Thanks TAGteach - From a Medical Student

This letter was sent to one of our TAGteachers by a medical student...

I had never done an LP (lumbar puncture), but I went through the simulation teaching using models with my instructor during JURSI orientation week. In her group the teaching method incorporated using "tag" points that allowed us to remember the sequence of steps in performing an LP. I had not thought about those tag points since that day we had training, which was about 6 months ago. Recently on my Neurology rotation, a resident had offered to let me do an LP, but first I had to explain the process, the contraindications, and indications for doing an LP. I was amazed at how easily I recalled the tag points in their correct order. The resident was impressed and let me perform the LP, which ended up being successful on the first try. I think there are many medical students that would benefit from the teaching method employed by my instructor where a procedure or physiological process is broken down into steps - tag points - that make a complicated pathway/procedure more manageable and easier to mentally process.

It is safe to assume, that the patient is grateful as well!

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TAGteacher Tale: Nursing Skills Practice

by Maggie Ouillette

Here's the latest on the tagging project I have been working on.

I needed more practice with placing long term IV catheters in home care patients, and wanted to set myself up for success. I decided to use TAGteach to help me to be successful.

The first step was to review the procedure and identify tag points. It's very tempting to want to have errorless learning by tagging everything.

A few months ago, I was working on developing tag points for teaching medication injections.I learned from that experience that tagging every individual step isn't practical or necessary.
My goal was to identify the tag points that were most important for me to perform the skill successfully.

In analyzing the previous practice session, it was very apparent that my anxiety played a role in my performance. I decided that the first tag point would address that issue.

Exercise One:

The first exercise involved a behavior that would enhance my ability to remain calm and focused.
  
Walk to doorway, stop, take two deep breaths before entering the room. My husband tagged me for this one.

The instructions " After you stop at the doorway, the tag point is TAKE TWO DEEP BREATHS".

Rationale:This behavior will help learner (me) to maintain focus and relax prior to interacting with the patient.

I practiced walking to the doorway, stopping and taking two deep breaths. My husband Jim tagged me. I repeated the exercise five time, was successful each time.

Applications for medical and nursing students.
This deep breath behavior could be used for the multiple 'first' experiences, such as hands on procedures. Students could work in groups in the classroom setting, taking turns tagging one another.

Exercise Two: 

The second exercise involved naming each of the items listed. I wrote a list of all the supplies (fourteen items) needed for the procedure, including extra items that might be needed.

The instructions: "the tag point is NAME AN ITEM ON THE LIST".

Rationale: Immediate recall of all items needed for the procedure will help the procedure to go smoothly.
My husband tagged me each time I named an item. If I hadn't named all listed items, my husband waited a few seconds, then said "try again"

I performed the exercise four times. By the third time I was naming all items on the list without hesitation.Its amazing how good I felt that I was able to rattle off the items on the list.

Applications for medical and nursing students.
This exercise could be used to help familiarize students with supplies needed for procedures. A hands-on version would be easy to set up in a classroom situation, with students tagging one another for retrieving specific items.

I realize that these exercise may seem oversimplified. They are valuable because they start the learner at a point of success which can be built upon. Tag points should always be individualized for the specific learners.

The other behaviors that I will work on will be: advancing the introducer into the vein, handling the catheter with sterile forceps, and removing tourniquet immediately after veinpuncture.

More to come

Maggie Ouillette
Whitmore Lake Michigan

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TAGteacher Tale - Teaching Lumbar Puncture to Medical Students

If you have ever had to (or ever will have to) undergo a painful and invasive medical procedure, you really hope that the doctor has been well trained and has had lots of practice before it is your turn. Dr. Karen McLean tells us about how she is using TAGteach to help teach medical residents to do lumbar punctures and also to help a colleague improve clinical reasoning skills:

The students who participated in the Lumbar Puncture / TAG study were in a linking week between their preclinical years and their clinical rotations.  They did this on Thursday and started on the wards on Monday.  It just so happened that I took over one of the clinical services for Internal Medicine the day after the study and one of my new students on Monday was one who had been in the TAG group – coincidentally we had to do an LP a couple of days later – the statistical probability of that happening were not high!

The junior resident was doing the procedure but the student (by now very excited to be even peripherally involved in the first real procedure of his clinical career!) was there so I asked if he could remember the tag points – which he did almost perfectly (we both sailed right past one of them and did not remember it till the procedure was over – he was the first to point out that we had missed one!).  He relayed and explained the tag points as the resident was doing the procedure, before each step where we had placed a tag point in the teaching session. He had the wording down pat and the order correct.

It was neat to see a week later that he had the points, the wording and the order still firmly embedded in his mind and was able to retrieve them very quickly with no prompting or cueing.

Unrelated to the study, I have been working with a senior resident who has been having some difficulties with clinical reasoning. One of his challenges is presenting information clearly, using appropriate language so that information can quickly and accurately be conveyed to his attending physicians (especially in the middle of the night when you have been awakened from REM sleep by the beeper!).

One of our sessions focused on getting him to use terms that convey “semantically meaningful chunks of information”.   In trying to convey what that might sound like, I gave some examples and suggested we could call these “sound bytes” - short phases that convey a lot of meaning and help the listener start to draw conclusions about the case.  He offered the term “high calorie phrases” as his preferred descriptor.  (Our sessions do usually start around coffee time!)  In any case ‘high calorie’ worked better for him and I tagged him every time he was able to use an appropriate ‘high calorie’ descriptor in his case presentation.

What impressed me about this was that he was clearly making a huge effort to reorganize information in his mind to assess where he could use appropriate terms – it made him really think and start to apply some of the skills we have been working on.

I won’t say it was a major breakthrough as he has been working hard and steadily making progress but I think it crystallized an important concept in a way that we had not so clearly been able to achieve up till then.

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TAGteacher Tale - TAGtone for Medical Students

Thanks to Dr. Karen McLean for telling us about her application of TAGteach with medical students.

I recently took the TAG teach workshop in LA and thoroughly enjoyed it. (Thanks Theresa and Hello fellow students!) I use tagging in the hospital environment where I teach medical students and residents, particularly in physical examination skills or procedures at the bedside. This has been enthusiastically received by the residents who all want their own taggers so they can practice in small groups (they are preparing for a major exam). For use at the bedside I want a "tag tone" that fits better (is less intrusive) in the hospital environment. The click is harsh and may be disruptive or annoying to some patients (we have few single rooms), if used repeatedly. Sadly the clicker plus is not readily available.

There is an iphone clicker app for a clicker but I have found nothing for blackberry (my device of choice), and the iphone app as far as I know only produces the "click". I want a higher pitched tone, more musical than metallic, that will blend better into the ambient background noise, yet still be audible to small groups at the bedside. Our IT guys suggested two options - one being to use the custom profiles (for setting alerts) on the BB and the "try it" function to trigger the tone - that proved to be a bust as the time delay is anywhere
from almost 1 to 3 seconds, even though there are some suitable tones already available on the device.

The second suggestion was to try an online sound generator and import it into the device (should work for any device). After a few unsuccessful attemtps I found a site that works like a charm and within about 5 minutes I was able to generate and load to my blackberry a couple of suitable tones. (my IT guys call me an "early adopter" - but I am definitely not a techno-geek.) On my device this plays instantly with a press of the trackball as long as I have it selected.

If you are interested in trying it out for yourself - here is the website and the steps I used - it is pretty intuituve.

http://www.planetofnoise.com/midi/morse2mid.php

This website is intended for generating morse code ring tones – but if you pick a single letter and adjust the SPEED, PITCH and SOUND functions you can get pretty much what you want. For example, the letter 'e' gives you a single tone, 'h' is a short burst and 'm' is biphasic. I like the pitch high (3) because I want it to be less audible to older folk (which includes the majority of my patients) who often have high frequency hearing loss.

The "make Morse" bar allows you to check out the sound and keep adjusting paramters until you have what you want. Then click on "this file" as per the instructions and it will bring it up as a file on a webpage by itself. If you use the "file" option on the menu bar and "send page by e mail" you can then get it on your device, down load the attachment to a ring tone file...and there you have it. (this last is a little different than the instructions on the website.)

To use it you just open the ring tone file, select the one you want and hit play.

Now, I can get rid of one more thing from my pockets and I will always have my "tagger" with me. Next I am going to see if I can find a sound that is close enough to a clicker to work with my dogs and I won't have to have a clicker in every room in my house and every carry bag I use for classes!

Karen McClean

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