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Scenario-based Skill Teaching ATLS ® 10th Edition

7 skills stations Airway (x2) Breathing Circulation Disability Secondary Survey Adjuncts Trauma Team

Skills stations Airway Breathing Circulation Disability Secondary Survey Adjuncts Trauma Team Appear in the course in a logical order – for all candidates A B/C D…………

Skills stations Airway Breathing Circulation Disability Secondary Survey Adjuncts Trauma Team Multiple stations need to run in parallel eg. 4 airway stations for 16 candidates

Skills stations Airway Breathing Circulation Disability Secondary Survey Adjuncts Trauma Team Skills taught or demonstrated in the context of unfolding scenario(s) Stimulus questions

Skills stations Airway Breathing Circulation Disability Secondary Survey Adjuncts Trauma Team Need to know (cognitive) skills (demo/discuss) Need to do (psychomotor) skills (DO)

1. airway Basic Advanced Paediatric/Surgical Airway assessment demo/discuss Laryngeal mask (or tube) insertion – DO Basic airway (paed v adult) Jaw thrust LEMON Nasal airway, suction, oral airway - DO Oral endotracheal intubation – demo/discuss Surgical cricothyroidotomy - DO Bag Valve Mask (1 and 2 person) - DO Needle cricothyroidotomy - Do

2. breathing (1) Breathing assessment – DO or demo/discuss Needle decompression – DO Chest drain (thoracostomy tube) insertion – DO Elderly chest injury – demo/discuss Sucking chest wound – demo/discuss Severe chest injury scenario – demo/discuss

2. breathing (2) Introduction and skill level ascertainment scenario 1 (m-cycle) Assessment to detect life-threatening injuries – DO or interactive discussion case 1 progression Needle decompression of tension pneumothorax – DO case 1 what next? Insertion of intercostal drain – DO close scenario

2. breathing (3) scenario 2 (elderly fall) case 2 progression Assessment to detect life-threatening injuries – re-cap case 2 progression Management of haemo-pneumothorax in elderly – interactive discussion

2. breathing (4) scenario 3 (propellor) case 3 progression Assessment to detect life-threatening injuries – re-cap case 3 progression Management of open (sucking) pneumothorax - demo/discuss occlusive dressing case 3 what next? Insertion of intercostal drain – re-cap Surgical referral - discuss

2. breathing (5) ? ? ? Summary and closure scenario 4 (car) Assessment to detect life-threatening injuries – re-cap case 4 progression Management of life-threatening injuries – discussion Aortic injury case 4 what next? Interventions and investigations Definitive (surgical) care ? ? ? Summary and closure

3. circulation Assessment of Shock – demo/discuss Wound packing – demo/discuss Application of tourniquet – demo/discuss Insertion of intra-osseous needle – DO Application of pelvic binder – demo/discuss Femoral access – DO or demo/discuss Non-haemorrhagic shock – demo/discuss

4. disability Assessment of neurological status – demo/discuss Evaluation of C spine injury – demo/discuss Reassessment of changing neurological status – demo/discuss Referral process – demo/discuss Detailed neurological exam – demo/discuss Log roll – demo/discuss (rotate all roles) Elderly patient assessment of neurological status – demo/discuss Central cord syndrome assessment – demo/discuss

5. secondary survey Application of hard collar - DO Perform secondary survey patient 1 – demo/discuss Perform secondary survey patient 2 – demo/discuss Open fracture management – demo/discuss Perform secondary survey patient 3 – demo/discuss Perform secondary survey patient 4 – demo/discuss

6. adjuncts eFAST probe positioning/scanning – demo/discuss Chest X ray interpretation – DO Pelvic X ray interpretation – DO Spine X ray interpretation - DO

10th edition Scenario Based Teaching Scenarios unfold throughout the skills stations At relevant point in scenario, students identify a skill to be performed Skill is taught using 4 stage model Scenario continues Skills are identified as: Demonstration only (need to know of) Performance (need to do)

Miller’s Pyramid Metacognitive knowledge Procedural knowledge Conceptual knowledge Factual knowledge Miller, GE, 1990;65

Krathwohl’s modified Bloom’s Cognitive Taxonomy Real Life Practice Initial Assessment Skills scenarios Manual & m learning Krathwohl, 2002, p216

Skills station 1 video

Principles of teaching a psychomotor skill (ATLS) Conceptualisation – scenario drawing on knowledge from manual Visualisation – seeing the skill Verbalisation – hearing the skill, then describing the skill Practice – performing the skill Reinforcement & correction – whilst performing the skill Skill mastery Skill autonomy

ATLS model of skill acquisition Conceptualisation – facilitator does, all watch Visualisation – facilitator does and describes, (all watch and listen) 3. Verbal – facilitator does and learner A describes 4. Practical – learner A describes and then does (instructor auto corrects)

Skills station 2 video

Skills station 3 video

Skills station 4 video

Why scenarios? Greater participant engagement - asking and answering questions Improved integration of knowledge and skill Improved transfer of knowledge and understanding through application More opportunity to identify gaps – immediate feedback Alpha testing showed more engagement from learners Mimics learning in clinical practice

Facilitators will: Present scenarios to contextualise ATLS principles Ask range of questions to elicit application of knowledge Build on questioning to help students identify interventions Use four stage approach to facilitate skill acquisition Scaffold different levels of learning Immediate situational feedback

Learners will: Demonstrate understanding of context by responding to scenario questions Apply knowledge from manual by suggesting interventions Develop relevant skills by 4 stage approach Be engaged throughout Identify knowledge gaps with immediate feedback Relate scenario to real life practice

Pitfalls or risks Not using scenario, just teaching skills Lecturing, using no questions Discussion, no skills Lack familiarity with scenario and skill Side tracking – requiring facilitator focus Multiple conversations – requiring group dynamics management Errors made in 4th stage – requiring immediate facilitator correction Time!

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