Scientific Letter
Clinical simulation in the polytraumatized patient. Application in medical students
Simulación clínica en el paciente politraumatizado. Aplicación en estudiantes de Medicina
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Application in medical students" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "389" "paginaFinal" => "391" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M.A. Ballesteros, M. Feo González, B. Suberviola, E. Miñambres" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.A." "apellidos" => "Ballesteros" "email" => array:1 [ 0 => "gelesballesteros@yahoo.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M." "apellidos" => "Feo González" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "B." "apellidos" => "Suberviola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Miñambres" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Medicina Intensiva, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Facultad de Medicina, Universidad de Cantabria, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Simulación clínica en el paciente politraumatizado. Aplicación en estudiantes de Medicina" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1030 "Ancho" => 1742 "Tamanyo" => 115590 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluation of skills in clinical care to polytraumatized patients. The bar represents the median and the error bar the interquartile range (P25 and P75).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The Wilcoxon signed-rank test was used to analyze change in the skills evaluated. Significance level (<span class="elsevierStyleItalic">p</span>) was <.001 in all of them.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hm., hemodynamic.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Undergraduate and postgraduate medical education has traditionally been based on theoretical learning, acquiring clinical skills through the direct treatment with patients. Over the last few decades, patient's safety and ethical imperatives have been focusing on the patient's protection and, as a matter of fact, learning via trial and error is ill-advised on current patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In this context, clinical simulation has been developed as a teaching tool to provide comprehensive training that is risk-free for the patients.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Its use has been growing in clinical areas such as anesthesiology, intensive medicine, and emergencies, but above all it has focused on postgraduate training.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Medical students receive for the most part vertical training where the use of clinical simulation is just a formality. In this context, clinical simulation with medical students has focused on cases of shock, approach to sepsis or advanced life support, but for severe traumatic injury it is more limited.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A simulation activity was conducted at our service focused on severe traumas for 6th-year medical students during their intensive medicine practices. The objectives were to assess the effectiveness of simulation in the management of severe trauma among the students and determine their perceptions on the suitability of simulation for technical skills.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A cross-sectional prospective study was conducted with 6th-year medical students during their rotation at the intensive medicine unit of <span class="elsevierStyleItalic">Hospital Universitario Marqués de Valdecilla</span>, Spain in the 2017–2018 school year. High-fidelity simulation scenarios on Severe traumatic disease were used with groups of 8 students each. Each clinical case was developed by 2 students. They received a briefing session prior to developing each scenario. Each and every one of the cases was developed in a 15-min. period. The simulation was followed in real time by the rest of the workshop students. At the end of each case, a second 15-min. debate session was conducted to analyze how the case was developed and how the decisions were made. They were asked to make a voluntary assessment of the activity through questionnaires using the 5-point Likert scale (1<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>complete disagreement, 5<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>complete disagreement) and open questions. Some of the variables were evaluated before and after the teaching activity. All answers were anonymous.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There were 84 students, 64.5% of them women. Their mean age was 24 years (SD 1.2). The resources available, as well as the design of the activity were assessed positively. Also, the closeness and accessibility of the teaching staff were highlighted (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the self-evaluation of the capacities analyzed before and after the training activity. The degree of confidence acquired by the students after conducting the activity was significantly higher compared to the previous one, which underlines the greater capacity for leadership and make decisions before a case of Severe traumatic disease (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Similarly, the students underlined teamwork and the acquisition of leadership skills in the first person. They suggested increasing the frequency of these activities and expanding their use in the different academic courses. As positive points, they assessed the possibility of facing clinical cases (11 students), the practical character (32 students), and the possibility of participation in the first person (7 cases). Ninety-one-point-four per cent rated the course as excellent.</p><p id="par0030" class="elsevierStylePara elsevierViewall">High-fidelity simulation allowed students to perform in a clinical scenario using the same resources they will have available in their routine clinical practice. On the other hand, it allowed the detection of possible improvements for future editions and adapt it to the vision contributed by the students. Finally, it made student self-evaluation easy, confirming its role as an effective tool for educational practices.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The students’ knowledge prior to post-simulation increased significantly and their confidence in being able to handle severe trauma improved as well. These aspects are consistent with previous experiences above all regarding nursing students,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> where this teaching tool is more established. A vertical, more individualistic learning focused on the academic performance of medical studies could explain this difference.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It has been reported that throughout their university training students do not have defined objectives to attain in terms of technical skills, unlike knowledge goals that are clearly established.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Simulation may be useful as a teaching tool to complete that technical profile of the students. However, generalizing clinical simulations in the Medical Science syllabus has not been achieved. It has been postulated that technical and economic requirements and the need for a large staff properly trained are obstacles for this consolidation. Nevertheless, data that question the “actual” cost of medical education are scarce and controversial.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> The experience gained in other disciplines like nursing, along with its generalization in postgraduate training, suggest that there may be a place for it in the undergraduate studies of Medical Schools.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The development of experiences like ours has brought Intensive Medicine closer to Medical students. Also, these conclusions are consistent with simulation projects from other disciplines like neurosurgery.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> This is another strong point of simulation, that it allows filling the existing gap between academic training and actual medical practice. This reflects the need to modify syllabi to engage students in their medical specialty and complement clinical knowledge with suitable practical skills. We believe that student motivation can be enhanced through the use of simulations. Producing highly competitive medical professionals in the coming years would result in a future generation of well-trained intensivists.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The work has limitations. There was one group of students only. Subjective opinions have been assessed and the effectiveness of skill acquisition in the clinical practice was not measured. It was conducted in one center only with a relatively small sample size, which is why it cannot be generalized to other simulation scenarios.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Clinical simulation can facilitate clinical reasoning and the acquisition of technical skills. Severe traumatic disease is a good model because it requires a systematic approach, the cross-sectional integration of knowledge, developing leadership, and a correct decision-making process. Our pilot study suggests the possibility of including clinical simulation in the undergraduate training of Medical students. On top of facilitating the acquisition of practical skills, it brings students closer to the Intensive Medicine specialty.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">None reported.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ballesteros MA, Feo González M, Suberviola B, Miñambres E. Simulación clínica en el paciente politraumatizado. Aplicación en estudiantes de Medicina. Med Intensiva. 2020;44:389–391.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1030 "Ancho" => 1742 "Tamanyo" => 115590 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluation of skills in clinical care to polytraumatized patients. The bar represents the median and the error bar the interquartile range (P25 and P75).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The Wilcoxon signed-rank test was used to analyze change in the skills evaluated. Significance level (<span class="elsevierStyleItalic">p</span>) was <.001 in all of them.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Hm., hemodynamic.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Categorical variables were expressed as median and interquartile range (IQR).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Objectives and content</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The duration of the course was suitable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The in-depth level of the topics was suitable \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The content of the course fulfilled my training needs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The objectives of the course were achieved \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Methodology</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The methodology used was the most suitable one for the objectives and contents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The methodology used enabled active participation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The practices were useful and enough \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Utility</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The expectations I had regarding the utility of the workshop have been met \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The contents of the course have proven useful and met my expectations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I am going to be able to apply the knowledge acquired to my professional clinical practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Means</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The technical means have worked correctly during the workshop \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (IQR 3.5–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The facilities have made learning easier \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 (IQR 4–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Teaching staff</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The teaching staff exhibited good competence level \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 5–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The teaching staff managed to maintain a good level of awareness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 5–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span> The teaching staff prompted debate and discussion and was close to the students \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (IQR 5–5) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2350926.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Assessment of the simulation workshop “Severe traumatic disease”.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Training in the care of the critical and multiple-injured patient: role of clinical simulation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 8 | 14 |
| 2024 October | 55 | 37 | 92 |
| 2024 September | 56 | 51 | 107 |
| 2024 August | 51 | 64 | 115 |
| 2024 July | 64 | 40 | 104 |
| 2024 June | 57 | 47 | 104 |
| 2024 May | 57 | 24 | 81 |
| 2024 April | 39 | 36 | 75 |
| 2024 March | 48 | 25 | 73 |
| 2024 February | 28 | 41 | 69 |
| 2024 January | 37 | 41 | 78 |
| 2023 December | 29 | 38 | 67 |
| 2023 November | 51 | 45 | 96 |
| 2023 October | 33 | 29 | 62 |
| 2023 September | 37 | 36 | 73 |
| 2023 August | 31 | 26 | 57 |
| 2023 July | 38 | 32 | 70 |
| 2023 June | 30 | 13 | 43 |
| 2023 May | 43 | 40 | 83 |
| 2023 April | 32 | 25 | 57 |
| 2023 March | 50 | 26 | 76 |
| 2023 February | 56 | 37 | 93 |
| 2023 January | 27 | 33 | 60 |
| 2022 December | 58 | 32 | 90 |
| 2022 November | 67 | 46 | 113 |
| 2022 October | 56 | 51 | 107 |
| 2022 September | 38 | 42 | 80 |
| 2022 August | 49 | 50 | 99 |
| 2022 July | 43 | 53 | 96 |
| 2022 June | 34 | 31 | 65 |
| 2022 May | 42 | 44 | 86 |
| 2022 April | 40 | 39 | 79 |
| 2022 March | 44 | 54 | 98 |
| 2022 February | 37 | 27 | 64 |
| 2022 January | 50 | 45 | 95 |
| 2021 December | 46 | 53 | 99 |
| 2021 November | 33 | 35 | 68 |
| 2021 October | 63 | 90 | 153 |
| 2021 September | 27 | 34 | 61 |
| 2021 August | 25 | 41 | 66 |
| 2021 July | 31 | 26 | 57 |
| 2021 June | 24 | 24 | 48 |
| 2021 May | 31 | 38 | 69 |
| 2021 April | 176 | 130 | 306 |
| 2021 March | 65 | 38 | 103 |
| 2021 February | 76 | 30 | 106 |
| 2021 January | 63 | 32 | 95 |
| 2020 December | 55 | 30 | 85 |
| 2020 November | 27 | 22 | 49 |
| 2020 October | 1 | 1 | 2 |
| 2020 September | 1 | 2 | 3 |
| 2020 July | 16 | 9 | 25 |
| 2020 June | 34 | 26 | 60 |
| 2020 May | 21 | 21 | 42 |
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