Is it better to watch before or listen while doing? A randomized trial of video-modelling versus telementoring for out-of-scope tube thoracostomy insertion performed by search and rescue medics

Background: Most trauma deaths occur prehospital before a patient can be transported to definitive care. Remote lifesaving interventions (RLSIs) are thus required to save lives and may need to be performed by nonsurgical providers. Informatics may assist such providers. Theoretical assistance may be provided through expert remote telementoring (RTM) or just-in-time video modelling (VM), a form of behavioural modelling, wherein a video tutorial is reviewed immediately before the RLSI, with no current data to favour either method. Methods: Search and rescue technicians (SAR techs) were asked to perform a tube thoracostomy (TT) on a realistic surgical simulator. SAR techs were randomly allocated to RTM or VM. The VM group watched a preprepared video illustrating TT immediately before the procedure. Participants in the RTM group wore a heads-up video camera and were guided by a trauma surgeon giving real-time guidance. Standard outcomes included basic demographics as well as objective measures of success, safety and tube security for the TT procedure. Results: Twenty-four SAR techs (23 men, 1 woman), with a median age of 37 years (interquartile range 12 yr) and a median of 16.5 years (IQR 11 yr) of military experience participated. There was no difference in age, gender or years of experience between the groups. Thirteen were randomly assigned to VM with 12 of 13 (92%) being successful, 12 of 13 (92%) safe, and 12 of 13 (92%) secure in their TT placement. Eleven were randomly assigned to RTM with 11 of 11 (100%) being successful, 11 of 11 (100%) safe and 11 of 11 (100%) secure in mentored TT placement. The total trial time was significantly faster using RTM when the time to watch the video was included (VM 290 s [standard deviation (SD) 38 s] v. RTM 244 s [SD 50 s], p = 0.02) with mentoring, even despite 3 (27.2%) of the sessions experiencing video disruptions (albeit with intact audio). However, if the time to watch the video was discounted, VM was quicker (VM 114 s [SD 38 s] v. RTM 244 s [SD 50 s], p < 0.001). Statistically, there was no difference (p = 1.00) between mentored (11) or video-modelled SAR techs in terms of safety, success or tube security when performing the TT. However, with VM, 1 subject cut himself with the scalpel, 1 did not puncture the pleura and 1, while deemed safe, technically successful and secure, had a barely adequate tube placement. There were no such issues in the mentored group. Conclusion: Random evaluation of out-of-scope RLSIs