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J Surg Educ. 2018 Feb 26. pii: S1931-7204(17)30652-9. doi: 10.1016/j.jsurg.2018.02.001. [Epub ahead of print]

High-Fidelity Emergency Department Thoracotomy Simulator With Beating-Heart Technology and OSATS Tool Improves Trainee Confidence and Distinguishes Level of Skill.

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Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts.
Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia.
Department of Surgery, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts; Learning Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
Division of Trauma and Acute Care Surgery, Medical College of Wisconsin-Froedtert Trauma Center, Milwaukee, Wisconsin. Electronic address:



Resuscitative Thoracotomy or Emergency Department Thoracotomy (EDT) is a time-sensitive and potentially life-saving procedure. Yet, trainee experience with this procedure is often limited in both clinical and simulation settings. We sought to develop a high-fidelity EDT simulation module and assessment tool to facilitate trainee education.


Using the Kern model for curricular development, a group of expert trauma surgeons identified EDT as a high-stakes, low-frequency procedure. Task analysis identified 5 key steps of EDT: (1) opening chest/rib spreader utilization; (2) pericardiotomy/cardiac repair; (3) open cardiac massage; (4) clamping aorta; and (5) control of pulmonary hilum. A high-fidelity simulator with beating-heart technology was built. The previously validated Objective Structured Assessment of Technical Skills (OSATS) was adapted to create the "EDT-OSATS" which assessed performance along several domains: (1) Surgical technique (key steps); (2) general skills; and (3) global rating. A pilot test was performed to compare board-certified trauma surgeons (i.e., Experts) with categorical general surgery interns (i.e., Novices). Each subject received preparatory materials, completed a presimulation quiz, performed a videotaped procedure on the EDT simulator, and completed a postmodule survey. Two independent raters scored performances using the EDT-OSATS. Groups were compared in descriptive and unadjusted analyses. We hypothesized that our EDT simulation module would distinguish between expert vs novice performance and improve trainee confidence.


Simulation laboratory at Massachusetts General Hospital in Boston, MA.


Trauma surgeons (Experts, n = 6) and categorical general surgery interns (Novices, n = 8).


Experts scored significantly higher than Novices on nearly all components of the EDT-OSATS, including: (1) surgical technique: pericardiotomy (4.2 vs 3.4, p = 0.040), cardiac massage (3.6 vs 2.4, p = 0.028), clamping aorta (4.1 vs 3.3, p = 0.035), control of pulmonary hilum (4.8 vs 3.4, p < 0.001); (2) general skills: time/motion (4.1 vs 2.9, p = 0.011), knowledge and handling of instruments (4.3 vs 3.1, p = 0.004), and (3) global rating (3.9 vs 2.9, p = 0.026). There was no statistical difference between groups on opening chest/rib spreader utilization (3.8 vs 3.3, p = 0.352) or procedure time (204sec vs 227sec, p = 0.401), though Experts scored numerically higher than Novices on every measure. Novices reported significantly increased confidence after the simulation (3.1 vs 1.4, p = 0.001). Ninety-three percent (13/14) of participants found the simulator realistic.


Our novel high-fidelity beating-heart EDT simulator is realistic and improves trainee confidence in this low-frequency, high-stakes emergency procedure. The EDT-OSATS tool differentiates between performances of experienced surgeons vs novice trainees on the beating-heart simulator. This training module and accompanying assessment instrument hold promise as a learning tool for clinicians who may perform emergency department thoracotomy.


Medical Knowledge; Patient Care; Practice Based Learning and Improvement; beating-heart technology; emergency department thoracotomy (EDT); graduate medical education; high-fidelity simulation; surgical education

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