Structured Nasal Packing Module Training Using Intubation Mannequin For Undergraduate Students

Nasal packing is a skill which all primary care physicians should possess. The current curriculum does not include this skills training in undergraduate stud-ies. The aim of this study is to evaluate the ef(cid:977)icacy of structured nasal packing module for 3rd MBBS students in the skills lab and to evaluate the improvement of student’s con(cid:977)idence level in managing epistaxis. Project proposal approval was obtained from the Institutional review board in Saveetha Medical College & Hospital. After obtaining informed consent, 114 students of III MBBS-Part I was included in the study. They were divided into 3 batches. Students were given study material and video at least one day before the session. A brief lecture followed by a demonstration of nasal packing was done. Students were allowed to practice nasal packing on intubation mannequins in the presence of faculty. Con(cid:977)idence level questionnaire were given to assess their con(cid:977)idence level before and after practicing on mannequins. Question 1 was on instrument use, 2 on traditional anterior nasal packing, 3 on ivalon pack and 4 on postnasal pack with foley’s catheter. The mean con(cid:977)idence level scores before and after hands on training on mannequin were 9.18 and 12.45 respectively. T-test and Wilcoxon Signed Ranks Test was done to compare the results. There was a statistically signi(cid:977)icant improvement in the con(cid:977)idence level of students following hands on training (p value: 0.000). Practicing nasal packing on intubation mannequins improved the con(cid:977)idence level of students in managing patients with epistaxis


INTRODUCTION
Epistaxis or bleeding from the nose is a common complain which a primary care physician encounters. About 60% of individuals will have epistaxis at least once in their lifetime. It can vary from mild bleeding to profuse bleeding. It could be lifethreatening in a few patients. It is a common emergency faced by the primary care physician. The irstline management of epistaxis with a nasal pack is usually done in an emergency (Ho and Chan, 2008). Nasal packing skill will be very useful to the primary care physician in these circumstances (Almaç, 2005). However, most primary care physicians are not con ident to perform nasal packing worldwide (Mace and Narula, 2004). Nasal packing is a skill which all primary care physicians should possess (Ferguson et al., 2016). The current curriculum does not include this skills training in undergraduate studies. There is gross underrepresentation of this skill in undergraduate training worldwide (Powell et al., 2011). Training students with mannequin will be a good option. This study aims to evaluate the nasal packing module for undergraduates in skills lab using intubation mannequin, which is already available in the skills lab. The aims of this study are, 1. Evaluate the ef icacy of structured nasal packing module for 3rd MBBS students in the skills lab.
2. Evaluate the improvement of student's con idence level in managing epistaxis.

MATERIALS AND METHODS
The nasal packing module with intubation mannequin was developed. The learning objective of the module was as follows, At the end of the session participants should be able to, Contents of study material, video and lecture were validated. The con idence level of students was used to evaluate this module. The con idence level questionnaire (Table 1)    Students were given study material and video at least one day before the session. A brief lecture followed by a demonstration of nasal packing was done. Con idence level questionnaire were given to assess their con idence level before practicing on mannequins. Students were allowed to practice nasal packing on intubation mannequins in the presence of faculty. Appropriate feedback was given to students during practice. Objective structured clinical examination was done to ensure all students achieved the desired learning. Con idence level questionnaire were given to assess their conidence level before and after practicing on mannequins. Feedback about the module was obtained.

RESULTS AND DISCUSSION
The overall mean con idence levels scores before and after hands on training on mannequin were 9.18 and 12.45, respectively ( Figure 1). T-test and Wilcoxon Signed Ranks Test was done to compare the results. There was a statistically signi icant improvement in the con idence level of students following hands on training (p value: 0.000 ).
Con idence level in using Thudicum nasal speculum and Tilley's nasal dressing forceps on a patient in an emergency, anterior nasal packing with paraf in gauze, anterior nasal packing with Ivalon and posterior nasal packing with Foley's catheter were analyzed separately (Figure 2). There was a statistically signi icant improvement in the con idence level of students in each parameter following hands on training (p value: 0.000).
Skills and simulation laboratories provides a safe and protective environment for learning medical skills. It allows students to practice repetitively. The disproportion between a number of students and patients, legal issues and fewer exposures to emer-  (Sugarman and Alderson, 1995). But some anatomical features like the friction of nasal mucosa and elasticity of nares could not be mimicked.
Technology can be used to improve skills in medical education via simulation. Simulators can imitate an emergency situation requiring nasal packing. It reduces student's anxiety in facing epistaxis patients without concern regarding patient safety. It can be used as a self-learning module. Simulators also improve the performance of students as their conidence improves. Computer-assisted learning has shown better outcomes in a study done by (Glicksman et al., 2009). The study by Carr et al. (1999) added that computer-assisted learning improves both cognitive and psychomotor training. A study done with low idelity nasal simulators showed an increase in con idence level in handling epistaxis patients Maher (2013). Multi sensorial cadaver sim-ulators for nasal packing also signi icantly improved the con idence level of students (Kurien et al., 2013). Unfortunately, simulators are expensive hence not available in most medical colleges.
Most skills labs are equipped with mannequins for airway, intravascular cannula, urinary catheterization, suturing, etc. Mannequins for nasal packing are rarely available as nasal packing mannequins are expensive. Using Intubation mannequin, which would be already available in most skills lab for nasal packing, would be a cheap alternative.
Nasal packing requires skill requires good practice and technique to arrest bleeding. The anxiety of the patient and their relatives aggravate the stress level of junior doctors. Untrained doctors can traumatize nasal mucosa or injure the turbinates. This can make the situation worse. Junior doctors should have pro iciency in nasal packing so that it can be performed quickly and successfully (Kravchik and Pester, 2019). The ideal nasal packing module should give students the con idence to face epistaxis patients and be able to perform nasal packing. This module meets the requirements. Feedback obtained from students was encouraging.
However, the con idence of students would be higher after performing on the patient. But this module can be the irst step in learning this skill.

CONCLUSIONS
Intubation mannequins are available in the most skills lab. Nasal packing with these Intubation mannequins improved the con idence level of students in managing patients with epistaxis. Instead of waiting for a costlier alternative, nasal packing skills training can be started with intubation mannequin.