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An Unembalmed Cadaveric Preparation for Simulating Pleural Effusion: A Pilot Study of Chest Percussion Involving Medical Students

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Title: An Unembalmed Cadaveric Preparation for Simulating Pleural Effusion: A Pilot Study of Chest Percussion Involving Medical Students
Language: English
Authors: Cook, Mark S., Kernahan, Peter J.
Source: Anatomical Sciences Education. Mar-Apr 2017 10(2):160-169.
Availability: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
Peer Reviewed: Y
Page Count: 10
Publication Date: 2017
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Anatomy, Medical Education, Science Instruction, Human Body, Simulation, Medical Students, Intervention, Experimental Groups, Control Groups, Comparative Analysis, Hands on Science, Measurement Techniques, Self Efficacy, Skills, Learner Engagement, Instructional Effectiveness
DOI: 10.1002/ase.1640
ISSN: 1935-9772
Abstract: Cadaveric simulations are an effective way to add clinical context to an anatomy course. In this study, unembalmed (fresh) cadavers were uniquely prepared to simulate pleural effusion to teach chest percussion and review thoracic anatomy. Thirty first-year medical students were assigned to either an intervention (Group A) or control group (Group B). Group A received hands-on training with the cadaveric simulations. They were instructed on how to palpate bony landmarks for identifying the diaphragm and lobes of the lungs, as well as on how to properly perform chest percussion to detect abnormal fluid in the pleural space. Students in Group B practiced on each other. Students in Group A benefited from the training in several ways. They had more confidence in their percussive technique (A = mean 4.3/5.0, B = 2.9/5.0), ability to count the ribs on an intact body (A = mean 4.0/5.0, B = 3.0/5.0), and ability to identify the lobes of the lungs on an intact body (A = mean 3.8/5.0, B = 2.3/5.0). They also demonstrated a greater ability to locate the diaphragm on an intact body (A = 100%, B = 60%) and detect abnormal pleural fluid (A = 93%, B = 53%) with greater confidence (A = mean 3.7/5.0, B = 2.5/5.0). Finally, the hands-on training with the unembalmed cadavers created more excitement around learning in Group A compared with Group B. This study shows that simulating pleural effusion in an unembalmed cadaver is a useful way to enhance anatomy education.
Abstractor: As Provided
Entry Date: 2017
Accession Number: EJ1131890
Database: ERIC
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  Value: <anid>AN0121502213;[8z8k]01mar.17;2018Aug09.09:39;v2.2.500</anid> <title id="AN0121502213-1">An unembalmed cadaveric preparation for simulating pleural effusion: A pilot study of chest percussion involving medical students. </title> <p>Cadaveric simulations are an effective way to add clinical context to an anatomy course. In this study, unembalmed (fresh) cadavers were uniquely prepared to simulate pleural effusion to teach chest percussion and review thoracic anatomy. Thirty first ‐ year medical students were assigned to either an intervention (Group A) or control group (Group B). Group A received hands ‐ on training with the cadaveric simulations. They were instructed on how to palpate bony landmarks for identifying the diaphragm and lobes of the lungs, as well as on how to properly perform chest percussion to detect abnormal fluid in the pleural space. Students in Group B practiced on each other. Students in Group A benefited from the training in several ways. They had more confidence in their percussive technique (A = mean 4.3/5.0, B = 2.9/5.0), ability to count the ribs on an intact body (A = mean 4.0/5.0, B = 3.0/5.0), and ability to identify the lobes of the lungs on an intact body (A = mean 3.8/5.0, B = 2.3/5.0). They also demonstrated a greater ability to locate the diaphragm on an intact body (A = 100%, B = 60%) and detect abnormal pleural fluid (A = 93%, B = 53%) with greater confidence (A = mean 3.7/5.0, B = 2.5/5.0). Finally, the hands ‐ on training with the unembalmed cadavers created more excitement around learning in Group A compared with Group B. This study shows that simulating pleural effusion in an unembalmed cadaver is a useful way to enhance anatomy education. Anat Sci Educ 10: 160–169. © 2016 American Association of Anatomists.</p> <p>gross anatomy education; medical education; physical examination; cadaver model; unembalmed cadaver; fresh cadaver; pleural effusion; chest percussion</p> <p>The goal of any medical anatomy course should be to provide the fundamental knowledge of the human body needed to (<reflink idref="bib1" id="ref1">1</reflink>) understand normal function, (<reflink idref="bib2" id="ref2">2</reflink>) begin to recognize dysfunction and pathology, and (<reflink idref="bib3" id="ref3">3</reflink>) provide examples of how this foundational knowledge is necessary for accurate diagnosis and competent care.</p> <p>One of the ways to move students beyond rote memorization in anatomy, so that they may think about it in a clinical context, is to develop hands ‐ on clinical experiences that complement topics being covered in the course. There is evidence to support that this type of experiential learning improves understanding and retention of the subject matter and helps develop the critical thinking necessary for diagnosing and treating illness (Kolb, [<reflink idref="bib15" id="ref4">15</reflink>] ; Harrell et al., [<reflink idref="bib13" id="ref5">13</reflink>] ; Prince et al., [<reflink idref="bib29" id="ref6">29</reflink>] ; Bergman et al., [<reflink idref="bib4" id="ref7">4</reflink>] ; Sugand et al., [<reflink idref="bib36" id="ref8">36</reflink>] ).</p> <p>The type of learning that occurs when students get early clinical exposure to patient care is referred to as “authentic learning” (Pawlina and Drake, [<reflink idref="bib27" id="ref9">27</reflink>] ), and prepares students for the critical ‐ thinking and problem ‐ solving expected of physicians. The activities conducted in an authentic classroom should be as realistic as possible and provide content and skills that are useful and applicable to the practice of medicine. The assumption underlying this approach is that students will learn what is meaningful to them (Chang et al., [<reflink idref="bib6" id="ref10">6</reflink>] ).</p> <p>There is increasing awareness of the value of experiential learning in an anatomy course. Increasingly, clinical context is being incorporated into medical anatomy courses to augment learning in a number of ways (Drake, [<reflink idref="bib9" id="ref11">9</reflink>] ). It is now common to find radiologic imaging (Phillips et al., [<reflink idref="bib28" id="ref12">28</reflink>] ), ultrasonography (Nelson and Traub, [<reflink idref="bib24" id="ref13">24</reflink>] ; Steadman et al., [<reflink idref="bib35" id="ref14">35</reflink>] ; Zaia et al., [<reflink idref="bib42" id="ref15">42</reflink>] ), and surface anatomy sessions (Aggarwal et al., [<reflink idref="bib2" id="ref16">2</reflink>] ; Sugand et al., [<reflink idref="bib36" id="ref17">36</reflink>] ) during early medical education.</p> <p>Simulation in medical education is increasing in popularity because it has been shown to be an effective way to introduce clinical context and is helpful in strengthening students' knowledge base (Friedman et al., [<reflink idref="bib12" id="ref18">12</reflink>] ; Chakravarthy et al., [<reflink idref="bib5" id="ref19">5</reflink>] ; Sperling et al., [<reflink idref="bib34" id="ref20">34</reflink>] ). Formalin ‐ preserved (embalmed) cadavers have been useful for teaching thoracocentesis, pleural biopsy, chest ‐ tube insertion, thoracostomy, bone marrow biopsy, paracentesis, percutaneous liver biopsy and arthrocentesis (Weaver et al., [<reflink idref="bib41" id="ref21">41</reflink>] ; Proano et al., [<reflink idref="bib30" id="ref22">30</reflink>] ). The benefit of using human cadavers include no risk of patient harm or discomfort and the ability to repeat examinations and procedures several times if necessary. It also helps to reduce anxiety in the first ‐ year medical student. This environment leads to an increase in feelings of confidence and competence by participants (Morgan and Cleave ‐ Hogg, [<reflink idref="bib23" id="ref23">23</reflink>] ).</p> <p>When students are engaged in the clinical encounter of simulation, they are gaining knowledge and understanding through visual, tactile and auditory stimuli (McLachlan and Patten, [<reflink idref="bib21" id="ref24">21</reflink>] ; Sperling et al., [<reflink idref="bib34" id="ref25">34</reflink>] ). However, embalmed cadaveric tissue is stiff and lacks the natural tissue texture and response for other clinical simulations to be successful. When a more “life ‐ like” experience is desired, unembalmed (fresh) cadavers are preferred.</p> <p>Unembalmed cadavers have been used to simulate vascular surgical procedures (Aboud et al., [<reflink idref="bib1" id="ref26">1</reflink>] ; Reed et al., [<reflink idref="bib31" id="ref27">31</reflink>] ), laparoscopic procedures (Levine et al., [<reflink idref="bib18" id="ref28">18</reflink>] ), urologic procedures (Ahmed et al., [<reflink idref="bib3" id="ref29">3</reflink>] ), surgical airway approaches (Latif et al., [<reflink idref="bib17" id="ref30">17</reflink>] ) and other procedures and skills integral to the practice of emergency medicine (Tabas et al., [<reflink idref="bib37" id="ref31">37</reflink>] ). Even though some simulated procedures are easier to perform on a mannequin, students have more of an appreciation for unembalmed cadaveric preparations for learning clinical skills (Ocel et al., [<reflink idref="bib25" id="ref32">25</reflink>] ).</p> <p>When it is desirable to provide preclinical medical students with the experience of examining a body with pathology, unembalmed cadavers can be prepared in creative ways to simulate the abnormality. For example, Janseen and colleagues surgically released the anterior cruciate ligament (ACL) on one side of an unembalmed cadaver so medical and physical therapy students could assess normal and ACL ‐ deficient knees by performing the Lachman test (Janseen et al., [<reflink idref="bib14" id="ref33">14</reflink>] ).</p> <p>The cadaveric preparation described in the current study arose from the desire to provide students the opportunity to perform a thoracic examination on a “patient” with pathology, specifically one with abnormal fluid in the pleural space (pleural effusion).</p> <p>At the University of Minnesota, first ‐ year medical students attend weekly physical examination sessions, called Essentials of Clinical Medicine (ECM), concurrent with their human anatomy course. During ECM sessions, students review common pathologies and clinical examination procedures on each other under the supervision of a clinical specialist. The ECM sessions parallel the material being covered in the anatomy course. Immediately following the lectures and laboratory dissections of the thorax in anatomy class, students attend an ECM session to inspect, palpate, percuss and listen to thoracic sounds (heart and lungs) with a stethoscope. They are not, however, evaluated on their techniques.</p> <p>Chest percussion is a common component of the clinical chest physical examination, where the objective is often to determine if the area under consideration is filled with air, fluid or solid material (Schneiderman, [<reflink idref="bib33" id="ref34">33</reflink>] ). During percussion, acoustic energy is introduced at the body surface and the resulting sound changes are detected. This is typically accomplished by the examiner placing the middle finger of the non ‐ dominant hand against the chest and striking the tip of it with the middle finger of the other hand using a rapid wrist flexion movement. The examiner listens for the acoustic response of the chest wall, noting amplitude and pitch. This “conventional percussion” is performed without a stethoscope, as opposed to auscultory percussion. A hollow (resonating) sound is indicative of air, while a dull (less ‐ resonating) sound is more suggestive of fluid ‐ filled, and a flat (non ‐ resonating) sound of solid structures.</p> <p>Manual implementation of percussion is qualitative, subjective and skill dependent. It is a simple, yet important, skill that continues to have diagnostic value during a physical examination. It not only provides a relatively quick and simple assessment of the thoracic environment, but also provides foundational knowledge for performing ultrasound (which the medical students are formally trained on later in their first year). It is also a technique that is useful for physicians working in austere environments where they may not have immediate access to advanced diagnostic imaging. Without proper training and exposure to the technique before seeing patients, medical students may not appreciate the reliability and clinical utility of the skill. Practicing on each other during clinical training sessions may improve confidence in performing the technique, but does not improve confidence in being able to detect abnormal fluid in the pleural space as seen with pleural effusion. This is because students are only able to assess normal “patients” and usually do not have the opportunity to compare a normal finding with an abnormal one. So, even though students report confidence in performing chest percussion following their ECM session, they do not express confidence in being able to detect pleural effusion in their future patients. This realization led to the purpose of the current study, which was to determine (<reflink idref="bib1" id="ref35">1</reflink>) if pleural effusion could be simulated in an unembalmed cadaver, (<reflink idref="bib2" id="ref36">2</reflink>) if the preparation could be an effective way of reviewing thoracic anatomy through chest percussion, and (<reflink idref="bib3" id="ref37">3</reflink>) if the model could be used to enhance student ability and confidence in detecting intrathoracic pathology (pleural effusion).</p> <hd id="AN0121502213-2">MATERIALS AND METHODS</hd> <p>Unembalmed (fresh) cadavers (without a history of lung disease) were used in this study in order to best represent life ‐ like tissue with regard to tissue texture and pliability. While supine, the cadavers had a tracheotomy performed so that they could be mechanically ventilated. To perform the tracheotomy, a 3 cm vertical midline incision was made centered over the cricothyroid membrane. A transverse incision was made in the membrane and a number 6 French cuffed endotracheal tube (Mallinckrodt Cuffed Basic Endotracheal Tube, Covidien, Minneapolis, MN) was inserted and advanced to the level of the sternal notch. The balloon was inflated and the tube secured with sutures. The tube was connected to an adult manual pulmonary resuscitator (Dynarex Corporation, Orangeburg, NY) and equal bilateral ventilation was confirmed by observation and auscultation.</p> <p>Following intubation, an incision was made at the mid ‐ axillary line of the 5<sups>th</sups> intercostal space and tunneled in a superior direction entering the thoracic cavity. A 12 French chest tube (Argyle PVC Thoracic Catheter, Covidien, Minneapolis, MN) was then inserted into the pleural space and directed posteriorly and inferiorly. The tube was secured in place with sutures. The skin on the other side of the body was also incised, sutured and dressed in order to prevent study participants from knowing which side has the fluid introduced.</p> <p>The cadavers were then moved into a naturally slumped sitting position, with upper limbs resting on bedside tables, simulating the patient position for thoracic examination. Through the chest tube, 1 liter of saline solution was introduced into the pleural space on one side. The chest tube was then removed and the incision sutured closed and dressed. The level of the fluid in the pleural space was then confirmed with a SonoSite Titan ultrasound machine (SonoSite, Inc., Bothell, WA) by placing the head on the thorax and pointing toward the pleural space before, during and after the fluid introduction. The hyperechoic images (signifying fluid) that had not been present prior to fluid insertion were visible. A 30 cm long ventilation tube was then attached and the lungs were mechanically ventilated with an adult manual pulmonary resuscitator (Dynarex Corporation, Orangeburg, NY). Ventilation of the lungs was easily confirmed visually and by stethoscope. The chest could be seen expanding and relaxing with ventilation and airflow could be heard with a standard (3M<sups>TM</sups> Littmann<sups>®</sups> Classic) stethoscope (3M Corp., St Paul, MN). The cadaveric preparation is shown in Figure [NaN] . During simulations, the cadavers were draped so that only the back was visible.</p> <hd id="AN0121502213-3">Study Design</hd> <p>The study design is a randomized control trial of hands ‐ on educational intervention designed to encourage students to think about the internal anatomy of the thorax when performing a common clinical assessment (percussion) on an intact body. The study also examined student self ‐ assessed confidence via survey responses and competence of student performance of chest percussion and detection of pleural effusion. The trial consisted of a control group and an intervention group. The intervention group received hands ‐ on training with a cadaveric simulation while the control group did not. Primary measurements of competency and confidence were made after the intervention.</p> <p>Thirty first ‐ year medical students (12 male, 18 female) at the University of Minnesota volunteered for the study during their gross anatomy course. First year medical students at the University of Minnesota take human anatomy during their first semester. The course is considered a “traditional” anatomy course with didactic lectures taught in a regional approach with corresponding laboratory sessions for embalmed cadaveric dissections. There are 33 regional topics covered during the course covering extremities, thorax, abdomen, pelvis, head and neck. The course is taught over 18 weeks. The lectures, prerecorded PowerPoint presentations, are viewed by students (on their course website) before the laboratory sessions. The laboratory sessions are dissection ‐ based with four students per cadaver. The laboratories are staffed by primary faculty and teaching assistants (third ‐ year medical students). Throughout the anatomy course, students attend ECM sessions to correspond with the topics covered in anatomy. The current study commenced immediately following the study of the thorax in anatomy and ECM.</p> <p>The study was conducted outside of regularly scheduled class sessions. Students were informed that their participation was voluntary and would not affect their grade in the course. They were also informed that information obtained from the questionnaires and evaluations would be anonymous. Students were notified that they could withdraw from the study at any time. No volunteers for the study were rejected or withdrew.</p> <p>Internal Review Board (IRB) exemption status was granted based on the use of nonliving subjects (IRB # 1508E77481). This study was conducted in the anatomy laboratory at the University of Minnesota. The study participants were first ‐ year medical students at the University of Minnesota during the 2015–2016 academic year.</p> <p>Once the list of participants was finalized, they were randomly assigned to Group A (n = 15) or Group B (n = 15). Students in Group A would be the intervention group and receive hands ‐ on training in chest percussion. Students in Group B served as the control and did not receive the hands ‐ on training.</p> <hd id="AN0121502213-4">Pretest Instructional Video</hd> <p>The study began with all participants (Groups A and B) watching a three ‐ minute instructional video discussing proper chest percussion technique and commentary on how to detect pleural effusion. The video, which was available to students through their anatomy course website, showed a senior physician with clinical experience with chest percussion (P.J.K.) demonstrating proper technique for chest percussion and what would be expected with pleural effusion. The “patient” in the video was a volunteer third ‐ year medical student with normal lungs.</p> <hd id="AN0121502213-5">Pretest Survey</hd> <p>Once all students viewed the pretest video, they completed a pretest survey, which used a five ‐ point Likert scale ranging from 5 = strongly agree to 1 = strongly disagree, to assess their confidence with thoracic surface anatomy and performing chest percussion to detect fluid in the pleural space. Specifically, the survey asked the students if they were confident in their ability to (<reflink idref="bib1" id="ref38">1</reflink>) palpate and identify the ribs posteriorly, (<reflink idref="bib2" id="ref39">2</reflink>) locate the dome of the diaphragm on an intact body, (<reflink idref="bib3" id="ref40">3</reflink>) locate the fissures and lobes of each lung on an intact body, (<reflink idref="bib4" id="ref41">4</reflink>) percuss the thorax using good technique, and (<reflink idref="bib5" id="ref42">5</reflink>) be able to detect abnormal fluid in the pleural space.</p> <hd id="AN0121502213-6">Intervention</hd> <p>Immediately following the completion of the pretest survey, the 15 students in Group A engaged in the hands ‐ on cadaveric intervention. The intervention, taught by the senior physician (P.J.K.), consisted of a 15 min training session which included a demonstration of palpation and chest percussion, followed by hands ‐ on training with unembalmed cadavers. One to three students participated during each training session. There were two unembalmed, ventilated cadavers with simulated pleural effusion available during training. During the hands ‐ on training, students were given feedback on their body position, hand/finger position, percussing technique, and detecting different chest sounds. Students also learned how to palpate the angles of the scapula, count the ribs (posteriorly) and identify the position of the lungs and their lobes. The students practiced chest percussion with the cadavers in a sitting position with the upper limbs resting on a table (Fig. [NaN] ). With pleural effusion simulated unilaterally in a cadaver (see Methods), students had the opportunity to experience both normal and abnormal lungs. The students were initially not told if the cadavers had “pleural effusion,” but were asked to perform chest percussion and make a determination. They were then allowed to spend more time practicing until they were confident with their technique.</p> <hd id="AN0121502213-7">Testing</hd> <p>One week after the intervention group (Group A) had received the hands ‐ on training, all students (from Groups A and B) attended a testing session. The set ‐ up for the testing laboratory was the same as for the intervention laboratory. Two more cadavers had 1 liter of saline introduced into the pleural space (via chest tube) on one side and were mechanically ventilated, through a tracheotomy, with a manual pulmonary resuscitator. An incision was made on the “non ‐ effused” side and sutured, as to blind the students to the side with fluid. The cadavers were placed in a sitting position with arms resting on a table. Students were then tested, one at a time, and evaluated by a third ‐ year medical student who was previously trained by the physician who conducted the intervention. The medical student evaluator did not know which group a student was in. The evaluator assessed the competence of the first ‐ year medical students in performing chest percussion to detect fluid using check ‐ list scores. A response of “yes” or “no” was checked for the ability to correctly locate the angles of the scapula, the ribs, the location of the dome of the diaphragm. They were then evaluated on their ability to use proper technique for percussing the thorax, listening for sounds and making the determination of whether or not they detected fluid in the pleural space. Students were also asked to comment on their level of confidence with their assessment. The evaluator was instructed not to provide any feedback to the students during testing. At the end of the testing, the evaluator asked the participants if they received the hands ‐ on training during the prior week in order to compare the performance of each group. All testing was completed on the same day.</p> <p>At the conclusion of the testing session, the cadaveric preparations were used to train third year medical students in thoracocentesis and chest tube placement (open thoracostomy). However, they were not included in the chest percussion pilot.</p> <hd id="AN0121502213-8">Post ‐ Test Survey</hd> <p>One week after the intervention, a post ‐ test survey was completed by all students participating in the study (Groups A and B). The first part of the post ‐ test survey was identical to the pretest survey. It asked the students if they were confident in their ability to (<reflink idref="bib1" id="ref43">1</reflink>) palpate and identify the ribs posteriorly, (<reflink idref="bib2" id="ref44">2</reflink>) locate the dome of the diaphragm on an intact body, (<reflink idref="bib3" id="ref45">3</reflink>) locate the fissures and lobes of each lung on an intact body, (<reflink idref="bib4" id="ref46">4</reflink>) percuss the thorax using good technique, and (<reflink idref="bib5" id="ref47">5</reflink>) be able to detect abnormal fluid in the pleural space. In addition, the post ‐ test survey asked (yes or no) if participation in the study (<reflink idref="bib1" id="ref48">1</reflink>) created excitement around learning anatomy, (<reflink idref="bib2" id="ref49">2</reflink>) helped with their understanding of lung anatomy, (<reflink idref="bib3" id="ref50">3</reflink>) stimulated further discussion in anatomy with peers, and (<reflink idref="bib4" id="ref51">4</reflink>) encourage further exploration of the respiratory system. The students in the intervention group (A) were also asked if the hands ‐ on training with the unpreserved cadavers (<reflink idref="bib1" id="ref52">1</reflink>) helped improve confidence in performing chest percussion, (<reflink idref="bib2" id="ref53">2</reflink>) helped them understand the location of the lungs and respiratory diaphragm in an intact body, and (<reflink idref="bib3" id="ref54">3</reflink>) if the overall experience with the cadaveric simulation was beneficial and would be useful to future medical students.</p> <hd id="AN0121502213-9">Data Analysis</hd> <p>The statistical software package R, version 3.2.2 (R Foundation for Statistical Computing, Vienna, Austria) was used to perform all inferential analyses. Each item on the postsurvey and the testing day evaluations were analyzed separately; as such, the Holm ‐ Bonferroni adjustment for multiple tests was used to adjust the P ‐ values. The statistical significance level of 0.05 was used to evaluate the adjusted P ‐ values. Normality could not be assumed because the items that comprise the two measures are not continuous; as such, non ‐ parametric tests were used. Five of the nine items that comprise the post ‐ survey (i.e., part 1) were ordinal, so Pearson's Chi ‐ squared test was used to compare the two groups on those items. For the Pearson's Chi ‐ squared tests, any response option not used by participants in either group was excluded from the analysis. The remaining four items on the post ‐ survey (supplemental questions) and all items on the evaluation on testing day were dichotomous, so Fisher's Exact test was used to compare the two groups on those items.</p> <hd id="AN0121502213-10">RESULTS</hd> <p>Thirty first ‐ year medical students participated in the pilot study, which took place after their studies of the thorax in the gross anatomy course and after they practiced chest percussion on each other in ECM.</p> <p>The initial (Pretest) survey revealed several things about the study participants (Table [NaN] ). They were not confident they could identify the ribs (by number), locate the position of the dome of the diaphragm, or locate the position of the lobes and fissures of the lungs on an intact body. They also expressed lack of confidence in their chest percussion technique and their ability to detect abnormal fluid in the pleural space. On a five ‐ point Likert scale where 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree and 5 = strongly agree, the mean was 2.57 or less for all questions.</p> <p>Results of Pretest and Post ‐ test Surveys for Group A (intervention group) and Group B (control group)</p> <p> <ephtml> <table><tr><th align="left" /><th align="center">Pretest</th><th align="center">Post ‐ test</th></tr><tr><th>Question</th><th align="center">Mean (±SD)</th><th align="center">Group</th><th align="center">Mean (±SD)</th><th align="center">Median</th><th align="center">χ<sup>2</sup></th><th align="center">P ‐ value</th></tr><tr><td align="left">I am confident with my ability to palpate and identify the ribs posteriorly.</td><td align="char" char=".">2.50 (±0.68)</td><td align="center"><p>A</p><p>B</p></td><td align="left"><p>4.07 (±0.59)</p><p>2.93 (±0.70)</p></td><td align="center"><p>4</p><p>3</p></td><td align="char" char=".">14.37</td><td align="char" char=".">0.022</td></tr><tr><td align="left">I am confident with my ability to locate the dome of the diaphragm on an intact body.</td><td align="char" char=".">2.57 (±0.77)</td><td align="center"><p>A</p><p>B</p></td><td align="left"><p>4.00 (±0.65)</p><p>2.60 (±0.82)</p></td><td align="center"><p>4</p><p>3</p></td><td align="char" char=".">15.45</td><td align="char" char=".">0.024</td></tr><tr><td align="left">I am confident in my ability to locate the fissures and lobes of the lungs on an intact body.</td><td align="char" char=".">2.33 (±0.80)</td><td align="center"><p>A</p><p>B</p></td><td align="left"><p>3.80 (±0.77)</p><p>2.27 (±0.79)</p></td><td align="center"><p>4</p><p>2</p></td><td align="char" char=".">15.99</td><td align="char" char=".">0.024</td></tr><tr><td align="left">I am confident with my manual technique for percussing the thorax.</td><td align="char" char=".">2.50 (±0.82)</td><td align="center"><p>A</p><p>B</p></td><td align="left"><p>4.27 (±0.70)</p><p>2.93 (±0.79)</p></td><td align="center"><p>4</p><p>3</p></td><td align="char" char=".">13.82</td><td align="char" char=".">0.024</td></tr><tr><td align="left">I am confident with my ability to detect fluid in the pleural space using manual percussion technique.</td><td align="char" char=".">1.93 (±0.78)</td><td align="center"><p>A</p><p>B</p></td><td align="left"><p>3.80 (±0.86)</p><p>2.53 (±0.74)</p></td><td align="center"><p>4</p><p>3</p></td><td align="char" char=".">12.89</td><td align="char" char=".">0.047</td></tr></table> </ephtml> </p> <p>1 Pretest was administered to all students (n = 30). Identical post ‐ tests were administered to intervention group A with hands ‐ on training in chest percussion (n = 15) and to control group B (n = 15) without hands ‐ on training. Likert scale used: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree and 5, strongly agree.</p> <p>The thirty students were randomly assigned to one of two groups. Group A (intervention) received hands ‐ on training with an unembalmed cadaver prepared to simulate pleural effusion on one side. Group B (control) did not receive the hands ‐ on training. One week after the intervention, all thirty students were evaluated on their ability to palpate the superior angle of the scapula and locate the dome of the diaphragm (posteriorly) on the intact cadaver. They were then instructed to properly perform chest percussion, identify the side of abnormal fluid accumulation and rate their confidence with their assessment. Those students that engaged in hands ‐ on training did significantly better with the evaluation (Fig. [NaN] ). Students in Group A were significantly more likely to place their middle finger on intercostal spaces than students in Group B (odds ratio; OR = NA; P = 0.015). Also, despite not being statistically significant (see limitations below), students in Group A pointed to the dome of the diaphragm (OR = NA, P = 0.101) and correctly identified the side of the lung with fluid (OR = 11.26, P = 0.141), more frequently than students in Group B, with Group B scoring at about chance levels on these two items. Students in Group A also reported greater confidence of their assessment during the testing day evaluation, than students in Group B, although the difference was not statistically significant (OR = 7.38, P = 0.127). Finally, no significant differences were observed during the testing day evaluation between Group A and Group B in regard to their ability to palpate superior angle of scapula (OR = NA, P = 0.672), whether they tapped their middle finger (OR = NA, P = 0.966), and whether they paused to listen for sound (OR < 0.001, P = 1.000). The values of the odds ratios for five items could not be estimated (and given the value of NA, not applicable) because all students in one group (always Group A) all received a yes on these items during the evaluation.</p> <p>One week after the testing, all thirty students completed a post ‐ test survey. The first part of the survey was identical to the pretest survey (Table [NaN] ). Students in Group A rated themselves as significantly more confident than students in Group B on all five post ‐ survey items related to confidence. Group A reported more confidence in their ability to palpate and identify the ribs posteriorly (χ<sups>2</sups> = 14.37, P = 0.022), with 86% of Group A compared to 20% of Group B selecting agree or strongly agree on this item. Group A also reported greater confidence in their ability to locate the dome of the diaphragm on an intact body (χ<sups>2</sups>= 15.45, P = 0.024), with 80% of Group A and only 13% of Group B selecting agree or strongly agree on this item. Group A reported greater confidence in their ability to locate the fissures and lobes of each of the lungs on an intact body (χ<sups>2</sups> = 15.99, P = 0.024), with 86% of Group A and just 6% (one participant) of Group B selecting agree or strongly agree on this item. Group A reported greater confidence in their manual technique for percussing the thorax (χ<sups>2</sups> = 13.82, P = 0.024), with 86% of Group A and 26% of Group B selecting agree or strongly agree on this item. Finally, Group A reported greater confidence in their ability to detect fluid in the pleural space using manual percussion technique (χ<sups>2</sups> = 12.89, P = 0.047), with 66% of Group A and only 6% (one participant) of Group B selecting agree or strongly agree on this item. A comparison of the post ‐ test survey responses to the pretest responses shows the improvement in confidence expressed by Group A following their hands ‐ on training (Fig. [NaN] ).</p> <p>Students in Groups A and B were asked additional questions on the post ‐ test survey, regarding the impact that the study had on them (Fig. [NaN] ). They were asked if their participation in the study helped them understand lung anatomy better, generate conversation among their peers around the respiratory system and make it more exciting to study anatomy. Group A reported that involvement in the study created more excitement around learning anatomy (OR = 9.95, P = 0.046), with 80% of Group A and 26% of Group B selecting yes on this item. No significant differences were found between Group A and B in whether involvement in the study helped them understand the anatomy of the lungs (OR = 8.94, P = 0.063), stimulated discussion of the respiratory system among peers (OR = 7.38, P = 0.063), or encouraged further exploration of other topics concerning the lungs or respiratory system (OR = 6.58, P = 0.169).</p> <p>The last part of the post ‐ test survey included questions for the intervention group only (Fig. [NaN] ). It reveals how helpful the unembalmed ‐ cadaver simulation described in this study was. All students stated the simulation felt life ‐ like. Most of the students (13 of 15) felt the simulation helped with the understanding of lung position in the intact body. Most of the students (13 of 15) felt that the simulation helped with their confidence performing chest percussion in the clinical setting. Most of the students (14 of 15) felt the unembalmed ‐ cadaver simulation was beneficial and would be useful to future groups.</p> <hd id="AN0121502213-11">DISCUSSION</hd> <p>During the current climate of reduced hours for teaching anatomy in the traditional sense, it has become more important to develop innovative ways to teach more efficiently and effectively, and to demonstrate the value/relevance of anatomy as a subject at a time of radical curriculum change (Turney, [<reflink idref="bib39" id="ref55">39</reflink>] ; Drake et al., [<reflink idref="bib10" id="ref56">10</reflink>] ; Craig et al., [<reflink idref="bib7" id="ref57">7</reflink>] ). Exploring ways to enhance the learning experience in anatomy has been the focus of numerous recent studies (Sugand et al., [<reflink idref="bib36" id="ref58">36</reflink>] ). One of the ways to accomplish this is to provide more clinical context to anatomical instruction through procedural simulation. The learning that occurs during a low ‐ tension, hands ‐ on activity has been shown to be enhanced by such experiences (Ericsson, [<reflink idref="bib11" id="ref59">11</reflink>] ).</p> <p>The main objective is the current study was to investigate if using an unembalmed cadaver to stimulate pleural effusion would prove to be a good model for teaching chest percussion and enhance learning in first ‐ year medical students. Specifically, the aim was to determine if hands ‐ on training would increase student confidence and competence with performing chest percussion and if the intervention would improve knowledge of thoracic anatomy in being able to locate the position of the lungs and diaphragm in the intact body as well as surface landmarks.</p> <p>Once fluid was introduced into the pleural space of the cadaver using a chest tube, the lungs were mechanically ventilated so students could compare normal and abnormal conditions with chest percussion. The hands ‐ on training with the unembalmed cadaveric preparation was perceived as “life ‐ like” by the study participants and increased self ‐ assessed confidence by students who completed the intervention. Specifically, once the students in the intervention received instruction on how to detect abnormal fluid in the pleural space with chest percussion, and experienced the difference between normal and abnormal conditions, they felt more confident they would be able to detect the difference in their future patients compared to those in the control group (Table [NaN] and Fig. [NaN] ). These findings are consistent with previous studies showing that hands ‐ on clinical skills training using cadavers leads to better performance on the skill during subsequent testing (Weaver et al., [<reflink idref="bib41" id="ref60">41</reflink>] ; Proano et al., [<reflink idref="bib30" id="ref61">30</reflink>] ; van der Vlugt and Harter, [<reflink idref="bib40" id="ref62">40</reflink>] ; Martin et al., [<reflink idref="bib20" id="ref63">20</reflink>] ; Oxentenko et al., [<reflink idref="bib26" id="ref64">26</reflink>] ; Tabas et al., [<reflink idref="bib37" id="ref65">37</reflink>] ).</p> <p>The results of the current study also suggest that the hands ‐ on training the students received in their surface anatomy class (ECM) was sufficient enough to learn the technique of chest percussion, but did not produce confidence in their ability to recognize abnormalities (such as pleural effusion). During the testing session, students in the intervention and control group consistently used good technique for percussing (tapped on the middle finger and paused to listen to the sound). However, there was a significant difference in their ability to interpret the response (Fig. [NaN] ). This is most likely due to the fact that they practice on each other during surface anatomy classes without the opportunity to assess “patients” with abnormal conditions. Without being able to examine the thorax of a person with pleural effusion, students know they are unlikely to recognize an abnormality and may simply “go through the motions” of the examination and not appreciate its utility.</p> <p>Another finding in this study is how useful the hands ‐ on intervention was for reviewing general thoracic anatomy and the location of the lungs and diaphragm in the intact body. Prior to the study, all of the participants completed the study of the thorax in their anatomy course. This included didactic lectures and (embalmed) cadaveric dissections in the laboratory. As is conventional, the dissections are carried out with the body supine. The anterior chest wall is reflected superiorly, remaining attached at the sternoclavicular joints. The thoracic dissection proceeds in the sequence described in Grant's Dissector (Tank, [<reflink idref="bib38" id="ref66">38</reflink>] ). This is the context in which students learn thoracic anatomy. During the intervention of the current study, students were instructed on how to perform chest percussion on the posterior thorax and what to listen for. However, they were also instructed on how to use bony landmarks, such as ribs and the scapula, for locating the diaphragm and various lobes of the lungs. There was a significant difference between the intervention group (A) and control group (B) when instructed to point to the dome of the diaphragm on the cadaver posteriorly (Fig. [NaN] ). All 15 of the students in the intervention group were able to point to its correct position (predetermined and verified using ultrasound) while only 9 of the 15 students in the control group were able to (within two intercostal spaces). These results seem to indicate that students learn thoracic anatomy from the perspective of dissection and do not necessarily transfer that knowledge outside of that context. The same could probably be said for other structures such as the liver and kidneys. In light of this finding, it may be beneficial to include a posterior prosection of the thorax and abdomen in the laboratory for this additional perspective. The ability to understand the location of organs in the intact body is especially important when it comes to interpreting ultrasound images.</p> <p>The improved confidence, competence and overall understanding of thoracic anatomy experienced by students who received the hands ‐ on, experiential training in the current study is consistent with other reports of the benefits of clinical simulations (Morgan and Cleave ‐ Hogg, [<reflink idref="bib22" id="ref67">22</reflink>] ; Devitt et al., [<reflink idref="bib8" id="ref68">8</reflink>] ; Steadman et al., [<reflink idref="bib35" id="ref69">35</reflink>] ). Even though the benefits of the current study were only analyzed over the short ‐ term, Liddell et al. ([<reflink idref="bib19" id="ref70">19</reflink>] ) reported that the acquisition of procedural skills in a more structured, low ‐ stress environment has long ‐ term effect on the level of competence in procedural skills and self ‐ rated confidence. In the educational literature, it has been estimated that taking part in simulated exercises (where students practice what they have learned) could result in up to 75% retention compared to retaining 20% of what they hear in a lecture (Lalley and Miller, [<reflink idref="bib16" id="ref71">16</reflink>] ).</p> <p>Although the current study describes the usefulness of an unembalmed cadaveric preparation in teaching chest percussion, it would also work well for ultrasound laboratory sessions.</p> <p>Understanding the importance of such a demonstration, Zaia et al. ([<reflink idref="bib42" id="ref72">42</reflink>] ) conducted an ultrasound workshop with simulated conditions in an unembalmed cadaver (including orbital foreign body, retrobulbar hematoma, bone fracture and joint effusion). They intended to have the participants observe the pleural effusion that was described as “naturally occurring” in the cadaver, but turned out to be the only condition the participants did not improve in comfort of identifying. In another study, Salamonsen et al. ([<reflink idref="bib32" id="ref73">32</reflink>] ) used a pleural effusion phantom (Thoracentesis Phantom; Blue Phantom) to train medical students on using ultrasound to detect the presence of, and mark an appropriate site for drainage for, pleural effusion. However, the phantom model does not afford the realism of ventilated lungs and moving tissue planes. The unembalmed cadaveric preparation described in the current study provides a real ‐ life ultrasound image of the condition, with lung expansion and relaxation, and more realistic fluid removal with thoracentesis. It also allows students to visualize the movement of the visceral pleura relative to the parietal pleura during mechanical ventilation. The simulation described in the current study would be ideal for students learning to detect pleural effusion using ultrasound as well as performing fluid drainage.</p> <p>It would be understandable for one to question whether it would be worth the added time and cost to prepare an unembalmed cadaveric simulation to teach medical students about chest percussion when they are likely to learn how to use ultrasound as a more objective measure of diagnosing effusion (pleural or cardiac). The response to this valid question is twofold. First, chest percussion as a clinical screen continues to have diagnostic value during a physical examination, especially in environments and situations where clinicians may not have immediate access to advanced diagnostic imaging. Secondly, the results of this study indicate that the cadaveric simulation not only provided a means of teaching chest percussion, but also reinforced the understanding of the importance of using bony landmarks to locate structures in the intact body, a knowledge critical for establishing a starting point for understanding ultrasonography.</p> <p>Disadvantages to using unembalmed cadavers include cost, availability and storage (requires dedicated facility). However, the Anatomy Bequest Program at the University of Minnesota has the ability to provide embalmed or unembalmed cadavers for teaching medical students, depending on the purpose. The cost of the unembalmed cadaveric exercise in the current study were kept at a minimum because the bodies were useful for other courses and research projects. It is recognized that many programs do not have access to, or storage facilities for, unembalmed cadavers.</p> <hd id="AN0121502213-12">Study Limitations</hd> <p>This study has a number of limitations, including the small size of the group of participants (which may have interfered with determining statistical significance), observer ‐ dependent scoring on test day (although the observer was “blind” to participant's group), the use of unvalidated test instruments (surveys and check ‐ lists), potential cadaveric anxiety and the lack of hand ‐ written comments from participants.</p> <p>Because of the small sample size, coupled with the limited possible variation on the dichotomous items (i.e., evaluation on testing day items and post ‐ survey part 2 items), the current analysis is likely underpowered in regard to these items. As such, non ‐ significant findings should be interpreted with caution, particularly for the dichotomous items where the P ‐ value is less than 0.20. For the items where the P ‐ value is less than 0.20, it is probable that increasing the variation in the response options and/or increasing the sample size (and therefore statistical power) would reduce the magnitude of these P ‐ values. In other words, the non ‐ significant results associated with P ‐ values less than 0.20 likely represent Type II errors.</p> <p>Another limitation pertains to the test instruments used. The surveys and test day assessment were designed by the authors to assess aspects of confidence and competence with the subject matter considered to be relevant. None were validated or assessed for reliability. For a test to be valid, it must (<reflink idref="bib1" id="ref74">1</reflink>) test what it purports to test and (<reflink idref="bib2" id="ref75">2</reflink>) give results that are reproducible (i.e., give the same results on repeated applications). Future work will attempt to validate the test instruments.</p> <p>In addition, the anxiety around working with the unembalmed cadaver simulation cannot be ignored. This was the first time the students were involved in such a life ‐ like, hands ‐ on exercise. It is possible that the time the students in the intervention group spent with the cadaveric preparation eased some of their anxiety when they were evaluated on the testing day. Those students in the control group were evaluated on the testing day without the opportunity to acclimate to the ventilated cadaver.</p> <p>Finally, we recognize the lack of hand ‐ written qualitative research results, which may have provided additional direction for future studies. The qualitative surveys administered in this study were designed to assess student perceptions. The assessment of student perceptions from the quantitative surveys in this study were designed to assure standardization of qualitative results. For this reason, individual comments regarding student experience were not solicited.</p> <hd id="AN0121502213-13">CONCLUSIONS</hd> <p>Thirty students participated in a randomized controlled trial of an unembalmed cadaver model simulating pleural effusion. The study demonstrated the technical feasibility of the model to reproduce reliably a common clinical scenario (pleural effusion). The model can be used successfully to teach both assessment skills (chest percussion) and procedural skills (thoracocentesis and tube thoracostomy). The study also demonstrated (within the statistical limitations discussed above) that focused intervention can enhance anatomical and clinical skills learning.</p> <hd id="AN0121502213-14">ACKNOWLEDGMENTS</hd> <p>The authors would like to thank the donors to the University of Minnesota Anatomy Bequest Program for their thoughtfulness, generosity and important contribution.</p> <hd id="AN0121502213-15">NOTES ON CONTRIBUTORS</hd> <p>MARK S. COOK, P.T., Ph.D., is an assistant professor and assistant director of the Program in Human Anatomy in the Department of Integrative Biology and Physiology at the University of Minnesota in Minneapolis, MN. He teaches human anatomy to undergraduates, dental students, medical students and residents. His research interest is in anatomical education.</p> <p>PETER J. KERNAHAN, M.D., Ph.D., is an assistant professor and lecturer in the Department of Integrative Biology and Physiology and adjunct associate professor of surgery at the University of Minnesota Medical School in Minneapolis, MN. He teaches human anatomy to undergraduates, dental students, medical students and residents. His research interest is in surgical anatomy education.</p> <hd id="AN0121502213-16">LITERATURE CITED</hd> <p>1 Aboud E, Al ‐ Mefty O, Yaşargil MG. 2002. New laboratory model for neurosurgical training that simulates live surgery. 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Teaching procedural skills to medical students: One institution's experience with an emergency procedures course. Ann Emerg Med 40 : 41 – 49.</item> <item>41 Weaver ME, Kyrouac JP, Frank S, Rabinovich S. 1986. A cadaver workshop to teach medical procedures. Med Educ 20 : 407 – 409.</item> <item>42 Zaia BE, Briese B, Williams SR, Gharahbaghian L. 2012. Use of cadaver models in point ‐ of ‐ care emergency ultrasound education for diagnostic applications. J Emerg Med 43 : 683 – 691.</item> </ulist> <p>Graph: Unembalmed cadaveric preparation with body in naturally slumped position, upper limbs resting on a table. A ventilation tube is attached to a tracheotomy tube (hidden by blanket) for mechanical ventilation. This was the only part of the cadaver the students accessed for hands ‐ on training and testing of chest percussion.</p> <p>Graph: Test day assessment. Each bar represents the number of “yes” responses (out of 15) to each question. Group A, intervention; Group B, control.</p> <p>Graph: Comparison of mean responses from pretest questionnaire (combined A + B) and post ‐ test questionnaire for Group A (intervention) and Group B (control). Means were determined from five ‐ point Likert scale: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; and 5, strongly agree.</p> <p>Graph: Supplemental post ‐ survey questions for Groups A and B. Each bar represents the number of “yes” responses (out of 15) to each question. Group A, intervention; Group B, control.</p> <p>Graph: Post ‐ test survey questions for Group A only with “yes” or “no” answers (n = 15).</p> <aug> <p>By Mark S. Cook and Peter J. Kernahan</p> </aug> <nolink nlid="nl1" bibid="bib1" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib2" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib3" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib15" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib13" firstref="ref5"></nolink> <nolink nlid="nl6" bibid="bib29" firstref="ref6"></nolink> <nolink nlid="nl7" bibid="bib4" firstref="ref7"></nolink> <nolink nlid="nl8" bibid="bib36" firstref="ref8"></nolink> <nolink nlid="nl9" bibid="bib27" firstref="ref9"></nolink> <nolink nlid="nl10" bibid="bib6" firstref="ref10"></nolink> <nolink nlid="nl11" bibid="bib9" firstref="ref11"></nolink> <nolink nlid="nl12" bibid="bib28" firstref="ref12"></nolink> <nolink nlid="nl13" bibid="bib24" firstref="ref13"></nolink> <nolink nlid="nl14" bibid="bib35" firstref="ref14"></nolink> <nolink nlid="nl15" bibid="bib42" firstref="ref15"></nolink> <nolink nlid="nl16" bibid="bib12" firstref="ref18"></nolink> <nolink nlid="nl17" bibid="bib5" firstref="ref19"></nolink> <nolink nlid="nl18" bibid="bib34" firstref="ref20"></nolink> <nolink nlid="nl19" bibid="bib41" firstref="ref21"></nolink> <nolink nlid="nl20" bibid="bib30" firstref="ref22"></nolink> <nolink nlid="nl21" bibid="bib23" firstref="ref23"></nolink> <nolink nlid="nl22" bibid="bib21" firstref="ref24"></nolink> <nolink nlid="nl23" bibid="bib31" firstref="ref27"></nolink> <nolink nlid="nl24" bibid="bib18" firstref="ref28"></nolink> <nolink nlid="nl25" bibid="bib17" firstref="ref30"></nolink> <nolink nlid="nl26" bibid="bib37" firstref="ref31"></nolink> <nolink nlid="nl27" bibid="bib25" firstref="ref32"></nolink> <nolink nlid="nl28" bibid="bib14" firstref="ref33"></nolink> <nolink nlid="nl29" bibid="bib33" firstref="ref34"></nolink> <nolink nlid="nl30" bibid="bib39" firstref="ref55"></nolink> <nolink nlid="nl31" bibid="bib10" firstref="ref56"></nolink> <nolink nlid="nl32" bibid="bib7" firstref="ref57"></nolink> <nolink nlid="nl33" bibid="bib11" firstref="ref59"></nolink> <nolink nlid="nl34" bibid="bib40" firstref="ref62"></nolink> <nolink nlid="nl35" bibid="bib20" firstref="ref63"></nolink> <nolink nlid="nl36" bibid="bib26" firstref="ref64"></nolink> <nolink nlid="nl37" bibid="bib38" firstref="ref66"></nolink> <nolink nlid="nl38" bibid="bib22" firstref="ref67"></nolink> <nolink nlid="nl39" bibid="bib8" firstref="ref68"></nolink> <nolink nlid="nl40" bibid="bib19" firstref="ref70"></nolink> <nolink nlid="nl41" bibid="bib16" firstref="ref71"></nolink> <nolink nlid="nl42" bibid="bib32" firstref="ref73"></nolink>
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: An Unembalmed Cadaveric Preparation for Simulating Pleural Effusion: A Pilot Study of Chest Percussion Involving Medical Students
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Cook%2C+Mark+S%2E%22">Cook, Mark S.</searchLink><br /><searchLink fieldCode="AR" term="%22Kernahan%2C+Peter+J%2E%22">Kernahan, Peter J.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Anatomical+Sciences+Education%22"><i>Anatomical Sciences Education</i></searchLink>. Mar-Apr 2017 10(2):160-169.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Wiley-Blackwell. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8598; Fax: 781-388-8232; e-mail: cs-journals@wiley.com; Web site: http://www.wiley.com/WileyCDA
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 10
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2017
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Audience
  Label: Education Level
  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Anatomy%22">Anatomy</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Education%22">Medical Education</searchLink><br /><searchLink fieldCode="DE" term="%22Science+Instruction%22">Science Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Human+Body%22">Human Body</searchLink><br /><searchLink fieldCode="DE" term="%22Simulation%22">Simulation</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Experimental+Groups%22">Experimental Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Control+Groups%22">Control Groups</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Hands+on+Science%22">Hands on Science</searchLink><br /><searchLink fieldCode="DE" term="%22Measurement+Techniques%22">Measurement Techniques</searchLink><br /><searchLink fieldCode="DE" term="%22Self+Efficacy%22">Self Efficacy</searchLink><br /><searchLink fieldCode="DE" term="%22Skills%22">Skills</searchLink><br /><searchLink fieldCode="DE" term="%22Learner+Engagement%22">Learner Engagement</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1002/ase.1640
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1935-9772
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Cadaveric simulations are an effective way to add clinical context to an anatomy course. In this study, unembalmed (fresh) cadavers were uniquely prepared to simulate pleural effusion to teach chest percussion and review thoracic anatomy. Thirty first-year medical students were assigned to either an intervention (Group A) or control group (Group B). Group A received hands-on training with the cadaveric simulations. They were instructed on how to palpate bony landmarks for identifying the diaphragm and lobes of the lungs, as well as on how to properly perform chest percussion to detect abnormal fluid in the pleural space. Students in Group B practiced on each other. Students in Group A benefited from the training in several ways. They had more confidence in their percussive technique (A = mean 4.3/5.0, B = 2.9/5.0), ability to count the ribs on an intact body (A = mean 4.0/5.0, B = 3.0/5.0), and ability to identify the lobes of the lungs on an intact body (A = mean 3.8/5.0, B = 2.3/5.0). They also demonstrated a greater ability to locate the diaphragm on an intact body (A = 100%, B = 60%) and detect abnormal pleural fluid (A = 93%, B = 53%) with greater confidence (A = mean 3.7/5.0, B = 2.5/5.0). Finally, the hands-on training with the unembalmed cadavers created more excitement around learning in Group A compared with Group B. This study shows that simulating pleural effusion in an unembalmed cadaver is a useful way to enhance anatomy education.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2017
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1131890
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1131890
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1002/ase.1640
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 160
    Subjects:
      – SubjectFull: Anatomy
        Type: general
      – SubjectFull: Medical Education
        Type: general
      – SubjectFull: Science Instruction
        Type: general
      – SubjectFull: Human Body
        Type: general
      – SubjectFull: Simulation
        Type: general
      – SubjectFull: Medical Students
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Experimental Groups
        Type: general
      – SubjectFull: Control Groups
        Type: general
      – SubjectFull: Comparative Analysis
        Type: general
      – SubjectFull: Hands on Science
        Type: general
      – SubjectFull: Measurement Techniques
        Type: general
      – SubjectFull: Self Efficacy
        Type: general
      – SubjectFull: Skills
        Type: general
      – SubjectFull: Learner Engagement
        Type: general
      – SubjectFull: Instructional Effectiveness
        Type: general
    Titles:
      – TitleFull: An Unembalmed Cadaveric Preparation for Simulating Pleural Effusion: A Pilot Study of Chest Percussion Involving Medical Students
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            NameFull: Cook, Mark S.
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            NameFull: Kernahan, Peter J.
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              Y: 2017
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              Value: 1935-9772
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              Value: 10
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            – TitleFull: Anatomical Sciences Education
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