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MILITARY MEDICINE 177, 11:1316,2012

Mobile Learning Module Improves Knowledgeof Medical Shoofor Forward Surgioal Team MembersCarlI Schulman, MD,PhD ; LTC GeorgeD Garoia, MC USAf;M ary M.Wyckoff PhD ;

RobertC.Duncan, PhD ;KellyF. Withum,BS ;JillGraygo, MA, MPHABSTRACT Objective: Acute trauma care is characterized by dynamic situations that require adequate preparation toensure success for military health professionals. The use of mobile leaming in this environmetit can provide a solutionthat standardizes education and replaces traditional didactic lectures. Methods; A comparative evaluation with a pre-post test design regarding medical shock was delivered via either a didactic lecture or a mobile learning video module toU.S. Army Forward Surgical Team (FST) members. Participants completed a pretest, were randomly assigned totreatment group by FST, and then completed the post-test and scenario asses.sment. Results: One-hundred and thirteen FSTmembers patlicipated with 53 in the rnobile learning group and 60 in the lecture group (control). The percent mean scorefor the mobile learning group increased frotn 43.6 to 70 from pretest to post-test, with a scenario mean score of M =56.2. The percent mean score for the control group increased from 41.5 to 72.5, with a scenario mean score of M= 59.7.The two-way analysis of variance m ean score difference was 26.4 for the mobile learning group and 31.0 for the control,F = 2.18, (p = 0.14). Conclusions: Mobile leaming modules, coupled with a structured assessment, have the potential toimprove educational experiences in civilian and military settings.

INTRODU TIONMobile learning presents unique opportunities and challengesin a variety of health care settings, including hospitals, fieldresponse, and austere environments. The use of mobile leam-ing for trauma can provide a solution that standardizes edu-cation, replaces traditional didactic lectures, and facilitates just-in-time comm unication at the point-of-care. Residentsin surgical specialties are required to perform a rotation in atrauma and critical care department in order to gamer hands-on trauma patient treatment and management experience forboard certification as general surgeons.

Since the educational needs ofthetrainee are subordinate tothe needs of the patient in crisis-oriented emergency and criti-cal care settings, it is difficult for educa tors to facilitate leam -ing and for residents to gain hands-on experience . Additionally,with the growing trend of minimally invasive procedures,'opportunities for clinical leaming and practice have decreasedby as much as 30%.^ Researchers found that 64% of the physi-cian's informational needs were not being met during theirteaching rounds. * These limitations have challenged educatorsto find innovative solutions that seek to overcome limited fac-ulty resources and time constraints while also improving thequality of medical education as a whole.'*' '

E-leaming in general and mobile leaming in particularoffer models of leaming through which caregivers in chaoticand austere environments can have ongoing access to infor-mational resources, especially at the point-of-care.^ E-leamingrefers to the general use of electronic or World Wide Web-

Department of Surgery, University of Miami Miller School of Medi-cine,PO Box 016960 (D-40), Miami, FL33101.

t Army Trauma Training Center, Ryder Trauma Center, Jackson Memo-rial Hospital, 1800 NW 10th Avenue, T215, Miami, FL 33186.doi: 10.7205/MILMED-D-12-00155

based technology to deliver an array of solutions that enhanknow ledge and performance.^ Mobile learning is a subtypee-leaming that uses personal digital assistants to bring latest information to the point-of-care, with or without Innet access.^ These comprehensive technologies target bknowledge delivery and leaming enhancement in orderbuild knowledge and skills.^'* This is especially promiswhen these technological advancements utilize both mumedia instructional methods and content.'^'''' Mobile leamallows students to access the information according to thown schedules and provides additional opportunities review material as needed.Researchers have recently begun to assess the utilitynew education technologies. Some studies suggest that ingrating e-leaming technologies into an interprofessional heascience courses did not improve outcomes as comparedtraditional face-to-face group m ee tin g. However, .sevstudies have found that leaming improvements, resultfrom new educational platforms (i.e., technological advanments, mobile learning, and e-leaming), are equivalent

those resulting from traditional lecture formats. One stfound that medical students' performance on a urology knoedge acquisition examination, following a computer aileaming software program and after a standard lecture fmat, was statistically similar.'^ The focus of this evaluatdemonstrates statistical equivalence between mobile- lecture-based leaming in military trauma settings.METHODSU.S. Army Forward Surgical Team (FST) members rotatthrough the University of Miami/Ryder Trauma Center at Army Trauma Training Center (ATTC) from August 2010March 2011 were invited to participate in the evaluation. OFST per month trains at the ATTC for a duration of 2 we

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Mobile Learning for Foiward Surgical Team Membersbefore theii- intemational deploymen t. Consenting paiticipantswere randomly assigned to either the control group, whichconsisted of the traditional didactic lecture on medicalshock, or the mobile learning group, which viewed the shockmobile leaming lecture on an iPod Touch (Apple, Cupertino,California). The participants were randomly assigned to themobile leaming or control group as an entire FST to preventvideo information sharing while they were living in suchclose quarters.

Department of Surgery faculty and trauma fellows cre-ated the module content, which was then refined and editedby our Director of Surgical Education. The preproductionfinal product includes a PowerPoint (Microsoft, Redmond,Washington) presentation with an associated script. The pro-duction company uses these components, along with a nar-rated voice file of the script, to assure proper medicalpronunciation. The production company then works closelywith the Director of Surgical Education to create a high-quality multimedia presentation complete with professionalvoice, soundtrack, and live video or animation as neces-saiy. An iterative process and further information specificto particular anatomy or physiology are often required toenable the production company to understand the materialand transform it into an engaging leaming module.This evaluation used a pre-post test design to measuresubject matter knowledge, in this case the classification andtreatment of medical shock. The pretest and post-test wascreated by an expert panel of trauma and critical care cliniciansthat used the shock module script to derive the questions. The

pretest and post-test consisted of the same 10 multiple choicequestions (Appendix A). The patient case scenario assess-ment consisted of five multiple choice questions that includedtwo case scenarios with physical descriptions of the patients(Appendix B). All research assessments were pilot-testedwith a sample population of physicians.The pretests were disseminated and collected by a researchassistant immediately before participants viewed either themobile leaming module or the actual live lecture. Once allpretests were collected, students participating in the didacticlecture remained in the lecture hall with their peers andviewed the PowerPoint lecture given by a Department of Sur-

gery faculty member. The length of the lecture was approxi-mately 45 minutes. The PowerPoint lecture and script wereidentical to the mobile leaming module, but without the ani-mation or multimedia content. Students in the interventiongroup were given an iPod Touch with headphones and wereinstructed to access and view the entire shock module one time.The length of the shock mobile leaming module was 10 min-utes and 31 seconds. Upon completion, the iPod was col-lected by the research assi.stant. Immediately followingeither the lecture or viewing of the mobile leaming module,the research assistant again disseminated and collected thepost-test and a patient case scenario assessment that wasadministered to measure application of knowledge. All datacollected were coded and nonidentifiable. Informed consent

was obtained from all the participants, and the research studywas exempt approved by the Department of Defense andUniversity Institutional Review Boards.Databases were created using Excel (Microsoft, Redmond,Washington) and data were analyzed using SAS 9.2. Two-way analysis of variance tests were perfoiTned that comparedthe pre- and post-test score differences between the mobileand control groups, significance considered at p =0.05 level.Mean scores are represented in percentages with SD.R SU TSA total of 113 FST members from the ATTC participated inthe study. There were 53 FST members in the mobile leam-ing group and 60 in the didactic lecture control group(Table I). Descriptive statistics and a means comparison wereused to analyze the data. The percent mean score (SD) for themobile leaming group increased from 44 23 to 70 + 20from pretest to post-test, with a scenario assessment meanscore of 56 26. The percent mean score for the controlgroup also increased from 42 + 21 to 73 18 from pretest topost-test, with a scenario assessment mean score of 60 29.There was only one FST member from the control group thathad a decrease in score from pretest to post-test (10%) withno mobile leaming group participants decreasing their scores.A 2-way analysis of variance w as performed on the pretestand post-test score differences in order to compare the mob ileand control groups. For the mobile group, the mean differ-ence between the pretest and post-test score was 26.4 18.0.For the control group, the mean difference between the pre-test and post-test score was 31.0 18.0. Comparing the meandifferences in mobile and control groups resulted in anFvalueof 2.18, w hich w as not significant {p =0.14).Results nalysisby ositionIn the mobile leam ing group , there were 18 med ics, 24 nurses(Registered Nurses [RNs], Licenced Practical Nurses [LPNs],and Certified Registered Nurse Anestheti.sts [CRNAs]), physician assistant (PA), and 10 technicians (operating room andsurgical). The 60 participants in the control didactic lecturegroup had a similar breakdown of 22 medics, 21 nurses (RNs,LPNs, and CRNAs), 5 PAs, and 12 technicians (operatingroom and surgical). Table I demonstrates the breakdown ofthe different positions, mobile leam ing, and control groups.The means for pretest and post-test for the 18 medics inthe mobile leaming group wereM = 41 7 17.6 and 65.6 19.8, respectively, with a scenario assessment mean score of

TABLE 1.

FST MembersTotalMedicsNursesTechniciansPA

StudyMobile

531824101

PopulationControl

60222112

5

Total113404522

6

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Mobile Learning for Forward Surgical Team MembersM - 52.2 24. The mean difference betw een the pretest andpost-test score was 23.9 14.2. The means for pretest andpost-test for the 22 medics in the didactic lecture control groupwere M = 36.4 16.8 and 65.9 + 19, respectively, with ascenario assessment m ean score of M = 56.4 29.4. The meandifference between the pretest and post-test score was 29.5 18.1. Comparing the mean differences in mobile and controlgroups resulted in an F value of 0.98, which was not signifi-cant{p 0.32). Results are summarized in Tables II and III.

The m eans for pretest and post-test for the 24 nurses in themobile learning group were M = 50.8 25.7 and 78.8 15.4,respectively, with a scenario assessment mean score of M =69.2 22. The mean difference between the pretest and post-test score was 27.9 20.8. The means for pretest and post-test for the 21 nurses in the didactic lecture control groupwere M = 52.4 18.4 and 80.9 14.5, respectively, with ascenario assessment mean score of M = 72.4 18.4. Themean difference between the pretest and post-test score was28.6 17.4. Compai'ing the mean differences in mobile andcontrol groups resulted in anFvalue of 0.01, which was notstatistically significant {p= 0.90).

The means for pretest and post-test for the 10 techniciansin the mobile leaming group wereM - 25.0 8.5 and 54.0 19, respectively, with a scenario assessment mean score ofM = 30.0 + 19.4. The mean difference between the pretestand post-test score was 29.0 17.9. The means for pretestand post-test for the 12 technicians in the didactic lecturecontrol group wereM =22.5 10.6 and 62.5 16.6, respec-tively, with a scenario assessment mean score of M = 31.7 24.8. The mean difference between the pretest and post-testscore was 40.0 18.0. Comparing the mean differences inmobile and control groups resulted in an F value of 2.04,which was not statistically significant p =0.16).The mean for pretest and post-test for the one PA in themobile leaming group was M = 90.0 and 100, respectively,with a scenario assessment mean score of M = 80.0. Themean difference between the pretest and post-test score was10.0. The means for pretest and post-test for the five PAs inthe didactic lecture control group were M =64.0 16.7 and

TABLE II. FST MobileLeaming Group Mean Score Percent SDPosition

MedicNurseTechniciansPA

Pretest41.7 17.650.8 25.725.0 8 .5

90 0

Post-Test65.6+ 19.878.8 15.454.0 191 0

Scenario52.2 2469.2 22

30 19.480 0

TABLE III. FST Control Group Mean Score Percent SDPosition

MedicNurseTechniciansPA

Pretest36.4 16 .852.4 18.422.5 10.664.0 16.7

Post-Test65.9 1980.9 14.562.5 16.690.0 0

Scenario56.4 29.472.4 18.431.7 24.888.0 11

90.0 0, respectively, with a scenario assessment mean scof M = 88.0 11. The mean difference between the preand post-test score was 26.0 16.7. Comparing the mdifferences in mo bile and control groups resulted in anFvaof 0.66, which was not significant {p =0.42).There were no statistically significant differences fou

between the mobile and control groups in any of the differstudy populations. This suggests the two leaming modalitare equally effective. Figure 1 shows the comparison of mscore differences by group and FST member position.IS USSIONThe current data suggest that mobile leaming modules equivalent to traditional didactic lectures in trauma and crcal care for FST members. Both groups performed betterthe post-test than the pretest with a nonsignificant mean scdifference. The benefit of mobile leaming is found whcomparing the time needed for education. Traditionally, ttype of education is delivered as a didactic modality, whconsumes valuable time that could be spent on handssimulation and training activities. For comparison, many ditional didactic lectures are 30 to 60 minutes, whereas mobile leaming module is 10 minutes. The mobile leammodules can be paused and rewatched and do not requireinstructor, thus making it an ideal solution for educating FST members in austere deployment settings.

Trauma and critical care education currently face the cstant challenge of increasing time constraints as a resultclinical hour limitations, increased amounts of informatrequired to be retained, and the need for immediate abilityaccess infonnation in a trauma and critical care situat( just-in-time leaming ). Properly designed mobile leammodules can help to mitigate these significant challenges.addition, best practices like limiting written text on screaudio capability, and high-quality graphics are essentialthe success of any mobile module.' *

This prospective study was subject to certain limitatithat were primarily methodological in nature. The participa

Mobile Control

Medic Nurse Tech PAFST Member Position

FIGURE 1 . Comparison of mean score differences by group and posiThere were no statistically significant differences found between mobile control groups in each of the different study populations. This suggests the two leaming m odalities are not different.

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Mobile Learning for oiward Surgical Team Members

inistered 1 month after intervention, to deter-

earner satisfaction are two key outcomes that must be mea-ured when assessing this type of education.^'^The goal of this investigation was to determine whether

earn the medical shock module equally well with either theobile leaming modules or the traditional didactic lecture.his suggests that mobile learning modules are an effectiveeans of providing the same knowledge in about one-quarterhe amount of time needed to provide it in traditional d idacticlectures. Mobile learning modules, coupled with a structuredassessment, have the potential to improve educational expe-iences in civilian and military settings.

ACKNOWLEDGMENTShe authors thank the Army Trauma Training Center staff for their supportin completing this study. This work was funded by a Department of DefenseTelemedicine and Advanced Technology Research Center (TATRC) GrantW81XWH-09-1-0703.

APPENDIXA:PRETEST AND POST TESTFOR SHOCK(1) Hypovolemic shock is best defined as:

(a) Inadequate urine output(b) Low blood pressure(c) Massive blood loss(d) Inadequate tissue petfusion

(2) The first step in the treatment of hyp ovolemic shock is:(a) Crystalloid infusion(b) Blood transfusion(c) Secure the airway(d) Place a large central line

(3) The amount of blood loss in Class II shock is:(a) 500 to 750 cc(b) 750 to 1500(c) 1500 to 2000(d) >2000(4) One of the signs of Class II shock is:

(a) Hypotension(b) Oliguria(c) Confusion(d) Tachycardia

(5) Cardiogenic shock in the trauma patient may be sug-gested by:

(a) Tachycardia(b) Narrow Pulse Pressure(c) Jugular Venous Distension(d) Prominent heart sounds(6) The etiology of hypotension caused by septic shock maybe suggested by:

(a) Decreased capillary refill(b) Warm skin(c) Tachycardia(d) Decreased breath sounds(7) One of the most important aspects in the treatment ofseptic shock is:(a) Fever control(b) Source control(c) Multiple cultures(d) Limiting antibiotic therapy

(8) Neurogenic shock is caused by:(a) Decreased peripheral vasomotor tone(b) Traumatic brain injury(c) Seizures(d) Drug overdose

(9) A distinguishing feature of neurogenic shock is:(a) Marked tachypnea(b) Elevated catecholamine levels(c) Bradycardia(d) Cool, clammy skin

(10) Hypoadrenal shock should be considered if tbe cortisollevel is below:(a) 15 meg(b) 20 meg(c) 25 meg(d) 30 meg

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Mobile Learning for orward Surgical Team MembersAPPENDIX B: SCENARIO TEST FOR SHO CKPlease read the following patient scenarios and then theaccompanying question.CASE SCENARIOA patient arrives after a motor vehicle crash in which he wasa restrained driver, involved in a t-bone crash on the driver'sside.He presents with a Glasgow Coma Score of 15, a bloodpressure of 90/60, and a heart rate of 120. He complains ofback pain and abdominal pain, but has no peritoneal signs.Physical Description

N ormal oropharyngeal examinationNo facial traumaNo signs of respiratory distressCool and clammy skinU nable to move legs and weak arm movement

(1) This patien t most likely is suffering from?(a) Hypovolemic shock(b) Septic shock(c) Neurogenic shock(d) Cardiogenic shock(e) Hypoadrenal shockThe patient responds well to resuscitation but over the nexthour has another progressive decline in his vital signs. Contin-ued fluid administration does not seem to help the situation.All diagnostic tests so far (Chest X-ray [CXR], Pelvis X-ray,and Focused Assessment for Sonography in Trauma [FAST]

examination) have been negative. On reexamination, younotice he is now bradycard ic and has warm skin.(2) You are now suspicious for which type of shock.

(a) Hypovolemic shock(b) Septic shock(c) Neurogenic shock(d) Cardiogenic shock(e) Hypoadrenal shockThe patient is then admitted to the intensive care unit(ICU) and is eventually intubated for progressive respiratory

distress. In ICU day number 7, he is noted to be febrile andtachycardie. On physical examination, he has warm skinand intermittent hypotension. He is becoming oliguric.(3) The most likely cause for his hypotension is now:

(a) Hypovolemic shock(b) Septic shock(c) Neurogenic shock(d) Cardiogenic shock(e) Hypoadrenal shockCASE SCENARIO 2A 70-year-old pedestrian hit by car is admitted with a mildtraumatic brain injury, pulmonary contusions, and long-bone

fractures. He is in the ICU for continued monitoring. rounds in the moming, you notice he has been several lipositive on his fluid balance for the past few days. He is noliguric and hypotensive. He does not respond well to fchallenges. You notice he has JVD and an S3 gallup on phical ex amination.(4) The most likely cause for his hypotension is:

(a) Hypovolemic shock(b) Septic shock(c) Neurogenic shock(d) Cardiogenic shock(e) Hypoadrenal shockFurther diagnostic testing reveals a normal CXR. An eccardiogram shows a normal ejection fraction of 60 (normal heart function).

(5) The most likely diagnosis in this patient is:(a) Tension pneumothorax(b) Pulmonary embolus(c) Cardiac tamponade(d) Myo cardial infarction

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