Current use of live tissue training in trauma: a descriptive systematic review — author response
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* Luis Teodoro da Luz
* Bartolomeu Nascimento Junior
* Homer Tien

We thank Dr. Green for the insightful comments on our manuscript, which reviews the current evidence on the use of live tissue for trauma training.

We agree with Dr. Green that “there are ethical, educational and economic advantages to ending [live tissue training (LTT)] in favour of simulators for teaching trauma skills.” We also support the idea that “simulation should replace LTT where it leads the use of animals in medical training.” However, the conclusion that simulation is clearly superior to LTT across the spectrum of surgical trauma training based on the current literature may be disputed by some. While less complex surgical procedures conducted in the Advanced Trauma Life Support (ATLS) course1 were replaced by simulation devices, in the Acute Trauma Operative Management (ATOM)2 course LTT is still essential for teaching complex surgical procedures and manoeuvres. In the study mentioned in Dr. Green’s letter, a pilot randomized controlled trial of simulation and LTT (which in our opinion is one of the best-designed studies addressing this subject currently), Dr. Savage3 found no differences in uptake between the 2 training modalities. However, the author additionally stated that “inherent differences in both methods may require a third type of criterion standard model necessary to measure differences between the 2 training modalities.” The author further mentioned, “when a qualitative analysis of each modality is conducted, there are strengths and weaknesses in both.” Moreover, the author stated that “until more realistic simulators are developed, likely a combined training program using simulators and LTT will remain the preferred method of preparing medics for managing battlefield trauma,” which supports our statement. In another study4 by Drs. Cherry and Ali, the authors commented that “a wide range of training modalities exist, but each (including high-fidelity simulators) has limitations, and these challenges need to be overcome.”

Our research targeted a polemic subject: the use of LTT in trauma compared with the use of other simulation methods. The extensive systematic literature review demonstrated that there is limited evidence to conclude that one method is better than the other. Important problems involving the existing literature in this subject include small sample sizes (no power to detect differences). In addition, structured evaluations used to measure outcome are not previously validated, there is no measurement of interrater reliability, and consideration should be given to having more than 1 independent evaluator during each assessment so that another potential source of bias is avoided and outcomes are interpreted properly. Furthermore, in our search, studies were heterogeneous with respect to participants, interventions, controls, measurements and outcomes, limiting interpretation and generalizability. We agree that at present, simulation is a fundamental armamentarium for training in trauma, and we expect that this field is going to evolve and become more and more important in the future. However, we believe that studies with a better design/methodology still need to be conducted to definitively demonstrate whether simulation in trauma is more advantageous than LTT.

## References

1.  Ali J, Sorvari A, Pandya A.Teaching emergency surgical skills for trauma resuscitation — mechanical simulator versus animal model.ISRN Emergency Medicine 2012[Article ID 259864]
    
    

2.  Ali J, Ahmed N, Jacobs LM, et al.The Advanced Trauma Operative Management course in a Canadian residency program.Can J Surg 2008;51:185–9.
    
    

3.  Savage EC, Tenn C, Vartanian O, et al.A comparison of live tissue training and high-fidelity patient simulator: a pilot study in battlefield trauma training.J Trauma Acute Care Surg 2015;79:S157–63.
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fcjs%2F58%2F6%2FE6.2.atom) 

4.  Cherry RA, Ali J.Current concepts in simulation-based trauma education.J Trauma 2008;65:1186–93.
    
    [CrossRef](http://canjsurg.ca/lookup/external-ref?access_num=10.1097/TA.0b013e318170a75e&link_type=DOI) 
    
    [PubMed](http://canjsurg.ca/lookup/external-ref?access_num=19001992&link_type=MED&atom=%2Fcjs%2F58%2F6%2FE6.2.atom)