MILITARY MEDICINE, 177, 11:1316,2012

Mobile Learning Module Improves Knowledge of Medical Shook for Forward Surgioal Team Members
Carl I. Schulman, MD, PhD*; LTC George D. Garoia, MC USAf; Mary M. Wyckoff, PhD*; Robert C. Duncan, PhD*; Kelly F. Withum, BS*; Jill Graygo, MA, MPH*
ABSTRACT Objective: Acute trauma care is characterized by dynamic situations that require adequate preparation to ensure success for military health professionals. The use of mobile leaming in this environmetit can provide a solution that standardizes education and replaces traditional didactic lectures. Methods; A comparative evaluation with a prepost test design regarding medical shock was delivered via either a didactic lecture or a mobile learning video module to U.S. Army Forward Surgical Team (FST) members. Participants completed a pretest, were randomly assigned to treatment group by FST, and then completed the post-test and scenario asses.sment. Results: One-hundred and thirteen FST members patlicipated with 53 in the rnobile learning group and 60 in the lecture group (control). The percent mean score for 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 mean 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 to improve educational experiences in civilian and military settings.

INTRODUCTION Mobile learning presents unique opportunities and challenges in a variety of health care settings, including hospitals, field response, and austere environments. The use of mobile leaming for trauma can provide a solution that standardizes education, replaces traditional didactic lectures, and facilitates "just-in-time" communication at the point-of-care. Residents in surgical specialties are required to perform a rotation in a trauma and critical care department in order to gamer handson trauma patient treatment and management experience for board certification as general surgeons. Since the educational needs of the trainee are subordinate to the needs of the patient in crisis-oriented emergency and critical care settings, it is difficult for educators to facilitate leaming and for residents to gain hands-on experience. Additionally, with the growing trend of minimally invasive procedures,' opportunities for clinical leaming and practice have decreased by as much as 30%.^ Researchers found that 64% of the physician's informational needs were not being met during their teaching rounds."* These limitations have challenged educators to find innovative solutions that seek to overcome limited faculty resources and time constraints while also improving the quality of medical education as a whole.'*'"' E-leaming in general and mobile leaming in particular offer models of leaming through which caregivers in chaotic and austere environments can have ongoing access to informational resources, especially at the point-of-care.^ E-leaming refers to the general use of electronic or World Wide Web-

based technology to deliver an array of solutions that enhance knowledge and performance.^ Mobile learning is a subtype of e-leaming that uses personal digital assistants to bring the latest information to the point-of-care, with or without Internet access.^ These comprehensive technologies target both knowledge delivery and leaming enhancement in order to build knowledge and skills.^'* This is especially promising when these technological advancements utilize both multimedia instructional methods and content.'^'''' Mobile leaming allows students to access the information according to their own schedules and provides additional opportunities to review material as needed. Researchers have recently begun to assess the utility of new education technologies. Some studies suggest that integrating e-leaming technologies into an interprofessional health science courses did not improve outcomes as compared to traditional face-to-face group meeting." However, .several studies have found that leaming improvements, resulting from new educational platforms (i.e., technological advancements, mobile learning, and e-leaming), are equivalent to those resulting from traditional lecture formats. One study found that medical students' performance on a urology knowledge acquisition examination, following a computer aided leaming software program and after a standard lecture format, was statistically similar.'^ The focus of this evaluation demonstrates statistical equivalence between mobile- and lecture-based leaming in military trauma settings. METHODS U.S. Army Forward Surgical Team (FST) members rotating through the University of Miami/Ryder Trauma Center at the Army Trauma Training Center (ATTC) from August 2010 to March 2011 were invited to participate in the evaluation. One FST per month trains at the ATTC for a duration of 2 weeks

* Department of Surgery, University of Miami Miller School of Medicine, PO Box 016960 (D-40), Miami, FL 33101. t Army Trauma Training Center, Ryder Trauma Center, Jackson Memorial Hospital, 1800 NW 10th Avenue, T215, Miami, FL 33186. doi: 10.7205/MILMED-D-12-00155

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before theii- intemational deployment. " Consenting paiticipants were randomly assigned to either the control group, which consisted of the traditional didactic lecture on medical shock, or the mobile learning group, which viewed the shock mobile leaming lecture on an iPod Touch (Apple, Cupertino, California). The participants were randomly assigned to the mobile leaming or control group as an entire FST to prevent video information sharing while they were living in such close quarters. Department of Surgery faculty and trauma fellows created the module content, which was then refined and edited by our Director of Surgical Education. The preproduction final product includes a PowerPoint (Microsoft, Redmond, Washington) presentation with an associated script. The production company uses these components, along with a narrated voice file of the script, to assure proper medical pronunciation. The production company then works closely with the Director of Surgical Education to create a highquality multimedia presentation complete with professional voice, soundtrack, and live video or animation as necessaiy. An iterative process and further information specific to particular anatomy or physiology are often required to enable the production company to understand the material and transform it into an engaging leaming module. This evaluation used a pre-post test design to measure subject matter knowledge, in this case the classification and treatment of medical shock. The pretest and post-test was created by an expert panel of trauma and critical care clinicians that used the shock module script to derive the questions. The pretest and post-test consisted of the same 10 multiple choice questions (Appendix A). The patient case scenario assessment consisted of five multiple choice questions that included two case scenarios with physical descriptions of the patients (Appendix B). All research assessments were pilot-tested with a sample population of physicians. The pretests were disseminated and collected by a research assistant immediately before participants viewed either the mobile leaming module or the actual live lecture. Once all pretests were collected, students participating in the didactic lecture remained in the lecture hall with their peers and viewed the PowerPoint lecture given by a Department of Surgery faculty member. The length of the lecture was approximately 45 minutes. The PowerPoint lecture and script were identical to the mobile leaming module, but without the animation or multimedia content. Students in the intervention group were given an iPod Touch with headphones and were instructed to access and view the entire shock module one time. The length of the shock mobile leaming module was 10 minutes and 31 seconds. Upon completion, the iPod was collected by the research assi.stant. Immediately following either the lecture or viewing of the mobile leaming module, the research assistant again disseminated and collected the post-test and a patient case scenario assessment that was administered to measure application of knowledge. All data collected were coded and nonidentifiable. Informed consent

was obtained from all the participants, and the research study was exempt approved by the Department of Defense and University Institutional Review Boards. Databases were created using Excel (Microsoft, Redmond, Washington) and data were analyzed using SAS 9.2. Twoway analysis of variance tests were perfoiTned that compared the pre- and post-test score differences between the mobile and control groups, significance considered at p = 0.05 level. Mean scores are represented in percentages with SD. RESULTS A total of 113 FST members from the ATTC participated in the study. There were 53 FST members in the mobile leaming group and 60 in the didactic lecture control group (Table I). Descriptive statistics and a means comparison were used to analyze the data. The percent mean score (SD) for the mobile leaming group increased from 44 23 to 70 + 20 from pretest to post-test, with a scenario assessment mean score of 56 26. The percent mean score for the control group also increased from 42 + 21 to 73 18 from pretest to post-test, with a scenario assessment mean score of 60 29. There was only one FST member from the control group that had a decrease in score from pretest to post-test (10%) with no mobile leaming group participants decreasing their scores. A 2-way analysis of variance was performed on the pretest and post-test score differences in order to compare the mobile and control groups. For the mobile group, the mean difference between the pretest and post-test score was 26.4 18.0. For the control group, the mean difference between the pretest and post-test score was 31.0 18.0. Comparing the mean differences in mobile and control groups resulted in an F value of 2.18, which was not significant {p = 0.14).

Results Analysis by Position

In the mobile leaming group, there were 18 medics, 24 nurses (Registered Nurses [RNs], Licenced Practical Nurses [LPNs], and Certified Registered Nurse Anestheti.sts [CRNAs]), 1 physician assistant (PA), and 10 technicians (operating room and surgical). The 60 participants in the control didactic lecture group had a similar breakdown of 22 medics, 21 nurses (RNs, LPNs, and CRNAs), 5 PAs, and 12 technicians (operating room and surgical). Table I demonstrates the breakdown of the different positions, mobile leaming, and control groups. The means for pretest and post-test for the 18 medics in the mobile leaming group were M = 41.7 17.6 and 65.6 19.8, respectively, with a scenario assessment mean score of
TABLE 1. Study Population
Mobile FST MembersTotal Medics Nurses Technicians PA 53 18 24 10 1 Control 60 22 21 12 5 Total 113 40 45 22 6

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M - 52.2 24. The mean difference between the pretest and post-test score was 23.9 14.2. The means for pretest and post-test for the 22 medics in the didactic lecture control group were M = 36.4 16.8 and 65.9 + 19, respectively, with a scenario assessment mean score of M = 56.4 29.4. The mean difference between the pretest and post-test score was 29.5 18.1. Comparing the mean differences in mobile and control groups resulted in an F value of 0.98, which was not significant {p = 0.32). Results are summarized in Tables II and III. The means for pretest and post-test for the 24 nurses in the mobile 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 posttest score was 27.9 20.8. The means for pretest and posttest for the 21 nurses in the didactic lecture control group were M = 52.4 18.4 and 80.9 14.5, respectively, with a scenario assessment mean score of M = 72.4 18.4. The mean difference between the pretest and post-test score was 28.6 17.4. Compai'ing the mean differences in mobile and control groups resulted in an F value of 0.01, which was not statistically significant {p = 0.90). The means for pretest and post-test for the 10 technicians in the mobile leaming group were M - 25.0 8.5 and 54.0 19, respectively, with a scenario assessment mean score of M = 30.0 + 19.4. The mean difference between the pretest and post-test score was 29.0 17.9. The means for pretest and post-test for the 12 technicians in the didactic lecture control group were M = 22.5 10.6 and 62.5 16.6, respectively, with a scenario assessment mean score of M = 31.7 24.8. The mean difference between the pretest and post-test score was 40.0 18.0. Comparing the mean differences in mobile 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 the mobile leaming group was M = 90.0 and 100, respectively, with a scenario assessment mean score of M = 80.0. The mean difference between the pretest and post-test score was 10.0. The means for pretest and post-test for the five PAs in the didactic lecture control group were M = 64.0 16.7 and TABLE II.
Position Medic Nurse Technicians PA

90.0 0, respectively, with a scenario assessment mean score of M = 88.0 11. The mean difference between the pretest and post-test score was 26.0 16.7. Comparing the mean differences in mobile and control groups resulted in an F value of 0.66, which was not significant {p = 0.42). There were no statistically significant differences found between the mobile and control groups in any of the different study populations. This suggests the two leaming modalities are equally effective. Figure 1 shows the comparison of mean score differences by group and FST member position. DISCUSSION The current data suggest that mobile leaming modules are equivalent to traditional didactic lectures in trauma and critical care for FST members. Both groups performed better on the post-test than the pretest with a nonsignificant mean score difference. The benefit of mobile leaming is found when comparing the time needed for education. Traditionally, this type of education is delivered as a didactic modality, which consumes valuable time that could be spent on hands-on simulation and training activities. For comparison, many traditional didactic lectures are 30 to 60 minutes, whereas the mobile leaming module is 10 minutes. The mobile leaming modules can be paused and rewatched and do not require an instructor, thus making it an ideal solution for educating the FST members in austere deployment settings. Trauma and critical care education currently face the constant challenge of increasing time constraints as a result of clinical hour limitations, increased amounts of information required to be retained, and the need for immediate ability to access infonnation in a trauma and critical care situation ("just-in-time leaming"). Properly designed mobile leaming modules can help to mitigate these significant challenges. In addition, best practices like limiting written text on screen, audio capability, and high-quality graphics are essential to the success of any mobile module.'"* This prospective study was subject to certain limitations that were primarily methodological in nature. The participants

FST Mobile Leaming Group Mean Score Percent SD

Pretest 41.7 17.6 50.8 25.7 25.0 8.5 90 0 Post-Test 65.6+ 19.8 78.8 15.4 54.0 19 100 0 Scenario 52.2 24 69.2 22 30 19.4 80 0
Mobile Group Control Group

TABLE III.
Position Medic Nurse Technicians PA

FST Control Group Mean Score Percent SD

Pretest 36.4 16.8 52.4 18.4 22.5 10.6 64.0 16.7 Post-Test 65.9 80.9 62.5 90.0 19 14.5 16.6 0 Scenario 56.4 29.4 72.4 18.4 31.7 24.8 88.0 11
Medic Nurse Tech PA

FST Member Position FIGURE 1 . Comparison of mean score differences by group and position. There were no statistically significant differences found between mobile and control groups in each of the different study populations. This suggests that the two leaming modalities are not different.

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were randomly assigned to the mobile leaming or control group as an entire FST to prevent video information sharing while they were living in such close quarters. In addition, our study did not include a knowledge retention test, which would ideally be administered 1 month after intervention, to determine levels of infotTnation retention. This follow-up testing was prevented because of the intemational deployment of the FST after the training. Further data collection would aflow researchers to better understand how this type of leaming compares to traditional didactic lectures and how much knowledge is retained over time. Future research will include observational clinical research to evaluate if mobile leaming modalities change outcomes in clinical practice applications.

(2) The first step in the treatment of hypovolemic 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 C (c) 1500 to 2000 C C (d) >2000 C C (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 suggested by: (a) Tachycardia (b) Narrow Pulse Pressure (c) Jugular Venous Distension (d) Prominent heart sounds (6) The etiology of hypotension caused by septic shock may be 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 of septic 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 cortisol level is below: (a) 15 meg (b) 20 meg (c) 25 meg (d) 30 meg

CONCLUSIONS Although technological advances have allowed for the creation and advancement of multimedia leaming modules that can be reliably accessed by mobile technologies, additional evaluation and standardization is necessary.^'^"'^ Both validity studies that measure whether multimedia leaming modules are actually teaching what they are intended to teach and curricula that address what e-content should be included are still needed. Given tbe wide range in terms of quality of e-content currently available, knowledge acquisition and learner satisfaction are two key outcomes that must be measured when assessing this type of education.^'^ The goal of this investigation was to determine whether clinical trainees can appropriately use information provided via mobile leaming to acbieve a bigher standard-of-care. The data compiled from this research suggest that FST members learn the medical shock module equally well with either the mobile leaming modules or the traditional didactic lecture. This suggests that mobile learning modules are an effective means of providing the same knowledge in about one-quarter the amount of time needed to provide it in traditional didactic lectures. Mobile learning modules, coupled with a structured assessment, have the potential to improve educational experiences in civilian and military settings.

ACKNOWLEDGMENTS
The authors thank the Army Trauma Training Center staff for their support in completing this study. This work was funded by a Department of Defense Telemedicine and Advanced Technology Research Center (TATRC) Grant W81XWH-09-1-0703.

APPENDIX A: PRETEST AND POST-TEST FOR SHOCK (1) Hypovolemic shock is best defined as: (a) Inadequate urine output (b) Low blood pressure (c) Massive blood loss (d) Inadequate tissue petfusion

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APPENDIX B: SCENARIO TEST FOR SHOCK Please read the following patient scenarios and then the accompanying question. CASE SCENARIO 1 A patient arrives after a motor vehicle crash in which he was a restrained driver, involved in a t-bone crash on the driver's side. He presents with a Glasgow Coma Score of 15, a blood pressure of 90/60, and a heart rate of 120. He complains of back pain and abdominal pain, but has no peritoneal signs. Physical Description Normal oropharyngeal examination No facial trauma No signs of respiratory distress Cool and clammy skin Unable to move legs and weak arm movement (1) This patient most likely is suffering from? (a) Hypovolemic shock (b) Septic shock (c) Neurogenic shock (d) Cardiogenic shock (e) Hypoadrenal shock The patient responds well to resuscitation but over the next hour has another progressive decline in his vital signs. Continued 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, you notice he is now bradycardic 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 shock The 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 and tachycardie. On physical examination, he has warm skin and 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 shock CASE SCENARIO 2 A 70-year-old pedestrian hit by car is admitted with a mild traumatic brain injury, pulmonary contusions, and long-bone

fractures. He is in the ICU for continued monitoring. On rounds in the moming, you notice he has been several liters positive on his fluid balance for the past few days. He is now oliguric and hypotensive. He does not respond well to fluid challenges. You notice he has JVD and an S3 gallup on physical examination. (4) The most likely cause for his hypotension is: (a) Hypovolemic shock (b) Septic shock (c) Neurogenic shock (d) Cardiogenic shock (e) Hypoadrenal shock Further diagnostic testing reveals a normal CXR. An echocardiogram shows a normal ejection fraction of 60% (i.e., normal heart function). (5) The most likely diagnosis in this patient is: (a) Tension pneumothorax (b) Pulmonary embolus (c) Cardiac tamponade (d) Myocardial infarction

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Mobile Learning for Forward Surgical Team Members 15. Lipman AJ, Sade RM, Glotzbach AL, Lancaster CJ. Marshall MF: The incremental value of intemet-based instruction as an adjunct to classroom instruction: a prospective randomized study. Acad Med 2001; 76 (10): 1060-4. 16. Bhatti I. Jones K, Richardson L, Foreman D, Lund J, Tiemey G: E-leaming vs lecture: which is the best approach to surgical teaching? Colorectai Dis 2011; 13(4): 459-62. 17. Larvin M: E-leaming in surgical education and training. ANZ J Surg 2009; 79(3): 133-7. 18. Ridgway PF, Sheikh A, Sweeney KJ, et al: Surgical e-learning: validation of multimedia web-based lectures. Med Educ 2007: 41(2): 168-72. 19. Ruskin KJ: Mobile technologies for teaching and learning. Int Anesthesthiol Clin 2010; 48(3): 53-60.

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