Comparison of spinal mannequin based simulation teaching with conventional didactic method of teaching subarachnoid block in novices: A randomised controlled trial

Neuraxial anaesthesia is the standard and reliable technique of intraoperative and postoperative pain relief for patients undergoing surgeries.Neuraxial anaesthesia is difficult to learn and takes many years to attain expertise. [1] The evidence for teaching the skills and knowledge necessary to be competent and safe in neuraxial anaesthesia is limited, despite clinical acceptance of the technique. United Kingdom department of health recommended that health professional should learn skills in simulation environment before undertaking them in supervised clinical practice. [2]Invitro models provide novice safe medium to correct errors, gain motor skills and allow time to develop proficiency before undertaking procedures on patients. Many types of phantoms are available including water, tofu, beef gravy, gelatin, elastomeric rubber, turkey, beef, pork and fresh and embalmed cadavers. Each of these models has advantages and disadvantages in terms of fidelity, cost and availability.[3]The transformation from an unstructured and unsystematic approach to a more structured approach to teach procedural skills is much needed ,it is unethical for novices at any level of training to practice new skills on patients even if they have patients explicit consent. There are fewer opportunities to learn on patients due to a decreased tolerance for medical error and increased reluctance to accept risk to patients from learners. The ethics of learning on patients with inanimate alternatives are readily available, and hence exposing both patient and learner to avoidable risk. [4]In a study by Vander Wielen et al. , participants who viewed a brief instructional video  improved their ability to acquire ultrasound images and identify anatomical landmarks on a live model. However, a group randomized to a hands-on training session with an anatomy-based gel phantom (scanning session did not exceed ten minutes) was more successful than the video group in identifying anatomical landmarks when both were compared to a control group, reinforcing the value of handson experience and dynamic image interpretation to learn sonoanatomy.[5]Conventional didactic methods of learning where anaesthesia residents after observing a specific number of procedures under educator guidance when tried to perform the procedures faced many difficulties and their success dependent on many technical and non-technical factors. Performing neuraxial anaesthesia by conventional observational methods can be technically difficult and demand some amount of expertise and experience. Relying on individuals limited experience alone can lead to incorrect identification of the targeted epidural space.furthermore, without knowledge of anatomy and correct interpretation of sonoanatomy, novices can fail to recognize abnormal anatomy and may endanger patients with inadvertent dural puncture. This may also result in increased procedural time, multiple needle passes, unstable needle movements, patient discomfort and inadequate neuraxial blockade. Simulated training can be a valuable tool for acquiring knowledge and skills, gaining hands-on experience through repetitive practice of salient aspects of a procedure and provide some sensory feedback without harm to patients, and receiving individualized feedback. Declining learning opportunities in clinical practice and the need to maximize patient  safety dictate that cognitive and integrative stage should occur before learners practice on patients. [7]One area of uncertainty is the choice of the best model or phantom to teach ultrasoundâ€guided neuraxial anaesthesia technical skills. The rationale for training using inâ€vitro models is to provide novices with a safe medium to correct errors, gain motor skills and allow time to develop proficiency before undertaking procedures on patients. Lots of efforts are ongoing in examining the different components of the UGRA and many teaching methods have been used without fully researching their effectiveness. Only few studies are available on head to head comparison on different teaching models. Hence, we designed this study to determine if there was any advantage in using blue phantom spinal epidural model when training novices to perform neuraxial anaesthesia.