practice.
Materials and Methods Intentions. To establish an annual seminar emphasizing review of human anatomy pertinent to the assessment of the ill and injured patient. Also, to establish an annual seminar emphasizing the performance of invasive procedures in the Emergency Department (ED). Organization. Six 60 – 80-min stations comprise the seminar, each one focusing on a body region (face, arm, leg, thorax, airway, and neck) and accommodating 10 residents, a PGY4, and a faculty preceptor. To accommodate 30 students, each station is taught three times daily. In each station, students review relevant regional anatomy and practice emergency procedures such as cricothyrotomy and thoracotomy (Table 1). Materials and workspace. Undissected cadavers, cadaver dissection workspace, cadaver storage space, and classroom space (Table 2). Six standard anatomy dissections were prepared by one of the authors. Each dissection required approximately 20 h to complete. The dissections are maintained annually by the Anatomy Department at NYU using their standard procedures for storage of cadaver material. The dissections last for approximately 5 years, depending upon how carefully they are handled. See Figure 1 for an example of the face dissection. Photographs of these dissections are on the departmental web site at: www. med.nyu.edu/ERWeb/anatomy/anatomyallframes.html. Procedures were designed using human, porcine and plastic models. Nondissected knees and elbows were injected with methylene blue for arthrocentesis practice (8). The same legs were used to practice saphenous vein cutdown techniques. Nondissected human thoraces were used during the chest station for thoracostomy tube placement and thoracotomy practice. A cricothyrotomy practice model was created using porcine tracheas (Figure 2). A plastic retrograde intubation model was purchased and incorporated into the airway laboratory. An intubation practice station was created with plastic stan-
Clinical Anatomy in Emergency Medicine
349
Table 2. Suggested Daily Schedule Describing Pre-dissected Cadaver Models, Essential Supplies and Procedures Reviewed Day 1 Chest station
Day 2 Airway station
Time approx 90 minutes Time approx 90 minutes Cadaver thorax predissected Cadaver airway predissected One undissected cadaver thorax per group of 10 students Airway-Cam video-Dr. Richard Levitan Procedures to review Porcine airway models : 10 per group of 10 students. See Figure 2. Thoracostomy tube placement Procedures to review Thoracotomy Oropharyngeal intubation via various approaches Cross clamping aorta and hilum Surgical airway techniques via Melkner kit and cricothyrotomy Temporizing repair of ventricular laceration with suture and Nasotracheal intubation pledgets or Foley Supplies needed Supplies needed Porcine trachea: #1 per student Chest tubes: # 1 per 4 students Cricothyrotomy tray: #1 per student Needle drives: # 2 Plastic airway models for practice intubation Curved Sutures: #1 per student Melkner retrograde intubation kits Thoracotomy tray: #1 Pledgets: #4 Foley: #1 Face station Time: approx 60 min 30-min break Cadaver face predissected One undissected cadaver face per group Procedures to review Supraorbital block Infraorbital block Mental block Inferior alveolar block Lateral canthotomy Nasal packing Supplies 3-cc syringe: # 1 for demonstration Iris scissor, hemostat: #1 for demonstration Nasal packing: # 1 for demonstration Skull with removable mandible for demonstration
Neck station Time: approx 60 min 30-min break Cadaver neck predissected Procedures to review Subclavian vein cannulation via various approaches Internal jugular vein cannulation via various approaches Cricothyrotomy Supplies Cricothyrotomy kit: # 1 for demonstration Central venous cannulation kit: #1 for demonstration
Arm station Time: approx 80 min 10-min break Cadaver arm predissected 1 undissected cadaver arms per group of 5 students with 20 cc of methylene blue injected at elbow joint Procedures to review Arthrocentesis of elbow Median nerve block Radial nerve block Ulnar nerve block Digital block Supplies Methylene blue 10 cc per elbow joint 10-cc syringe: # 1 per 10 students 18-gauge needle: #1 per 5 students 3-cc syringe: #1 per 10 students
Leg station Time: approx 90 min Cadaver leg predissected 1 undissected cadaver legs per group of 5 students with knees injected with 60 cc of methylene blue Procedures to review Arthrocentesis of knee and ankle Saphenous vein cutdown Sural nerve block Saphenous nerve block Digital block Supplies Methylene blue 60 cc per knee joint 60-cc syringe: # 1 per 10 students 18-gauge needle: #1 per 5 students 3-cc syringe: #1 per 10 students Cutdown tray: # 2 per 10 students
dard Advanced Cardiac Life Support (ACLS) practice models. Lateral canthotomy technique was demonstrated on an intact human cadaver face.
investment in other plastic models. This budget will vary from institution to institution. Our annual budget was approximately $5000.
Budget. A budget for this laboratory includes the cost of cadaver material including transport, preservation and storage; dissector time; storage space; porcine products; protective garments; procedure supplies; and an initial
Instructors. An attending hand surgeon, trauma surgeon, and oral surgeon precepted the hand, thorax, and face tutorials, respectively. The remaining tutorials were precepted by faculty and senior residents from our department.
350
L. M. Campanella et al.
Figure 1. Face dissection.
Adjuncts. A laboratory manual was written and included an annual schedule, a syllabus, an annual projected budget, supplier contacts, a supply list, details of the structures to be dissected on each demonstration specimen, and photographs of the dissected models. A syllabus was prepared outlining anatomic details and procedures at each station and was provided to each participant before the course began. An interactive web page containing labeled photographs of dissections and course procedures was designed and is available at: www. med.nyu.edu/ERWeb/anatomy/anatomyallframes.htm Long-term administration. An anatomy committee, comprised of one faculty member, a PGY-4 advisor who served as the PGY-3 coordinator the year prior, a PGY-3 coordinator and a resident dissector, has been established. The committee holds organizational meetings before the seminar to facilitate its implementation. DISCUSSION Establishing a course of this nature requires that goals and objectives be outlined, a curriculum be designed, dissected models be prepared from preserved human cadavers, a syllabus be written, practice models be de-
veloped, a budget be prepared, and a system of evaluation and annual maintenance be devised. Similar courses have been previously described in the medical literature. Some have focused solely on procedures without offering a review of relevant anatomy, whereas others teach anatomy and dissection but not procedures (2–11,13). Maclean et al. attempted to combine both anatomy review and procedure practice, however the course they described was limited to a small group of residents and required a 5-day commitment (13). The dissections for this seminar were designed and created by one of the authors to demonstrate the structures of each region considered pertinent to clinical practice. The important structures were determined to be those discussed by Roberts and Hedges in their book, Clinical Procedures in Emergency Medicine (14). The syllabus for this seminar was written by each station’s PGY4 and was designed to provide the participants with an outline of clinically relevant anatomy to be reviewed as well as outlines for pertinent procedures. To encourage residents to study anatomy relevant to EM practice, the authors designed an interactive web page with labeled dissections for the ED at NYU. Residents are encouraged to review this web page before performing ED procedures.
Clinical Anatomy in Emergency Medicine
351
Figure 2. Porcine trachea cricothyrotomy model. A cleaned porcine larynx and trachea is stabilized on a foam board with with two roles of kerlex. A piece of porcine abdominal skin is stretched over the thyroid cartilage and fixed in place.
Procedure model design was based on a desire to closely simulate procedures on living patients for the practitioner. Preserved, undissected human cadavers were used to create models for the arm, leg, face, and thorax stations. Porcine products were altered to create cricothyrotomy practice models as the anatomy is similar to that of humans although larger in scale. The tracheas and skins are easily obtainable from a slaughterhouse and do not require further sacrifice of animals (15,16). An additional benefit of this approach is that each learner can work on his or her anatomic model without having to reuse a human cadaver. The arthrocentesis models of the elbow and knee, the chest tube model, the saphenous vein cutdown model, the thoracostomy tube placement and thoracotomy model were based very closely on those used at Albert Einstein School of Medicine. The intubation and retrograde intubation models were based upon plastic models used during the ACLS and ATLS classes taught by our department. The porcine trachea model was based upon a similar model described by Howard Grellar, MD and Richard Levitan, MD at the University of Pennsylvania School of Medicine (personal communication). The lateral canthotomy procedure was based upon the work of Vassallo et al. (17).
tissue. These restrictions are especially true for the chest and airway sessions because the preserved chest and lungs are rigid and fragile. Preservation of the cadavers leads to blood clots in the vasculature, making it impossible to practice cannulation of the central vasculature on preserved human cadavers. It is difficult to assess our course’s effect on procedural performance by residents. We are limited by the fact that our measurement tool was resident self-assessment of comfort with procedural competence before and after the course.
FUTURE CONSIDERATIONS We hope to design a better assessment tool for our model so that we may quantify the effect on residents’ performance of, and comfort level with, procedures on patients. We would like to expand our course to include more regions of the body and more procedures, including the anatomy pertinent to the trauma FAST examination.
CONCLUSION LIMITATIONS The experience of practicing on model materials may translate poorly to performing procedures on live human
Emergency Physicians are required to assess ill and injured patients and to perform invasive procedures. A course in human gross anatomy may be one way to improve the performance of a clinician’s physical assess-
352
L. M. Campanella et al.
ment and procedure skills. We have established a practical model for the review of clinically relevant anatomy and we have created a venue within which students can practice procedures. Given the current perspectives on graduate medical education, this course may serve to ameliorate some of the concerns with the use of patients as ‘practice models’ for interns and residents performing a procedure for the first time, and the ethical considerations of practice on the newly dead.
5. 6. 7. 8. 9.
Acknowledgments—Special thanks to David D. Sabatini, MD, and Bruce Ian Bogart, PhD and the NYU School of Medicine Department of Cell Biology for the use of the Anatomy Lab facilities for preparation of materials for this project.
PhD
10. 11. 12.
REFERENCES
13.
1. Cottam W. Adequacy of medical school gross anatomy education as perceived by certain postgraduate residency programs and anatomy course directors. Clin Anat 1999;12:55– 65. 2. Edison MI, Horgan S, Helton WS. Using small group workshops to improve surgical resident’s technical skills. Acad Med 2001;76: 557– 8. 3. Nelson MS. Clinical skills training of U.S. medical students. Acad Med 1993;68:926 – 8. 4. Hao J. The clinical skills laboratory: a cost effective venue for
14. 15. 16. 17.
teaching clinical skills to third year medical students. Acad Med 2002;77:152. Van der Vlugt T, Harter P. Teaching procedural skills to medical students: one institution’s experience with an emergency procedures course. Ann Emerg Med 2002;40;41–9. Block EF, Lottenber L, Flint L, Jakobsen J, Liebnitzky D. Use of a human patient simulator for advanced trauma life support course. Am Surg 2002;68:648 –51. Manyak MJ, Santangelo K, Hahn J, et al. Virtual reality surgical simulation for lower urinary tract endoscopy and procedures. J Endourol 2002;16:185–90. Nelson MS. Models for teaching emergency medicine skills. Ann Emerg Med 1990;19:333–5. Olshaker JS, Brown CK, Arthur DC, Tek D. Animal procedure lab surveys: use of the animal laboratory to improve physician confidence and ability. J Emerg Med 1989;7:593–7. Suner S, Simmons W, Savitt DL. A porcine model for instruction of lateral canthotomy. Acad Emerg Med 2000;7:837– 8. Hamilton GC, Nagy F. A course in Anatomy for Emergency Medicine Residents. J Emerg Med 1985;3:71– 4. Thomas H. Teaching procedural skills: beyond “see-one, do-one, teach-one”. Acad Emerg Med 1994;1:398 – 401. Maclean TA, Wagner MJ, Nagy F. Clinical anatomy: a review course for emergency medicine residents. J Emerg Med 1996;14: 383–7. Roberts JR, Hedges J. Clinical procedures in emergency medicine, 3rd edn. Philadelphia: Saunders Company; 1998. Ball MW. Emerging models in the USA: swine, woodchucks and the hairless guinea pig. Prog Clin Biol Res 1987;229:311–26. Sack WO. Essentials of pig anatomy. Ithaca, NY: Veterinary Textbooks; 1982. Vassallo S, Hartstein M, Howard D, Stetz J. Traumatic retrobulbar hemhorrage: emergent decompression by lateral canthotomy and cantholysis. J Emerg Med 2002;22:251– 6.
doi:10.1016/j.jemermed.2005.01.032
Education
A REVIEW OF CLINICALLY RELEVANT HUMAN ANATOMY IN EMERGENCY MEDICINE Lisa Marie Campanella,
MD,*
Helen Bloch, MD,† Maureen Gang, and Victoria Ort, PhD储
MD,‡
William Rennie,
MD,†§
*Emergency Medical Associates, Livingston, New Jersey, †Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, New York, ‡Department of Emergency Medicine, Bellevue Hospital-NYU School of Medicine, New York, New York, §Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, New York, and 储Department of Cell Biology, NYU School of Medicine, Division of Anatomy, New York, New York Reprint Address: Lisa Campanella, MD, 651 West Mt. Pleasant Road, Livingston, New Jersey
e Abstract—The objectives of this project were to establish a practical model for the review of clinical anatomy relevant to the assessment and care of the ill and injured patient, and to design practice models for invasive procedures using human cadaver, porcine cadaver, and plastic model material. A practical course based on the human gross anatomy of the face, neck, thorax, airway, arm, and leg was designed. Regional anesthesia techniques, arthrocentesis, saphenous vein cutdown, central venous and arterial cannulation, surgical airway, thoracostomy tube placement and thoracotomy were integrated into the appropriate practice stations. A syllabus was developed. A clinically relevant, online anatomy atlas demonstrating all of the above was developed. In conclusion, an anatomy review course combining clinically relevant, human, gross anatomy and procedure practice stations was established. © 2005 Elsevier Inc.
cate that “a majority of the residency programs report that gross anatomy is either extremely important or very important to mastery of their discipline . . . [and] . . . 57% of the residency program directors felt that residents need a refresher in gross anatomy upon their arrival” (1). Procedure classes and practice sessions on animal or plastic models are becoming more popular during residency training, however, they are not always good substitutes for practicing on the human body (2). In 1993, Nelson et al. reported that only four out of 60 U.S. medical schools surveyed offered procedure courses that included more than basic phlebotomy skills (3). Six years later, Hao et al. described their department’s development of a clinical skills laboratory on manikins for third year medical students (4). In 2002, Van der Vlugt et al. described their medical student procedure skills elective that includes practice on plastic models and fresh frozen cadavers (5). Several surgical specialties are using simulator models to instruct residents in procedures as well as practice of the focused abdominal sonography in trauma (FAST) examination and advanced trauma life support (ATLS) techniques (6,7). These articles clearly demonstrate that laboratories using cadaver material, animal products, and plastic models are becoming the preferred method for teaching procedures to residents and
e Keywords—anatomy; cadaver; procedures; emergency medicine; education
INTRODUCTION The optimal method and timing for teaching invasive procedures to medical students and residents has been the subject of a growing body of literature for the last 10 years. In 1999, Cottam reported survey results that indi-
Education is coordinated by Stephen R. Hayden, Diego, California
RECEIVED: 10 March 2004; FINAL ACCEPTED: 26 January 2005
SUBMISSION RECEIVED:
MD,
of the University of California San Diego Medical Center, San
13 December 2004; 347
348
L. M. Campanella et al.
Table 1. Suggested Daily Rotation Schedule for Three Groups of Students Day 1
Session 1 Session 2 Session 3
Day 2
Chest
Face
Arm
Airway
Neck
Leg
Group 1 Group 2 Group 3
Group 2 Group 3 Group 1
Group 3 Group 1 Group 2
Group 1 Group 2 Group 3
Group 2 Group 3 Group 1
Group 3 Group 1 Group 2
medical students (3–5,8 –10). Unfortunately, due to the limitations of the models, procedure laboratories often focus on the technical details of performing the procedure without thoroughly reviewing the pertinent human anatomy. In 1985, Hamilton and Nagy introduced the concept of incorporating an Emergency Medicine (EM) residents’ anatomy curriculum into their training. They created a course that involved review of anatomy, dissections, and some discussion of clinical correlation (11). In 1990, William Rennie and Helen Bloch established a clinically relevant Anatomy Review Course for a group of Emergency Medicine Residents at the Albert Einstein School of Medicine. In 1991, the same group sponsored a booth at the American College of Emergency Physicians to evaluate the anatomy knowledge base of clinicians. Over the last decade their course has been used as an example by other institutions, including our own, wishing to implement a clinically relevant anatomy review course. Thomas revisited this concept in the context of procedure education during the Society of Academic Emergency Medicine (SAEM) 1993 conference at which he outlined the “principles involved in teaching adult learners the critical procedure skills . . . in the practice of emergency medicine . . . [which] . . . include: 1) a review of pertinent anatomic structures, 2) the indications for the procedure, 3) supervised practice of the procedure on models, 4) the contraindications to the procedure, and 5) the possible complications from the procedure” (12). Maclean and colleagues revisited this topic in 1996 with a detailed description of an updated 5-day course that combined in-depth anatomy review with clinical correlation discussions, procedure practice, and radiology correlations (13). In collaboration with the Department of Anatomy at New York University (NYU) School of Medicine, a course, based on a similar program at Albert Einstein Medical School, was established incorporating a review of clinically relevant human gross anatomy on predissected cadavers and an integrated practical procedure laboratory. The course was limited to 8 h so that it could be provided to the entire residency program during protected conference time. The curriculum included a review of dissected structures of the face, neck, arm, leg,
airway, and thorax, as well as procedure stations pertinent to the Emergency Physician’s practice.
Materials and Methods Intentions. To establish an annual seminar emphasizing review of human anatomy pertinent to the assessment of the ill and injured patient. Also, to establish an annual seminar emphasizing the performance of invasive procedures in the Emergency Department (ED). Organization. Six 60 – 80-min stations comprise the seminar, each one focusing on a body region (face, arm, leg, thorax, airway, and neck) and accommodating 10 residents, a PGY4, and a faculty preceptor. To accommodate 30 students, each station is taught three times daily. In each station, students review relevant regional anatomy and practice emergency procedures such as cricothyrotomy and thoracotomy (Table 1). Materials and workspace. Undissected cadavers, cadaver dissection workspace, cadaver storage space, and classroom space (Table 2). Six standard anatomy dissections were prepared by one of the authors. Each dissection required approximately 20 h to complete. The dissections are maintained annually by the Anatomy Department at NYU using their standard procedures for storage of cadaver material. The dissections last for approximately 5 years, depending upon how carefully they are handled. See Figure 1 for an example of the face dissection. Photographs of these dissections are on the departmental web site at: www. med.nyu.edu/ERWeb/anatomy/anatomyallframes.html. Procedures were designed using human, porcine and plastic models. Nondissected knees and elbows were injected with methylene blue for arthrocentesis practice (8). The same legs were used to practice saphenous vein cutdown techniques. Nondissected human thoraces were used during the chest station for thoracostomy tube placement and thoracotomy practice. A cricothyrotomy practice model was created using porcine tracheas (Figure 2). A plastic retrograde intubation model was purchased and incorporated into the airway laboratory. An intubation practice station was created with plastic stan-
Clinical Anatomy in Emergency Medicine
349
Table 2. Suggested Daily Schedule Describing Pre-dissected Cadaver Models, Essential Supplies and Procedures Reviewed Day 1 Chest station
Day 2 Airway station
Time approx 90 minutes Time approx 90 minutes Cadaver thorax predissected Cadaver airway predissected One undissected cadaver thorax per group of 10 students Airway-Cam video-Dr. Richard Levitan Procedures to review Porcine airway models : 10 per group of 10 students. See Figure 2. Thoracostomy tube placement Procedures to review Thoracotomy Oropharyngeal intubation via various approaches Cross clamping aorta and hilum Surgical airway techniques via Melkner kit and cricothyrotomy Temporizing repair of ventricular laceration with suture and Nasotracheal intubation pledgets or Foley Supplies needed Supplies needed Porcine trachea: #1 per student Chest tubes: # 1 per 4 students Cricothyrotomy tray: #1 per student Needle drives: # 2 Plastic airway models for practice intubation Curved Sutures: #1 per student Melkner retrograde intubation kits Thoracotomy tray: #1 Pledgets: #4 Foley: #1 Face station Time: approx 60 min 30-min break Cadaver face predissected One undissected cadaver face per group Procedures to review Supraorbital block Infraorbital block Mental block Inferior alveolar block Lateral canthotomy Nasal packing Supplies 3-cc syringe: # 1 for demonstration Iris scissor, hemostat: #1 for demonstration Nasal packing: # 1 for demonstration Skull with removable mandible for demonstration
Neck station Time: approx 60 min 30-min break Cadaver neck predissected Procedures to review Subclavian vein cannulation via various approaches Internal jugular vein cannulation via various approaches Cricothyrotomy Supplies Cricothyrotomy kit: # 1 for demonstration Central venous cannulation kit: #1 for demonstration
Arm station Time: approx 80 min 10-min break Cadaver arm predissected 1 undissected cadaver arms per group of 5 students with 20 cc of methylene blue injected at elbow joint Procedures to review Arthrocentesis of elbow Median nerve block Radial nerve block Ulnar nerve block Digital block Supplies Methylene blue 10 cc per elbow joint 10-cc syringe: # 1 per 10 students 18-gauge needle: #1 per 5 students 3-cc syringe: #1 per 10 students
Leg station Time: approx 90 min Cadaver leg predissected 1 undissected cadaver legs per group of 5 students with knees injected with 60 cc of methylene blue Procedures to review Arthrocentesis of knee and ankle Saphenous vein cutdown Sural nerve block Saphenous nerve block Digital block Supplies Methylene blue 60 cc per knee joint 60-cc syringe: # 1 per 10 students 18-gauge needle: #1 per 5 students 3-cc syringe: #1 per 10 students Cutdown tray: # 2 per 10 students
dard Advanced Cardiac Life Support (ACLS) practice models. Lateral canthotomy technique was demonstrated on an intact human cadaver face.
investment in other plastic models. This budget will vary from institution to institution. Our annual budget was approximately $5000.
Budget. A budget for this laboratory includes the cost of cadaver material including transport, preservation and storage; dissector time; storage space; porcine products; protective garments; procedure supplies; and an initial
Instructors. An attending hand surgeon, trauma surgeon, and oral surgeon precepted the hand, thorax, and face tutorials, respectively. The remaining tutorials were precepted by faculty and senior residents from our department.
350
L. M. Campanella et al.
Figure 1. Face dissection.
Adjuncts. A laboratory manual was written and included an annual schedule, a syllabus, an annual projected budget, supplier contacts, a supply list, details of the structures to be dissected on each demonstration specimen, and photographs of the dissected models. A syllabus was prepared outlining anatomic details and procedures at each station and was provided to each participant before the course began. An interactive web page containing labeled photographs of dissections and course procedures was designed and is available at: www. med.nyu.edu/ERWeb/anatomy/anatomyallframes.htm Long-term administration. An anatomy committee, comprised of one faculty member, a PGY-4 advisor who served as the PGY-3 coordinator the year prior, a PGY-3 coordinator and a resident dissector, has been established. The committee holds organizational meetings before the seminar to facilitate its implementation. DISCUSSION Establishing a course of this nature requires that goals and objectives be outlined, a curriculum be designed, dissected models be prepared from preserved human cadavers, a syllabus be written, practice models be de-
veloped, a budget be prepared, and a system of evaluation and annual maintenance be devised. Similar courses have been previously described in the medical literature. Some have focused solely on procedures without offering a review of relevant anatomy, whereas others teach anatomy and dissection but not procedures (2–11,13). Maclean et al. attempted to combine both anatomy review and procedure practice, however the course they described was limited to a small group of residents and required a 5-day commitment (13). The dissections for this seminar were designed and created by one of the authors to demonstrate the structures of each region considered pertinent to clinical practice. The important structures were determined to be those discussed by Roberts and Hedges in their book, Clinical Procedures in Emergency Medicine (14). The syllabus for this seminar was written by each station’s PGY4 and was designed to provide the participants with an outline of clinically relevant anatomy to be reviewed as well as outlines for pertinent procedures. To encourage residents to study anatomy relevant to EM practice, the authors designed an interactive web page with labeled dissections for the ED at NYU. Residents are encouraged to review this web page before performing ED procedures.
Clinical Anatomy in Emergency Medicine
351
Figure 2. Porcine trachea cricothyrotomy model. A cleaned porcine larynx and trachea is stabilized on a foam board with with two roles of kerlex. A piece of porcine abdominal skin is stretched over the thyroid cartilage and fixed in place.
Procedure model design was based on a desire to closely simulate procedures on living patients for the practitioner. Preserved, undissected human cadavers were used to create models for the arm, leg, face, and thorax stations. Porcine products were altered to create cricothyrotomy practice models as the anatomy is similar to that of humans although larger in scale. The tracheas and skins are easily obtainable from a slaughterhouse and do not require further sacrifice of animals (15,16). An additional benefit of this approach is that each learner can work on his or her anatomic model without having to reuse a human cadaver. The arthrocentesis models of the elbow and knee, the chest tube model, the saphenous vein cutdown model, the thoracostomy tube placement and thoracotomy model were based very closely on those used at Albert Einstein School of Medicine. The intubation and retrograde intubation models were based upon plastic models used during the ACLS and ATLS classes taught by our department. The porcine trachea model was based upon a similar model described by Howard Grellar, MD and Richard Levitan, MD at the University of Pennsylvania School of Medicine (personal communication). The lateral canthotomy procedure was based upon the work of Vassallo et al. (17).
tissue. These restrictions are especially true for the chest and airway sessions because the preserved chest and lungs are rigid and fragile. Preservation of the cadavers leads to blood clots in the vasculature, making it impossible to practice cannulation of the central vasculature on preserved human cadavers. It is difficult to assess our course’s effect on procedural performance by residents. We are limited by the fact that our measurement tool was resident self-assessment of comfort with procedural competence before and after the course.
FUTURE CONSIDERATIONS We hope to design a better assessment tool for our model so that we may quantify the effect on residents’ performance of, and comfort level with, procedures on patients. We would like to expand our course to include more regions of the body and more procedures, including the anatomy pertinent to the trauma FAST examination.
CONCLUSION LIMITATIONS The experience of practicing on model materials may translate poorly to performing procedures on live human
Emergency Physicians are required to assess ill and injured patients and to perform invasive procedures. A course in human gross anatomy may be one way to improve the performance of a clinician’s physical assess-
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ment and procedure skills. We have established a practical model for the review of clinically relevant anatomy and we have created a venue within which students can practice procedures. Given the current perspectives on graduate medical education, this course may serve to ameliorate some of the concerns with the use of patients as ‘practice models’ for interns and residents performing a procedure for the first time, and the ethical considerations of practice on the newly dead.
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Acknowledgments—Special thanks to David D. Sabatini, MD, and Bruce Ian Bogart, PhD and the NYU School of Medicine Department of Cell Biology for the use of the Anatomy Lab facilities for preparation of materials for this project.
PhD
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