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Using cognitive task analysis to determine the percentage of critical information that experts omit when describing a surgical procedure

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Using cognitive task analysis to determine the percentage of critical information that experts omit when describing a surgical procedure

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USING COGNITIVE TASK ANALYSIS TO DETERMINE THE
PERCENTAGE OF CRITICAL INFORMATION THAT EXPERTS
OMIT WHEN DESCRIBING A SURGICAL PROCEDURE

by

Maryann Tolano-Leveque

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2010

Copyright 2010 Maryann Tolano-Leveque
ii
DEDICATION

This work would not have been possible without the love and support of my
husband, Rod Leveque, who has been a great motivator. He has shared my anxieties,
challenges, and sacrifices in completing this dissertation. Without his constant
encouragement I would still be working on this project. He has been the greatest support
in my life and I look forward to having more time to spend with him.
This work is also dedicated to the memory of my nephew, Carlos De Leon who
died during the initial stages of this research. His loss is a constant reminder of the
importance of family, love, and happiness.

iii

ACKNOWLEDGEMENTS

I would like to express my deepest appreciation to my committee without which I
could not have completed this dissertation. To Dr. Richard Clark, who set the structure
and pace for this work. Without his experience and thorough knowledge of Cognitive
Task Analysis this work would not have been possible. To Dr. Maura Sullivan, whose
smile, advice, and list of resources made the process less overwhelming. To Dr. Kenneth
Yates, for the time he spent with me on countless phone calls, in meetings, and for the
infinite number of emails with deadline reminders and reading suggestions. Without his
guidance and persistent help, this work would not be complete.
Finally, I would like to thank my colleagues and research partners Dr. Leslie
Tirapelle, Dr. Eko Canillas, Dr. Patrick Crispen, Dr. Joon Kim, and Dr. Craig Bartholio,
who endured the process with me and provided a tremendous amount of emotional and
psychological support. Without their bright minds and constant collaboration this project
would have been insurmountable.
iv
TABLE OF CONTENTS

Dedication ii
Acknowledgements iii
List of Tables vi
List of Figures vii
Abstract viii

Chapter 1: Review of Literature 1
Statement of the Problem 2
Purpose of the Study 4
Review of the Literature 5
Current Training and Assessment Methods for Surgical Residents 5
Barriers to the Current Training Model 7
Limited exposure 7
Seventy percent rule 7
Knowledge Types 8
Declarative 8
Procedural 9
Expertise 9
Definition of expertise 9
Developing expertise and automation 10
The Internal and External Factors of Task Complexity 11
Prior knowledge 12
Cognitive Task Analysis 13
What is CTA? 13
Evidence for CTA-based training 14
Evidence for CTA-based training in medicine 15
Why is CTA important in surgical training? 18

Chapter 2: Methods 19
Design 19
Tasks 20
Open cricothyrotomy surgical procedure 20
Central venous catheter surgical procedure 21
Sample 21
Procedure for Data Collection 22
Phase 1. Collect Preliminary Knowledge 22
Phase 2. Identify Knowledge Representations 22
Phase 3. Apply Focused Knowledge Elicitation Methods 23

v
Phase 4. Analyze and Verify Data Acquired 24
CTA coding scheme 24
Inter-rater reliability 24
Development of the CTA report and data analysis 25
Phase 5. Format Results for the Intended Application 26

Chapter 3: Results 27
Research Question 1 27
Round 1 Data 28
Round 2 Data 32
Research Question 2 34
Open Cricothyrotomy Surgical Procedure 35
Central Venous Catheter Surgical Procedure 36
Comparison of Prior Knowledge among Subject Matter Experts 37
Information Recalled 38
Decision and Action Step Omissions 40

Chapter 4: Conclusions 43
Research Question 1 44
Research Question 2 44
Limitations 47
Selection of subject matter experts 47
Task analyst consistency 47
Summary 49
Implications 50
Conclusion 51

References 52

Appendices 59
Appendix A: CTA Coding Scheme 59
Appendix B: CTA Inter-Rater Reliability Coding Sheet 60
Appendix C: CTA Gold Standard for the 61
Appendix D: Procedure Steps for the 74
Appendix E: CTA Gold Standard Protocol 79

vi
LIST OF TABLES

Table 1: Comparison of the Type of Information Captured by
SMEs for the Open cricothyrotomy Surgical Procedure 29

Table 2: Comparison of Omissions between Types of Steps in
the Open Cricothyrotomy Surgical Procedure 30

Table 3: Total gold Standard Action and Decisions Steps
Recalled per SME for Round 1 and Round 2 for the
Open Cricothyrotomy Procedure 32

Table 4: Total Gold Standard Decision Steps Recalled per SME for
Round 1 and Round 2 for the Open Cricothyrotomy Procedure 33

Table 5: Total Gold Standard Action Steps Recalled per SME for Round
1 and Round 2 for the Open Cricothyrotomy Surgical Procedure 34

Table 6: Prior Knowledge Indicators for the Open Cricothyrotomy
Subject Matter Experts 36

Table 7: Prior Knowledge Indicators for the Central Venous Catheter
Subject Matter Experts 37

Table 8: Comparison of the Open Cricothyrotomy and the Central
Venous Catheter Surgical Procedures 38

Table 9: Comparison of the Action and Decision Steps Recalled by
SMEs for the Central Venous Catheter Surgical Procedure 39

Table 10: Comparison of Omissions between Types of Steps in the
Central Venous Catheter Surgical Procedure 40

Table A1: CTA Inter-rater Reliability Coding Sheet 60
Table A2: Procedure Steps for the Open Cricothyrotomy
Surgical Procedure 74

vii
LIST OF FIGURES

Figure 1: Decision and Action Steps Captured in Percentages for
the Open Cricothyrotomy Surgical Procedure 31

Figure 2: Decision and Action Steps in Percentages for
the Central Venous Catheter Surgical Procedure 41

viii
ABSTRACT

This study used cognitive task analysis (CTA) knowledge elicitation strategies to
find the percentage and type of information that experts omit when describing how to
perform a surgical procedure. CTA is a method by which a trained analyst can extract and
capture information that has been automated and is non-conscious to an expert. This
information includes critical decision points and judgments involved in the expert’s
performance of the procedure. Based on the current research literature, the hypothesis for
this study was that surgical experts would omit approximately 70% of the critical
decision steps necessary to perform the Open Cricothyrotomy and Central Venous
Catheter surgical procedures. More specifically, this study sought to determine if there is
a difference in knowledge omissions based on the experts’ prior knowledge of the
procedures.
This descriptive study took a mixed-methods approach. Qualitative methods were
used to conduct semi-structured interviews while quantitative methods were used to
analyze the data by using frequency counts to determine how much information was
omitted when compared with the final, expert-approved, “gold standard.” The “gold
standard” is an aggregate of the information elicited from six medical faculty at the
University of Southern California, Keck School of Medicine. Results showed that experts
for the Open Cricothyrotomy surgical procedure omitted 76.92% of the decision steps,
while experts for the Central Venous Catheter procedure omitted 34.52% of the decision
steps. Limitations of the study and implications for future research and task complexity
are discussed.
1
CHAPTER 1: REVIEW OF LITERATURE
For more than 100 years, the most popular approach for training surgical residents
was the Halsteadian (i.e., “see one, do one, teach one”) method (Halsted, 1904), in which
a physician-in-training; 1) watches a procedure performed; 2) performs the procedure
under supervision and finally; 3) teaches another intern the procedure (Velmahos,
Toutouzas, Sillin, Chan, Clark, Theodorou, & Maupin, 2004). This system of teaching
procedural skills in most surgical residency programs did not take into account the
underlying decisions that go through an expert’s mind while completing a task (Aggarwal
& Darzi, 2006), thereby leaving out potentially critical information. Hence, many
medical experts felt that the Halsteadian method, while good, was not sufficient (Britt,
Novosel, Britt & Sullivan, 2009; Grantcharov & Reznick, 2008; Reznick & MacRae,
2006; Scott, Cendan, Pugh, Minter, Dunnington, & Kozar, 2008). Surgical educators
responded to this problem by moving training outside of the clinical environment and
including emerging technologies such as simulation centers and multimedia instruction in
the training of surgical residents (Luker, Sullivan, Peyre, Sherman, & Grunwald, 2008).
However, the problem remains in that the content used to develop training simulations
and multimedia instruction continues to rely on experts for information.
The use of cognitive task analysis (CTA) elicitation strategies can be used to
develop more comprehensive instructional materials. By utilizing CTA to develop
surgical instruction, medical faculty are able to focus their training methods to ensure that
residents are learning the decision-making steps and judgments required to successfully
perform a procedure, (Luker et al., 2008). CTA informed instruction does not replace the
2
current methods, but adds to the instruction base and provides the learner with a more
complete set of instructions for performing a surgical procedure. Combining CTA with
the current teaching methods will; 1) add to the knowledge base from which surgical
instruction is developed; 2) ensure consistent training for all medical residents; 3)
communicate information efficiently from expert to learner, and; 4) speed up the learning
process, (Luker et al., 2008). Moreover, CTA can provide a method for measuring the
decision-making abilities and surgical judgments of medical residents.
Statement of the Problem
Over time, and through extensive practice, experts unwittingly automate much of
the procedural information necessary to complete a task, requiring less mental effort and
freeing up their working memory to focus on the novel elements of the task (Clark &
Elen 2006; Clark, de Croock, & van Mërrienboer, 2002). As a consequence of
automaticity, experts are likely to omit approximately 70% of the critical information
needed when describing how to perform a task (Chao & Salvendy, 1994; Clark, Feldon,
van Merriënboer, Yates, & Early, 2008; Feldon, 2007; Velhamos, et al., 2004). This can
cause serious problems when said experts are called upon to train surgical residents
(Clark, in press; Clark, Early, Pugh, Sullivan, & Yates, 2008; Clark & Elen, 2006; Chao
& Salvendy, 1994), and may explain why there is a 50% likelihood that experts will
make an error when explaining how to perform a procedure (Clark & Estes, 1996).
The omission of essential information during surgical training can lead to
disastrous consequences. “Surgical complications are a considerable cause of death and
disability around the world. They are devastating to patients, costly to health care
3
systems, and often preventable, though their prevention typically requires a change in
systems and individual behavior,” (Haynes, Weiser, Berry, Lipsitz, Breizat, Dellinger,
Herbosa, Joseph, Kibatala, Lapitan, Merry, Moorthy, Reznick, Taylor & Gawande, 2009,
p. 498). In general, higher stakes are tied to; 1) patient safety; 2) pressure for greater
accountability; 3) the rising costs of medical care; 4) limits to clinical exposure; 5) limits
to the work hours per week; and 6) a greater demand for surgeons, pressing them into the
operating room without thorough and complete training, (Grantcharov & Reznick, 2008;
Haynes et al., 2009; Scott et al., 2008). With an estimated 234 million surgeries
performed worldwide annually, surgical care has become an area of great interest
(Haynes et al., 2009). While the current Halsteadian method has been relied upon for
training medical students thus far (Bell, Britt, Sachdeva, J. Tarpley, & M. Tarpley, 2007)
it is no longer adequate for todays multifarious illnesses, emerging technologies,
increasingly complex surgical procedures, and the greater emphasis on mitigating
medical errors (Grantcharov & Reznick, 2008; Reznick & MacRae, 2006; Scott, Cendan,
Pugh, Minter, Dunnington, & Kozar, 2008).
Unfortunately, subject matter experts (SMEs), although highly sought after for
their extensive knowledge, are incapable of teaching automated and non conscious
knowledge without some helpful elicitation strategies (Ericsson, Krampe, & Tesch-
Römer, 1993). This is why Howell & Cooke (1989) suggest that a learner must know the
underlying steps that go through an expert’s mind while completing a task. The omission
of critical information by experts causes the unavoidable, yet helpful process of mental
automation. Automation is the effortless, or automatic retrieval of information that is
4
critical to a specific task (Schneider & Shiffin, 1977). Automation is vital to expertise
because it places fewer demands on the expert’s conscious working memory, which has a
limited capacity. When an expert begins to automate information s/he will typically start
with procedures. Procedural knowledge is knowing “how” to act and decide in order to
perform a task and involves both motor and cognitive skills (Clark & Estes, 1996; Gagne,
Yekovich C. W., Yekovich F. R., 1993). Because the potential for error in training is so
high, it follows that surgical residents who are trained by experts will likely experience
shortcomings when attempting to replicate learned procedures. This is where the
elicitation methods of cognitive task analysis (CTA) can be helpful.
CTA is a set of interview techniques used to effectively draw out and capture
unobservable cognitive processes, decisions, and judgments that underlie the behaviors of
expert performance (Chipman, Schraagen, & Shalin, 2000; Cooke, 1999; Yates, 2007).
CTA can draw out the expertise of medical faculty by capturing the information that is no
longer consciously available to them. CTA can also assist researchers in determining how
much information surgical experts omit. Previous studies using other surgical procedures
have shown that experts leave out approximately 70% of the critical information (Chao &
Salvendy, 1994; Clark et al., 2008; Feldon, 2007; Velhamos, et al., 2004).
Purpose of the Study
The purpose of this descriptive study is to answer the following questions:
1. What percentage of critical “when” and “how” information do experts omit when
describing the Open Cricothyrotomy surgical procedure?
5
2. Does the amount of an expert's prior knowledge and experience with a specific
task influence the amount of knowledge that s/he omits when describing how to
perform the task?
For the purposes of this study, “how” represents procedural knowledge, which
offers steps for how to complete a task and, with repetition, can become automated (Clark
& Elen, 2006). Therefore, “how” will represent the decision and action steps involved in
successfully performing the surgical procedures. “When” represents a subtype of
procedural knowledge, which is referred to as conditional knowledge. This type of
procedural knowledge includes IF-THEN conditions. The “IF” being a procedural cue
that alerts the surgical resident of what must be present in order to make a decision or
perform an action. “THEN” refers to the alternative that must be chosen if a decision is
being made or what action must be performed. Finally, both “when” and “how” represent
declarative knowledge that involves a conceptual understanding of the processes required
to perform a task and is consciously observable by the expert.
Review of the Literature
Current Training and Assessment Methods for Surgical Residents
Medical schools in the United States currently use a combination of computer
simulations and the apprenticeship model that was developed more than a century ago by
William Halsted for students at Johns Hopkins University (Reznick & MacRae, 2006).
One assessment method for this approach is the Objective Structured Assessment
of Technical Skills (OSATS), which scores residents using two tools (Reznick &
MacRae, 2006). The first tool is the task-specific checklist, which includes between 10
6
and 30 procedural elements that are considered essential to the task. The second
assessment tool is the global rating form, which includes the student’s behavior during
the task. The behavior can range anywhere from “respect for tissues” to the “appropriate
use of assistants” (Reznick & MacRae, 2006). The OSATS method resembles many
others that are currently in use, such as the McGill Inanimate System for Training and
Evaluation of Laparoscopic Skills (MISTELS) and the Imperial College Surgical
Assessment Device (ICSAD) (Reznick & MacRae, 2006).
Another training and assessment method that has gained popularity is simulated
instruction. Simulated instruction involves familiarizing surgical residents with the
equipment and tools necessary to perform a complicated procedure in a risk-free, virtual
environment (Scott et al., 2008). In other words, surgical residents will have had practice
before they ever reach the operating table. In this scenario, learners watch videos,
practice with expert guidance, and have their performances reviewed by said experts.
Finally, experts determine, based on observation, whether surgical residents are ready for
the operating room (Scott et al., 2008).
The use of emerging technologies could provide a more effective and efficient
method for students to learn than the current methods (Scott et al., 2008). Scott and
colleagues found that after the introduction of the 80-hour workweek in 2003, the
surgical community became more interested in the use of simulation as a way of “more
efficiently educating the trainees given the requisite limits in clinical exposure,” (Scott et
al., p. 189, 2008). Based on concerns over patient safety, the need to maximize
efficiency, limited work hours, and limited exposure to medical cases, the American
7
College of Surgeons (ACS) established a process by which medical training facilities
can apply to become accredited regional education institutes. Accordingly, the Residency
Review Committee, the Association of Program Directors in Surgery, and ACS
established a National Skills Curricula project, which encourages the use of technologies
and strategies for the use of simulations in surgical education.
Barriers to the Current Training Model
Limited exposure. One of the barriers to the current training and assessment
methods is limited exposure to clinical cases, which means that students are never
guaranteed exposure to all requisite cases, complications, or procedures (Clark, 2009;
Maupin, 2003; Scott et al., 2008). Another concern is that there are currently no
standardized pass/fail performance measures (Aggarwal & Darzi, 2006). Also, clinical
judgment and reasoning are critical components to solving problems in surgery, but to
date there is no method for accurately measuring how surgical residents make decisions
(Meterissian, 2006).
Seventy percent rule. The current apprenticeship model relies heavily on
surgical experts to teach residents what they know, which is counterproductive
considering that research results indicate that experts leave out approximately 70% of the
critical steps necessary to complete a task (Chao & Salvendy, 1994; Clark et al. 2008;
Feldon, 2007; Velhamos, et al., 2004). This results in experienced medical faculty
transferring erroneous and incomplete information to medical residents. For example,
Clark and colleagues (2008), asked 10 expert trauma surgeons to describe how to perform
8
an emergency shunt procedure. The 10 surgeons, all of whom were interviewed without
the use of CTA elicitation methods, omitted 68.75% of the necessary steps.
Sullivan and colleagues (2008) got similar results in a study in which three SMEs
were asked to think aloud while being videotaped performing a colonoscopy surgical
training. After the training, the experts participated in a CTA to create a 26-step checklist
and a 16-step cognitive demands table for the procedure. By comparing transcripts of the
videotape with the steps and decision points on the checklist and demands table, the
researchers identified the information the SMEs failed to articulate during the training
session (Sullivan et al., 2008). Results showed that all three surgeons left out at least 50%
of the action steps and 57% of the necessary decision steps to complete the procedure.
Finally, because of the likely omission of critical information by SMEs, Chao and
Salvendy (1994) recommend using multiple experts in order to get a comprehensive and
accurate list of the information required to perform a task. Chao and Salvendy (1994)
found that the percentage of procedural information acquired for a task from one expert
increases by 100% when using six experts.
Knowledge Types
Declarative. Anderson and Neves (1981) suggest that all incoming knowledge is
encoded declaratively as a set of facts. Declarative knowledge is observable and
consciously available if it is processed and stored in a person’s long-term memory (Clark
& Elen, 2006; Clark, 2008 Ormrod, 2008). In other words, it is knowledge that a SME
can articulate because s/he is consciously aware of it. Declarative knowledge refers to
what we know that we can consciously articulate to ourselves or others (Anderson, 1976).
9
Ormrod (2008) defines declarative knowledge as the way in which we consciously
experience the world around us. For example, what we read, hear, or observe and the
meaning we impose on perceived experiences. Tobias and Duffy (2009) define this
knowledge type as an “abstract representation of facts, concepts, processes, and
principles in episodic or semantic form,” (p. 162). The benefits of using declarative
knowledge are that it is relatively easy to learn and apply, while its drawback is that it can
be wrong whereas automated knowledge is almost always successful in the context where
it was automated (Anderson & Neves, 1981).
Procedural. Procedural knowledge consists of the “how-to” steps for completing
a task. It is normally automated and the SME may not be aware that s/he is using it to
complete a task (Clark & Elen, 2006; Clark, 2009; Bransford, Brown, & Cocking, 2000).
According to Clark (2009) all performance requires procedural knowledge, made up of
mental “productions.” Procedures consist of actions and decisions that accomplish an
objective under specific circumstances. Procedural knowledge includes “IF-THEN”
condition-action pairs (Anderson, 1993; Bransford, Brown & Cocking, 2000). This
knowledge is based on a condition (such as; If I wish to see what is in a room and the
room is dark) followed by an action (I must turn on the light).
Expertise
Definition of expertise. Feldon (2007) defines expertise as being attained when a
person has extensive successful experience and can quickly analyze and solve complex
problems in a specific domain. He further characterizes an expert as someone who has
extensive experience, high recall abilities, can reason abstractly, is highly reflective, can
10
recognize sophisticated patterns, and has an expanded capacity for working-memory in
a particular domain. In addition to the previously mentioned characteristics, an expert’s
extensive knowledge must, to a large degree, be automated in order to accommodate the
quick and effortless retrieval of essential information, thereby placing fewer demands on
working memory (Bransford, Brown & Cocking, 2000). Anderson and Schunn (1998)
add that experts are not necessarily more generally intelligent but instead have, over
many years, achieved significant and consistent accomplishments in a given field.
Developing expertise and automation. Expertise is developed over a long
period of time with continual practice in a particular domain. According to research by
Ericsson and others, the development of advanced expertise in a particular field requires
about 10 years of sustained, deliberate practice in that field (Charness, Krampe & Mayr,
1996; Chase & Simon, 1973; Ericsson & Lehmann, 1996; Simonton, 1999). While most
research supports the “70% rule,” at least one study suggests that up to 95% of the
information that experts utilize is unobservable (Wegner, 2008). The experience-based
knowledge is difficult to articulate because it has become automated (non-conscious) and
is not available to conscious inspection by the expert.
According to Clark (2006), the most common occurrence among experts is that
over time an expert’s performance knowledge gradually becomes automated, allowing
him/her to operate in an “auto-pilot” mode. As Clark (2006) puts it, “whenever we
recognize the conditions that reflect a performance goal, performance is initiated that
draws on available productions,” (p. 163). Automaticity, which has also been referred to
as “ballisticity” (Cowan & Logan, 1984), takes hold over time and begins to alleviate the
11
cognitive load experienced by the expert during complex tasks (Bransford, Brown &
Cocking, 2000).
The Internal and External Factors of Task Complexity
Based on the available literature, there are two approaches to defining task
complexity. The first approach defines a task as complex if it has a high number of task
elements that interact such that a change in one element can affect changes in other
elements of the task. The second approach suggests that task complexity is dependent on
the individual’s prior knowledge, experiences, and abilities relevant to the task. Based on
these definitions, the first approach refers to the external elements of the task while the
second approach is dependent on the internal factors of the person performing the task.
The first approach defines a task as complex based on its requirement for; 1) a
high volume of elements; 2) a high relationship between those elements; 3) diverse
relationships between elements; and/or 4) changes in elements or relationships between
elements over time (Sweller, 2006). Elements are defined as mental representations that
engage the cognitive process in arriving at a conclusion or informing an action (Sweller,
1994). Based on this approach, the task will determine the complexity for all people who
perform it. This means that the amount of procedural and declarative knowledge that has
to be constructed in order to accomplish a task is the measure of complexity of that task
for any given person.
However, the evidence best supports the second approach to task complexity,
which accounts for the prior knowledge of the individual performing a particular task. In
this definition, the complexity of a task is dependent on the individual’s prior knowledge
12
and experiences relevant to the task (Clark & Elen, 2006). For example, the task of
replacing a transmission may prove to be complex for a high school freshmen enrolled in
an auto shop course, but for an experienced mechanic it may be considered simple. Thus,
task complexity is dependent on an individual’s abilities as they relate to that particular
task. According to cognitive load theory, there are different levels of cognitive load
being encountered by people with varying degrees of prior knowledge and experience
(van Merriënboer, 1997). In the previous example, a high school student in auto shop will
likely experience a heavier cognitive load than a professional auto mechanic performing
the same task.
Therefore, the level of task complexity is not the same for all people. According
to Sweller (2006), the level of task complexity can vary for each individual depending on
his/her skill level and knowledge about the particular task. This makes defining the
complexity of a procedure difficult. For example, a surgical procedure that is complex for
a first-year resident may not be complex for a SME. The variance in the skill level and
knowledge of each individual is what makes defining the complexity of a procedure
difficult.
Prior knowledge. For the purpose of this study, prior knowledge is defined as:
The whole of a person’s actual knowledge that: (a) is a available before a certain
learning task, (b) is structured in schemata, (c) is declarative and procedural, (d) is
partly explicit and partly tacit, (e) and is dynamic in nature and stored in the
knowledge base. (Dochy, 1994 p. 4699)

13
Cognitive Task Analysis
What is CTA? CTA is a set of interview techniques used to effectively draw out
and capture unobservable cognitive processes, decisions, and judgments that underlie the
behaviors of expert performance (Chipman, Schraagen, & Shalin, 2000; Cooke, 1999;
Yates, 2007). Crandall, Klein, and Hoffman (2006) define CTA as a method that helps
researchers understand the thoughts that go through a person’s mind while accomplishing
a desired task. According to Crandall et al. (2006), the purpose of CTA is to capture how
people think while performing a complex task. Crandall et al. (2006) propose the
following:
The purpose of CTA is to capture the way the mind works, to capture cognition
… trying to understand and describe how [people] view the work they are doing
and how they make sense of events. Cognitive Task Analysis studies try to
capture what people are thinking about, what they are paying attention to, the
strategies they are using to make decisions or detect problems, what they are
trying to accomplish, and what they know about the way a process works. (p. 9)

Crandall and colleagues (2006) explain CTA further by defining the individual
terms. Cognition is the way people think about what they know and how they organize
and structure that information. Task is defined as the outcome that is to be achieved.
Analysis involves breaking the task down into parts in order to better understand how
those parts make up the whole. Using this model, the three primary aspects of CTA are;
1) knowledge elicitation; 2) data analysis; and 3) knowledge representation (Crandall et
al., 2006). Knowledge elicitation strategies are used to obtain information about “what
people know and how they know it: the judgments, strategies, knowledge, and skills that
underlie performance,” (Crandall et al. 2006, p. 10). Data analysis is the process of
14
structuring data, identifying findings, and discovering meaning (Crandall et al. 2006).
Finally, knowledge representations “include the critical tasks of displaying data,
presenting findings, and communicating meaning,” (Crandall et al. 2006, p. 21).
A third definition for CTA is that it seeks to capture both observable, physical
activity as well as the unobservable, cognitive processes required to perform a task
(Clark, Early, Moulton & Yates, 2008). According to Clark et al. (2008), the most
important goal of the various CTA methods is to accurately retrieve and record a
procedure that has become highly automated and cannot be easily described by the
expert. In other words, CTA attempts to capture a complete description of the cognitive
processes including declarative and procedural knowledge needed to complete a task, but
focuses more effort on non-conscious, automated decision knowledge (Clark et al. 2008).
Analysts use CTA methods to develop training materials so that novices can be trained to
use expert strategies. “CTA uses a variety of interview and observation methods to
capture the knowledge, goals, strategies, and decisions that underlie observable task
performance,” (Clark, et al., 2008).
Evidence for CTA-based training. CTA methods were used in a study to find
how expert radar system technicians effectively solved problems when encountering
system errors (Chipman, Schraagen, & Shalin, 2000). Findings showed that technicians
who underwent training prepared with information elicited using CTA methods solved
twice as many problems as those who did not receive the CTA-based training. Of those
that underwent the CTA-based training, their quality of reasoning increased by 78%
while their system knowledge improved by 60% (Chipman, Schraagen, & Shalin, 2000).
15
On average, training time for this study was reduced by 30% and sometimes by as
much as 60%, while technicians reduced time on task by at least 50%.
In another study, Chao and Salvendy (1994) used CTA methods to elicit
debugging, diagnosis and interpretation knowledge from 24 expert computer
programmers. Four types of knowledge elicitation methods were used; interview,
induction, repertory grid, and protocol method. The interview and induction methods
were more effective at capturing procedural knowledge than the repertory grid or
protocol methods.
Evidence for CTA-based training in medicine. In a study conducted by
Crandall and Getchell-Reiter (1993), CTA was performed to capture and compile
accurate information on the underlying thought processes of nursing experts in a neonatal
intensive care unit. A task analysis strategy for a version of CTA called “Critical
Decision Making” (CDM) (Klein, 1989) was used to elicit information from five SMEs
on the early assessment of infant infections. Once complete, a standardized guide with
the SMEs’ underlying cognitive knowledge was assembled and adapted into training
materials. CTA interviews identified approximately 30% more indicators of infections
than were described in previous research or the textbooks used to train nurses at that time.
These additional indicators are now used to train new neonatal nurses. Experienced
neonatal nurses were presented with the new training materials and 46% said they had
gained new knowledge, while 100% said they would have benefited from the materials
when they were novices.
16
In another study, nine trauma surgeons were interviewed using a standard “self
report” protocol and one surgeon was interviewed using CTA methods to elicit
declarative and procedural knowledge for performing an emergency shunt procedure to
temporarily restore blood flow to a damaged femoral artery. In this study, analysts found
that interviews conducted without CTA elicitation methods resulted in SMEs omitting
nearly 70% of the decision steps while the CTA elicitation strategies resulted in a more
comprehensive description, in which the expert omitted only 31.25% of the decision steps
(Clark et al., 2008).
In yet another study based on a dissertation by Maupin (2003), Velmahos et al.
(2004) found improved performance among 26 surgical residents, half of whom received
CTA based training on the placement of the central venous catheter (CVC). The
performance of residents receiving CTA instruction was compared with the performance
of the other half who received the expert-based, apprenticeship training methods
commonly used to train surgeons. The students in the apprenticeship group observed the
CVC procedure under the supervision of an experienced resident physician and followed
instruction using the traditional “see one, do one, teach one" approach. The students in
the CTA course received training based on information gathered from two SMEs. Part of
the CTA instruction included a lecture in the surgical skills laboratory and a manual
detailing the CVC procedure, which was based on the information collected from SMEs
using CTA elicitation strategies. Results showed that the experimental group had higher
scores on post-training tests (11 ± 1.86 versus 8.64 ± 1.82, P = 0.03), required fewer

17
attempts to insert the catheter into the vein (3.3 ± 2.2 versus 6.4 ± 4.2, P = 0.046), and
made fewer mistakes during the procedure.
In a more recent study, a group of one and two-year postgraduate students and
third-year medical residents were given CTA instruction on the Open Cricothyrotomy
surgical procedure. A written pretest and posttest were given to both groups and a
surgical skills checklist was used to assess each participant as s/he performed the surgical
procedure on an inanimate model. Results were compared to a group receiving traditional
training and showed that there was a significant difference between CTA and standard
instruction when it came to procedural knowledge. According to the results, medical
students and residents who received the CTA instruction outperformed the control group
in a demonstration of procedural action-steps on an inanimate model, but there was not a
significant difference in declarative knowledge (Tirapelle, 2010).
Finally, Sullivan, Brown, Peyre, Salim, Martin, Towfigh, and Grunwald (2007)
confirmed the effectiveness of CTA in a study on the instruction of percutaneous
tracheotomy (PT) placement. Again, in this study the group assigned to CTA-based
instruction performed significantly better than the control group on assessment checklists,
and scored higher on the procedure, both one month (CTA: 43.5 ± 3.7, control 35.2 ± 3.9,
P = .001) and six months (CTA: 39.4 ± 4.2, control: 31.8 ± 5.8, P = .004) after
instruction. This study also found that CTA-based instruction did a better job of aiding
students in the long-term transfer of information than the traditional approach.
These studies support the Clark et al. (2006) assertion that CTA methods are
substantially more effective for instruction than those developed using more traditional
18
expert “self report” techniques. Medical experts appear to unintentionally omit a
significant amount of information when attempting to teach others a surgical procedure.
Why is CTA important in surgical training? CTA methods have been
effectively used in military training, the private sector, and classroom environments with
positive effects. There are several advantages to CTA based training including; 1)
improved accuracy in training materials; 2) shorter training periods; and 3) a reduction of
time on task (Clark et al., 2008; Clark et al., 2006; Maupin, 2003; Schraagen et al., 2000;
Velhamos et al., 2004; & Yates, 2007). When applied properly, CTA-based instruction
can improve the accuracy and completeness of information while improving
performance.
Specifically, CTA can help the medical field to overcome training challenges in
four ways. First, it allows for the access of covert cognitive decisions that SMEs have
automated. Second, it allows for a detailed breakdown of automated, procedural steps in
order to create a concise yet comprehensive job-aid that learners can easily follow. Third,
it has been proven to accelerate the learning curve. Finally, the data collected using CTA
knowledge elicitation strategies can be used to create curricular modules to assist surgical
residents in the learning process.
Currently, surgical experts are often called upon to provide training for surgical
residents. In doing so, they appear to omit approximately 70% of the information,
judgments, and decision points necessary to complete the task (Clark et al., 2008; Feldon,
2004, 2007; Maupin, 2003;Velhamos, et al., 2004; Yates, 2007).

19
CHAPTER 2: METHODS
Since the amount and type of information omitted by experts when they describe
how they perform surgeries has not been the focus of most research, this dissertation will
attempt to determine how much of what type of information is captured in CTA
interviews with medical faculty. More specifically, this study uses CTA methods to
capture critical knowledge, including critical decisions and conceptual knowledge that
may be omitted by experts when describing a surgical procedure to students.

This study attempted to answer the following questions.
1. What percentage of critical “when” and “how” information do experts omit when
describing the Open Cricothyrotomy surgical procedure?
2. Does the amount of an expert's prior knowledge and experience with a specific
task influence the amount of knowledge that s/he omits when describing how to
perform the task?

Based on indications in the current research literature, the hypothesis for this
study is that surgical experts will omit approximately 70% of the critical information
necessary to perform the Open Cricothyrotomy and Central Venous Catheter surgical
procedures.
Design
In order to answer the proposed research questions, this descriptive study took a
mixed-methods approach. Qualitative methods were used in conducting semi-structured
20
interviews using CTA knowledge elicitation strategies as described by Clark, et al.
(2008). Quantitative methods were applied to analyze the data by using frequency counts
to determine how much information was omitted when compared with the final, expert-
approved, “gold standard.” The “gold standard” is an aggregate of the information
elicited from six subject-matter experts that was compiled into one report to establish a
complete record of the critical steps necessary to perform each of the surgical procedures.
The frequency of decision versus action steps were counted in the Open Cricothyrotomy
and Central Venous Catheter surgical procedures to determine the frequency and
percentage of action and decision steps.
However, as discussed in Chapter 1, this study measured the complexity of the
Open Cricothyrotomy and Central Venous Catheter surgical procedures by obtaining
information about each SME’s prior knowledge as it pertained to his/her surgical
procedure. A surgical procedure was considered to be more complex based on Clark’s &
Elen’s (2006) internal approach to task complexity, which is dependent on the prior
knowledge of the person performing the task.
This study was presented to the University of Southern California, Keck School
of Medicine’s (USC-KSOM) Institutional Review Board (IRB) for approval.
Tasks
Open Cricothyrotomy Surgical Procedure
The Open Cricothyrotomy surgical procedure involves making a vertical incision
on the cricothyroid membrane, inserting a tube through the cricothyroid, and finally into
21
the trachea (Rahm, 2004). An automatic ventilating device is then attached to the tube
to restore breathing through the airway.
Central Venous Catheter Surgical Procedure
The Central Venous Catheter surgical procedure is performed on one of six sites
in the body (the right/left internal jugular vein, the right/left subclavian vein, or the
right/left femoral vein). The procedure involves advancing a long catheter into the central
circulation system in order to; 1) gain venous access to provide fluids and drugs to the
patient; 2) gain access to central circulation to allow for hemodynamic monitoring; or 3)
place a central venous catheter line.
Sample
The sample population of experts for this study varied depending on the surgical
procedure. Six expert trauma surgeons participated in CTA interviews for the Open
Cricothyrotomy surgical procedure. One anesthesiologist, one critical care specialist, and
four trauma surgeons participated in the CTA interviews for the Central Venous Catheter
procedure. Experts were selected from the Department of Surgery at the USC-KSOM
located in Los Angeles, CA. The surgical experts for this study were selected based on
years of experience and success in performing each surgical procedure. In order to
capture all necessary information and to ensure the validity and completeness of the
required information for performing the Open Cricothyrotomy and Central Venous
Catheter surgical procedures, six subject-matter experts were used to compile information
for the eventual “gold standard,” (Chao & Salvendy, 1994; Clark et al., 2006). In order to
maintain confidentiality, each expert was identified by a letter of the alphabet. SMEs for
22
the Open Cricothyrotomy surgical procedure were assigned letters “U” through “Z.”
SMEs for the Central Venous Catheter surgical procedure were assigned letters “A”
through “F.”
Procedure for Data Collection
The data for this study was collected according to the method described in Clark
et al. (2008), which suggests conducting CTA in five phases. The steps for each phase are
described as follows:
Phase 1. Collect Preliminary Knowledge
The researcher became familiar with the domain, and identified the task sequence
and procedures that were analyzed. This phase included document analysis of books and
other resources that familiarized the researcher with the Open Cricothyrotomy or Central
Venous Catheter surgical procedures.
Phase 2. Identify Knowledge Representations
The information collected in phase one was used to identify and generate a
preliminary list of knowledge necessary to perform the surgical procedure. This involved
using concept maps or flowcharts in order to organize the information that was obtained
from the SMEs.
Phase 3. Apply Focused Knowledge Elicitation Methods
CTA methods were used to conduct semi-structured interviews with six SMEs for
each surgical procedure. Experts for each procedure were asked to answer questions
regarding the primary goal of the procedure, the equipment required, the major steps of
the procedure, the indications and contraindications for performing the procedure, and to
23
outline the conditions for each decision step. Experts were also asked to list the
standards required for successfully performing the procedures. Finally, the experts were
asked to include concepts that surgical residents may not be familiar with as well to
highlight problem areas for novices (i.e. recognizing indications for performing the
procedure or familiarity with the equipment).
The interviews drew out task details for performing key sub-tasks and captured
the following information (Clark et al. 2008):
1. The decisions that a surgeon is required to make when performing the task as
well as the alternatives to those decisions;
2. The concepts, biological and physical processes, and principles that surgical
experts use in moving toward a sub-task;
3. The conditions or events that initiate or lead up to the correct response/action;
4. The equipment or materials necessary to perform the task;
5. The sensory cues that are required for successful completion of the task,
including sound, touch, and smell; and
6. The indicators for standards required of surgeons performing the procedure
(e.g. quality, accuracy, and speed).
This phase was repeated during every interview. All interviews were recorded for later
transcription and evaluation.

24
Phase 4. Analyze and Verify Data Acquired
The information gathered from the SMEs via the semi-structured interviews was
used to create a protocol for the Open Cricothyrotomy and Central Venous Catheter
surgical procedures.
CTA coding scheme. Each of the 12 audio recordings were transcribed and
coded by a minimum of two trained analysts. Analysts reviewed each line of the
transcripts and coded every occurrence of declarative and procedural knowledge as well
as action and decision steps. The procedure for coding each interview was as follows:
1. Conduct semi-structured interviews with SMEs
2. Transcribe interviews and number each line
3. Have at least two analysts code each transcript
4. Analysts meet to establish inter-rater reliability
5. Format the information as a CTA protocol and include the line numbers for where
the information was found.
Inter-rater reliability. All coded transcripts were compared with at least one
analyst in order to calculate inter-rater reliability. Inter-rater reliability was determined by
analyzing the code for agreement between analysts (see Appendix A). In order to achieve
inter-rater reliability, the two analysts for each transcript met to go over their coding
schemes and discussed any disagreements until they came to an agreement on the
appropriate code for a given statement. If the analysts were not able to reach an
agreement they kept tallies of all disagreements, which were then added to the
25
agreements. The total number of agreements was divided by the sum of the
disagreements and agreements, to equal the percentage of inter-rater reliability.
Once the transcripts were coded by at least two analysts and the
agreements/disagreements were tabulated, the information was used to develop a CTA
report for each transcript.
Development of the CTA report and data analysis. The coding and
comparisons assisted in developing a CTA protocol, which incorporated the fewest steps
necessary to effectively perform the Open Cricothyrotomy and Central Venous Catheter
surgical procedures. Each report identified the goal of the procedure, major steps and
subtasks, necessary equipment, decision points for various conditions, and the indications
and contraindications for performing each procedure. Analysts created flowcharts based
on each SME’s final CTA report to ensure that all of the major action and decision steps
were captured for each transcript.
Each SME received an email with a draft of his/her CTA protocol and flowchart
attached in a word document. The protocol was reviewed by SMEs to confirm the
accuracy and comprehensiveness of the information. SMEs were asked to use track
changes to provide additional information or make corrections to the CTA protocol or
flowchart. After reviewing the CTA protocols, the SMEs replied with comments and/or
changes. This step was repeated until each SME was satisfied with his/her protocol. The
process resulted in a corrected version of the CTA protocol for each SME.

26
Phase 5. Format Results for the Intended Application
All SME protocols were aggregated into one comprehensive draft “gold
standard,” which was reviewed and edited for accuracy and completeness by each of the
six SMEs (per surgical procedure). This process produced the corrected and final “gold
standard” (see appendices B & J), which included the fewest necessary steps possible for
successfully completing the Open Cricothyrotomy and Central Venous Catheter surgical
procedures.
Microsoft Excel was used to create a table listing all of the required steps for
successfully performing the Open Cricothyrotomy and Central Venous Catheter surgical
procedures based on the “gold standards.” Each step was marked with a “1,” indicating
that the expert provided information in agreement with the “gold standard” or a “0,”
which indicated that the expert omitted information necessary to perform the task. The
frequency counts were converted into percentages in order to determine the amount of
information that the SMEs omitted when describing the Open Cricothyrotomy and
Central Venous Catheter surgical procedures.

27
CHAPTER 3: RESULTS
This study used CTA methods to capture critical knowledge in the form of
decision steps and conceptual knowledge that were omitted by experts when describing
the procedures. The two surgical procedures were also compared in order to determine
the difference in omissions based on the experts’ prior knowledge and experience with
the Open Cricothyrotomy and Central Venous Catheter surgical procedures. There were
a total of 46 steps in the Open Cricothyrotomy “gold standard.” Thirteen were decision
steps while the remaining 33 were action steps. All necessary steps for the Open
Cricothyrotomy surgical procedure are listed in Appendix C. The “gold standard” for the
Central Venous Catheter surgical procedure required 58 steps. There were 44 possible
action steps and 14 possible decision steps. All necessary steps for the Central Venous
Catheter surgical procedure are listed in Appendix E.
Research Question 1
What percentage of critical “when” and “how” information do experts omit when
describing the open cricothyrotomy surgical procedure?
In order to find the answer to the first research question SMEs were given credit
for describing a step if they mentioned it in their interview or described “how” to perform
it. For example, some SMEs may have simply said “locate the anatomic landmark”
during their interviews while others may have described how to do that without actually
saying it (i.e. “feel for the cricothyroid membrane”). The coding of the six interview
transcripts resulted in an average inter-rater reliability of 96%. Of the six interview
transcripts, the lowest inter-rater reliability was 91.53% while the highest inter-rater
28
reliability was 100%. In most cases, the analysts coding the transcripts were able to
reconcile differences via consensus. If analysts were not able to come to an agreement it
was tracked and averaged into the inter-rater- reliability.
Round 1 Data
SMEs U and W were the most thorough in describing how to perform the open
cricothyrotomy surgical procedure. They described 58.70% of the essential steps, while
SME X recalled 23.91% of the critical steps necessary to perform the Open
Cricothyrotomy surgical procedure. Overall, the SMEs recalled and reported 48.19% of
the information necessary to successfully perform the procedure.
There was a significant difference in the percentage of information that was
omitted for decision steps versus action steps. On average, the SMEs recalled 58.08% of
the action steps while only accounting for 23.08% of the decision steps. There was a
35% difference in the amount of information that SMEs communicated for action versus
decision steps. SME W communicated the largest number of decision steps, reporting
seven of 13 possible steps. SMEs X and Z reported the fewest, reporting only one out of
13 possible steps. This means that the most thorough SME recalled 53.85% of the
necessary decision steps, and the least thorough recalled 7.69%. In comparison, SME U
recalled the highest percentage of action steps with 75.76% and SME X recalled the
lowest with 30.30%.

29
Table 1
Comparison of the Type of Information Recalled by SMEs for the Open Cricothyrotomy
Surgical Procedure
SMEs Number of decision
steps RECALLED
out of 13 possible
per the Gold
Standard
Number of action
steps RECALLED
out of 33 possible
per the Gold
Standard
Total number of
decision & action
steps RECALLED
out of 46 possible
per the Gold
Standard
SME U 2 (15.38%) 25 (75.76%) 27 (58.70%)
SME V 4 (30.77%) 22 (66.67%) 26 (56.52%)
SME W 7 (53.85%) 20 (60.61%) 27 (58.70%)
SME X 1 (7.69%) 10 (30.30%) 11 (23.91%)
SME Y 3 (23.08%) 17 (51.52%) 20 (43.48%)
SME Z 1 (7.69%) 21 (63.64%) 22 (47.83%)
Overall Averages 3 (23.08%) 19.17 (58.08%) 22.17 (48.19%)

Based on the data collected during the initial interviews (Round 1 data), SMEs U
through Z recalled 58.7%, 56.52%, 58.70%, 23.91%, 43.48%, and 47.83% of the action
and decision steps necessary to successfully perform the Open Cricothyrotomy surgical
procedure. This means that collectively the SMEs averaged a 48.19% omission rate
while capturing only 51.81% of the required steps. Individually, the SMEs had between
a 63% and 41% omission rate in the information that they provided when explaining how
to perform the procedure. Two of the six SMEs recalled only 36.96% of the information
necessary to successfully perform the procedure.

30
Table 2
Comparison of Omissions between Types of Steps in the Open Cricothyrotomy Surgical
Procedures
SMEs Number of decision
step OMISSIONS
(out of 13 possible
per the Gold
Standard)
Number of action
step OMISSIONS
(out of 33 possible
per the Gold
Standard)
Total number of
decision & action
step OMISSIONS
(out of 46 possible
per the Gold
Standard)
SME U 11 (84.62%) 8 (24.24%) 19 (41.30%)
SME V 9 (69.23%) 11 (33.33%) 20 (43.48%)
SME W 6 (46.15%) 13 (39.39%) 19 (76.09%)
SME X 12 (92.31%) 23 (69.70%) 35 (63.04%)
SME Y 10 (76.92%) 16 (48.48%) 26 (56.52%)
SME Z 12 (92.31%) 12 (36.36%) 24 (52.17%)
Overall Omissions 10 (76.92%) 13.83 (41.92%) 23.83 (51.81%)

The greatest omission of information occurred with decision steps. Only three of
the 13 decision steps were mentioned by more than two SMEs and more than half of the
decision steps were mentioned by only one of the six SMEs. Five of the six SMEs
recalled between one and four decision steps, while only one was able to recall seven of
the 13 necessary decision steps. This means that at best 46.15% of the necessary
decision-making processes were excluded and at worst 92.31% were excluded. Overall,
the SMEs showed a higher percentage of recall for action steps versus decision steps.

31
Figure 1
Decision and Action Steps Recalled in Percentages for the Open Cricothyrotomy Surgical
Procedure

The results indicate that SMEs were better able to recall action steps versus
decision steps (as seen in Figure 1) when recounting how to perform the Open
Cricothyrotomy surgical procedure. At worst the SMEs recalled 30.30% of the action
steps necessary to perform the surgery and at best 75.76% of the required information
was obtained. Only six of the required 46 steps were mentioned by all six SMEs. All six
of those sub-tasks were categorized as action steps.

32
Round 2 Data
Once the interviews were transcribed, coded, and developed into a protocol for
each expert to review; the SMEs received a draft of their CTA reports. After reviewing
his/her transcript, each SME e-mailed the CTA report back with comments and/or
changes. This information comprises the Round 2 data.

Table 3
Total Gold Standard Action and Decisions Steps Recalled per SME for Round 1 and
Round 2 for the Open Cricothyrotomy Procedure
SMEs
No. of steps recalled
out of 46 possible
% of steps recalled
out of 46 possible steps
Round 1 Round 2 Increase Round 1 Round 2 Increase
SME U 27 27 0 58.70% 58.70% 0.00%
SME V 26 30 4 56.52% 65.22% 8.70%
SME W 27 28 1 58.70% 60.87% 2.17%
SME X 11 17 6 23.91% 36.96% 13.05%
SME Y 20 22 2 43.48% 47.83% 4.35%
SME Z 22 29 7 47.83% 63.04% 15.21%
Averages 22.17 25.5 3.33 48.19% 55.44% 7.25%

Although SMEs U and W were the most thorough in capturing action and
decision steps during Round 1 data collection, they were surpassed by SME V in Round
2. SME U added no additional information, SME W added one action step (2.17%
increase), and SME V added four action steps (8.70% increase). Overall, the SMEs
added an average of 3.33 steps creating a 7.25% increase in information recalled. There
was only a 5.13% (.67 steps added) information gain among decision steps and an 8.08%
(2.67 steps added) information gain among action steps (Tables 6 & 7).

33
Table 4
Total Gold Standard Decision Steps Recalled per SME for Round 1 and Round 2 for the
Open Cricothyrotomy Procedure
SMEs
No. of steps recalled
out of 13 possible
% of steps recalled
out of 13 possible steps
Round 1 Round 2 Increase Round 1 Round 2 Increase
SME U 2 2 0 15.38% 15.38% 0.00%
SME V 4 4 0 30.77% 30.77% 0.00%
SME W 7 7 0 53.85% 53.85% 0.00%
SME X 1 4 3 7.69% 30.77% 23.08%
SME Y 3 3 0 23.08% 23.08% 0.00%
SME Z 1 2 1 7.69% 15.38% 7.69%
Averages 3 3.67 0.67 23.08% 28.21% 5.13%

Based on the data collected during Round 2, SMEs U through Z recalled 58.70%,
65.22%, 60.87%, 36.96%, 47.83%, and 63.04% of the necessary action and decision
steps to successfully perform the Open Cricothyrotomy surgical procedure (Table 5).
SME X showed the largest increase in decision steps from Round 1 to Round 2 by
capturing an additional 23.08% (three steps added) of the information. In contrast, SME
X recalled the least number of decision steps by communicating one out of 13 possible
decision steps during Round 1 data collection.

34
Table 5
Total Gold Standard Action Steps Recalled per SME for Round 1 and Round 2 for the
Open Cricothyrotomy Surgical Procedure
SMEs
No. of steps recalled
out of 33 possible
% of steps recalled
out of 33 possible steps
Round 1 Round 2 Increase Round 1 Round 2 Increase
SME U 25 25 0 75.76% 75.76% 0.00%
SME V 22 26 4 66.67% 78.79% 12.12%
SME W 20 21 1 60.61% 63.64% 3.03%
SME X 10 13 3 30.30% 39.39% 9.09%
SME Y 17 19 2 51.52% 57.58% 6.06%
SME Z 21 27 6 63.64% 81.82% 18.18%
Averages 19.17 21.83 2.67 58.08% 66.16% 8.08%

SME Z showed the largest increase in action steps by recalling an additional
18.18% (six steps added) in Round 2. SME Z was the fourth most thorough in Round 1
data collection, but advanced to become the second most thorough SME for reporting
action and decision steps in Round 2 (63.04% recalled).
The results indicate that SMEs were better able to capture action steps versus
decision steps in both Round 1 and Round 2. When calculating averages for both action
and decision steps, the SMEs recalled 35% more action steps than decision steps during
Round 1 and 37.95% more action steps than decision steps for Round 2.
Research Question 2
Does the amount of an expert's prior knowledge and experience with a specific
task influence the amount of knowledge that s/he omits when describing how to perform
the task?
In order to address this question, the Open Cricothyrotomy and Central Venous
Catheter surgical procedures were examined and compared. Additional data was gathered
35
to determine the level of experience and prior knowledge that each SME had in their
respective surgical procedure.
Open Cricothyrotomy Surgical Procedure
Based on the information collected for the Open Cricothyrotomy surgical
procedure, SME W was the most accurate and recalled 58.70% of the necessary action
and decision steps after Round 1. SME W also had the most prior knowledge with 14
years of experience as a doctor and was tied for the most times performing the procedure
(10 times). In addition, SME W performed the procedure the closest to his interview date
(28 days prior to being interviewed by CTA analysts). SME V ranked second for
thoroughness and recalled 56.52% of the necessary steps to perform the procedure. SME
V also ranked second in prior knowledge with 18 years of experience as a doctor and was
tied for second in the number of times that he had performed the procedure (three times).
SME V was interviewed about 6.5 years after he had last performed the procedure. The
third most comprehensive was SME Z, who recalled 46.83% of the necessary steps and
also ranked third in prior knowledge. SME Z had 12 years of experience as a doctor, had
performed the procedure 10 times, and was interviewed 112 days after he had last
performed the procedure. Finally, SME Y was the least comprehensive, capturing
43.48% of the necessary action and decision steps. Accordingly, SME Y had the least
amount of prior knowledge with only seven years of experience as a doctor and having
performed the procedure three times. SME Y was interviewed 672 days after he last
performed the Open Cricothyrotomy surgical procedure.

36
Table 6
Prior Knowledge Indicators for the Open Cricothyrotomy Subject Matter Experts
SMEs
Years as
Doctor
# of times
SME has
performed
procedure
Days since
SME last
performed
procedure
% Decision
Step
Omissions
% Action
Step
Omissions
SME V
(interview date:
9/15/2009)
18 3 2352 69.23% 33.33%
SME W
(interview date:
9/14/2009)
14 10 28 46.15% 39.39%
SME Y
(interview date:
7/28/2009)
7 3 672 76.92% 48.48%
SME Z
(interview date:
7/28/2009)
12 10 112 92.31% 36.36%
AVERAGES 12.75 6.5 666.4 76.92% 41.92%

Central Venous Catheter Surgical Procedure
Based on the information collected for the Central Venous Catheter surgical
procedure, the number of years the SME has been a doctor has no correlation with the
omission rates for both action and decision steps. SME E had the least amount of prior
knowledge with only seven years of experience as a doctor and reported that he had
performed the procedure “hundreds” of times compared to the SMEs who had more
experience as doctors and had performed the procedure “thousands” of times. Yet SME E
tied for second in his comprehensiveness in explaining the procedure and recalled
70.69% of the necessary action and decision steps. SME E had also performed the
procedure on a live patient the day before his interview. SME D was the most
comprehensive, but ranked second to last for prior knowledge. SME D had 12 years of
experience as a doctor and had performed the procedure “hundreds” of times, while
37
SMEs C, B, and F had 32, 20, and 14 years of experience as doctors respectively and
SMEs C and B had performed the procedure “thousands” of times.

Table 7
Prior Knowledge Indicators for the Central Venous Catheter Subject Matter Experts
SMEs
Years as
Doctor
# of times SME has
performed
procedure
% Decision Step
Omissions
% Action Step
Omissions
SME B
(interview date:
9/8/2009)
20 Thousands 28.57% 34.09%
SME C
(interview date:
6/2/2009)
32 Thousands 35.71% 50.00%
SME D
(interview date:
9/21/2009)
12 Hundreds 35.71% 11.36%
SME E
(interview date:
6/29/2009)
7 Hundreds 28.57% 29.55%
SME F
(interview date:
9/14/2009)
14 Hundreds 35.71% 29.55%
AVERAGES 17 N/A 34.52% 29.93%

Comparison of Prior Knowledge among Subject Matter Experts for the Open
Cricothyrotomy and Central Venous Catheter Surgical Procedures
As seen in table nine, the SMEs for the Open Cricothyrotomy procedure SMEs
omitted 20.78% more information than the SMEs for the Central Venous Catheter
procedure. In addition, the Central Venous Catheter SMEs were able to capture a higher
percentage of action (70.08%) and decision (65.48%) steps in comparison to the SMEs in
the Open Cricothyrotomy procedure who recalled 58.08% of the action steps and only
23.08% of the decision steps. The Open Cricothyrotomy SMEs averaged 12.75 years as
38
doctors while the Central Venous Catheter SMEs averaged 17 years as doctors.
Finally, the SME with the most prior knowledge in the Open Cricothyrotomy surgery had
performed the procedure 10 times while the most experienced SME in the Central
Venous surgery had performed the procedure “thousands” of times.

Table 8
Comparison of the Open Cricothyrotomy and the Central Venous Catheter Surgical
Procedures
Procedure % of actions
OMITTED
% of decisions
OMITTED

% of total
actions/decisions
RECALLED
% of total
actions/decisions
OMITTED
Open
Cricothyrotomy
41.92%
(19.17 out of 33
= 58.08%
recalled)
76.92%
(3 out of 13 =
23.08% recalled)
48.19%

51.81%

Central Venous
Catheter
29.92%
(30.83 out of 44
= 70.08%
recalled)
34.52%
(9.17 out of 14 =
65.48% recalled)
68.97%

31.03%

Information Recalled for the Central Venous Catheter Surgical Procedure
When calculating the numbers for action and decision steps for the Central
Venous Catheter surgical procedure, SME D was the most thorough and described
82.76% of the steps, while SME C was the least comprehensive and only recalled 53.45%
of the steps. Overall, the SMEs recalled 68.97% of the information necessary to perform
the procedure and omitted 31.03%. There was a significant difference in the percentage
of information that was omitted for decision steps versus action steps. On average, the
SMEs recalled 30.83 out of 44 possible action steps (70.08%) while accounting for 9.17
out of 14 possible decision steps (65.48%).
39
There was a 4.6% difference in the amount of information that Central Venous
Catheter SMEs were able communicate for action versus decision steps. SMEs B and E
communicated the largest number of decision steps, reporting 10 of 14 possible while
SME A reported the least with only 8 out of 14 possible steps. This means that at best the
SMEs recalled 64.29% of the necessary decision steps, and at worst 57.14%. On average,
the SMEs recalled 65.48% of the necessary decision steps. In comparison, the SMEs
were able to communicate a collective 70.08% of the action steps with SME D capturing
the highest percentage at 88.64% of the action steps and SME C capturing the lowest at
50%.

Table 9
Comparison of the Action and Decision Steps Recalled by SMEs for the Central Venous
Catheter Surgical Procedure
SMEs Number of decision
steps RECALLED
out of 14 possible
per the Gold
Standard
Number of action
steps RECALLED
out of 44 possible per
the Gold Standard
Total number of
decision & action
steps RECALLED
out of 58 possible
per the Gold
Standard
SME A 8 (57.14%) 33 (75.00%) 41 (70.69%)
SME B 10 (71.43%) 29 (65.91%) 39 (67.24%)
SME C 9 (64.29%) 22 (50.00%) 31 (53.45%)
SME D 9 (64.29%) 39 (88.64%) 48 (82.76%)
SME E 10 (71.43%) 31 (70.45%) 41 (70.69%)
SME F 9 (64.29%) 31 (70.45%) 40 (68.97%)
Overall Averages 9.17 (65.48%) 30.83 (70.08%) 40 (68.97%)

The coding of the six interview transcripts resulted in an average inter-rater
reliability of 96.46%. Of the six interview transcripts, the lowest inter-rater reliability
was 92% while the highest inter-rater reliability was 99.61%.
40
Based on the data collected during the initial interviews (Round 1 data), SMEs
A through F recalled 70.69%, 67.24%, 53.45%, 82.76%, 70.69%, and 68.97%
respectively of the action and decision steps necessary to successfully perform the
Central Venous Catheter surgical procedure. This means that collectively the SMEs
averaged a 31.03% omission rate while capturing 68.97% of the required action and
decisions steps. Individually, the SMEs omitted between 46.55% and 17.24% of the
action and decision steps when explaining how to perform the Central Venous Catheter
procedure. One of the six SMEs recalled only 53.45% of the action and decision steps,
while the most thorough SME recalled 82.76%.

Table 10
Comparison of Omissions between Types of Steps in the Central Venous Catheter
Surgical Procedure
SMEs Number of decision
step OMISSIONS
(out of 14 possible
per the Gold
Standard)
Number of action
step OMISSIONS
(out of 44 per the
Gold Standard)
Total number of
decision & action step
OMISSIONS (out of
58 per the Gold
Standard)
SME A 6 (42.86%) 11 (25.00%) 17 (29.31%)
SME B 4 (28.57%) 15 (34.09%) 19 (32.76%)
SME C 5 (35.71%) 22 (50.00%) 27 (46.55%)
SME D 5 (35.71%) 5 (11.36%) 10 (17.24%)
SME E 4 (28.57%) 13 (29.55%) 17 (29.31%)
SME F 5 (35.71%) 13 (29.55%) 18 (31.03%)
Overall
Omissions
4.83 (34.52%) 23.67 (29.58%) 18 (31.03%)

Decision and Action Step Omissions
The greatest omission of information occurred with action steps. One SME
recalled 22 of the 44 action steps. More than half of the action steps were mentioned by
41
five of the six SMEs. The recall ability for action steps among the six SMEs ranged
between 53.45% and 82.76%, with one of the SMEs recalling 39 of the 44 necessary
action steps. This means that at best 11.36% of the necessary action steps were left out
and at worst 50% were omitted. Overall, the SMEs showed a higher percentage of recall
for action steps than decision steps.

Figure 2
Decision and Action Steps in Percentages for the Central Venous Catheter Surgical
Procedure

The results indicate that the Central Venous Catheter SMEs were better able to
capture action steps versus decision steps (as seen in Figure 4) when recounting how to
perform the procedure. Only two of the six SMEs recalled more decision steps as
42
opposed to action steps. SMEs B and C recalled 5.52% and 14.29% more decision
steps respectively. At worst, the SMEs recalled only 57.14% of the decision steps
necessary to perform the surgery and at best 71.43% of the required information was
obtained. Collectively, the SMEs recalled 65.48% of the decision steps while capturing
70.08% of all action steps. The decision and action steps combined to total 58 procedure
steps. Only one of the six SMEs mentioned more than 40% of the required 58 steps.

43
CHAPTER 4: CONCLUSIONS
The purpose of this study was to determine the effects of automaticity on an
expert’s ability to recall all necessary steps to successfully perform a task. Specifically,
this study measured how much critical information surgical experts omit when describing
the Open Cricothyrotomy and Central Venous Catheter surgical procedures, and then
found whether there is a difference in knowledge omissions depending on the prior
knowledge for each SME. It was hypothesized that, consistent with prior research in
expert omissions, the Open Cricothyrotomy and Central Venous Catheter surgical experts
would omit approximately 70% of the critical decision steps necessary to perform the
procedures because decisions tend to be more automated and subconscious than actions.
The results of this study were mixed, with the Open Cricothyrotomy SMEs omitting
76.92% of the decision steps and the Central Venous Catheter SMEs omitting 34.52% of
the decision steps. Overall knowledge omissions for the Open Cricothyrotomy surgical
procedure were 55.44% while overall knowledge omissions for the Central Venous
Catheter surgical procedure were 26.34%. It was also expected that the decision steps for
each surgery would be more difficult for the experts to communicate when compared
with their ability to recall action steps. This proved to be true for the Open
Cricothyrotomy surgical procedure (28.21% decision steps recalled versus 66.16% action
steps recalled), but not for the Central Venous Catheter surgical procedure (78.79%
decision steps recalled versus 70.42% action steps recalled). Two research questions
guided this study.
44
Research Question 1
What percentage of critical “when” and “how” information do experts omit when
describing the open cricothyrotomy surgical procedure?
The findings from this study indicate that experts are not able to accurately
communicate all of the “when” and “how” information for performing the Open
Cricothyrotomy surgical procedure. Errors of omission ranged between 34.78% and
63.04%. The rate of omission for decision steps was 76.92% and was in line with the
“seventy percent rule,” which suggests that SMEs fail to communicate approximately
70% of what they know (Chao & Salvendy, 1994; Clark et al. 2008; Feldon, 2007;
Velhamos, et al., 2004). Overall, the six experts for the Open Cricothyrotomy surgical
procedure averaged an omission rate of 51.81% for action and decision steps.
Research Question 2
Does the amount of an expert's prior knowledge and experience with a specific
task influence the amount of knowledge that s/he omits when describing how to perform
the task?
Based on the definition of task complexity and the prior knowledge indicators that
were collected from each expert, it was expected that SMEs for both surgical procedures
would fail to communicate approximately 70% of the critical decision steps necessary to
perform the procedure. In spite of this, the SMEs for the Central Venous Catheter
procedure were able to recall 65.48% of the decision steps while the Open
Cricothyrotomy SMEs were able to recall 23.08% of the decision steps. Overall, there
was a 76.92% omission rate in decision steps for the Open Cricothyrotomy SMEs and a
45
34.52% omission for the Central Venous Catheter SMEs. The results were unexpected
considering that the Central Venous Catheter SMEs had an average of 17 years of
experience as medical doctors and had performed the procedure either “hundreds” or
“thousands” of times. In comparison, their counterparts in the Open Cricothyrotomy
procedure had an average of 12.75 years experience as doctors and had performed the
procedure an average of 6.5 times. According to the data, the Central Venous Catheter
SMEs had the most prior knowledge and therefore should have omitted the most
information due to expert-automation. The conflicting results may be due to a variety of
factors.
First, the Central Venous Catheter procedure has received added attention due to;
1) controversies over errors; 2) the consensus among experts that the procedure has to be
taught differently; and 3) a previous study that found surgeons who described the
procedure omitted approximately 70% of the decision steps (Velmahos et al., 2004). This
study brought attention to patient safety, the problems involved in performing the
procedure, and may have caused the Central Venous Catheter SMEs to become more
aware of the procedure by talking or reading about it. There was also an article published
in the American Journal of Surgery that evaluated whether resident performance
improved after participating in a Central Venous Catheter simulation (Britt et al., 2009).
In addition, the hospital from which the SMEs were sampled has developed a “Central
Venous Access Competency” in order to clarify the procedure. A similar document does
not exist for the Open Cricothyrotomy procedure. This may explain why the omission
rate for the Central Venous Catheter procedure has decreased to 34.52% from the
46
previous Velhamos (2004) study. The Central Venous Catheter controversy has led to
a unique situation where doctors are significantly more aware of decisions steps involved
in this procedure because they have been discussing them. In this case, it may be close to
impossible to bring to light all of the confounds involved in the Central Venous Catheter
procedure.
Second, the data collected for prior knowledge is not complete with only four of
the six SMEs responding for the Central Venous Catheter procedure and five of the six
SMEs responding for the Open Cricothyrotomy procedure. There is a vast variation in the
prior knowledge numbers for the Central Venous Catheter data, which skews the
averages so that there is no meaningful pattern.
Finally, the “gold standard” was based on the transcripts of six SME interviews
that were conducted by various task analysts. The skill level of each task analyst
(interviewer) varied, and methods varied depending on the analyst and the surgical
procedure. The technique and style used to conduct the interview could have affected the
quality of the interview, which may have resulted in more or less information being
recalled by each SME. Thus, the inconsistency in task analysts may have had an impact
on the final data. If possible, future research on this topic should use the same task
analyst for all SME interviews and the creation of “gold standards” thereby, guaranteeing
there is a consistent methodology being applied across all CTA data collection.

47
Limitations
Selection of Subject Matter Experts
One limitation of this study is the number and selection of surgical experts
recruited to serve as SMEs. This study was limited to SMEs based on availability, which
may have affected the results. We chose to use six SMEs because the percentage of
procedural information acquired for a task from one expert increases by more than 30%
when using six experts (Chao & Salvendy, 1994). However, it is not known how many
SMEs are needed to create a “gold standard” for a surgical procedure because this area of
research is relatively new. In addition, an established “gold standard” of steps and
cognitive decision points for the Open Cricothyrotmy and Central Venous Catheter
surgical procedures does not exist in the literature. Therefore, we relied on our own
experts at our own institution. Because medical faculty adapt to performing a surgery
with methods used by their institution it is possible that the results may have been
different had we used surgical experts from other institutions.
Task Analyst Consistency
Although each task analyst was trained in conducting CTA interviews, coding,
and creating protocols, it is difficult to ensure consistency among seven analysts. This
was especially true when conducting CTA interviews and creating the “gold standard” for
each surgery. Despite the fact that each analyst was observed and guided by a person
experienced in conducting CTA interviews, it did not prevent analysts from using
suggestive questioning. As analysts became more familiar with their respective surgical
procedures, they were better able to detect when a SME omitted information and asked
48
follow-up questions to ensure that the information was captured. This type of
elicitation may explain why the SMEs for the Central Venous Catheter surgical procedure
did not omit the expected 70% of the decision steps necessary to perform the procedure.
Another concern was the method by which each research team developed its “gold
standard” protocol. Two different teams of researchers compiled data for the Central
Venous Catheter and the Open Cricothyrotomy surgical procedures. This could have
affected results in that the methodology may not have been the same. For example,
because the Central Venous Catheter group “chunked” its action steps to include a
“complete thought” (Bartholio, personal communication, 2010), each phase of the
procedure included multiple action steps. Because there were multiple action steps in
each “chunk” of information, each SME was given credit if s/he mentioned only one part
of the step within that “chunk.” This may have caused the Central Venous Catheter SMEs
to have artificially low omission rates for action steps. In contrast, the Open
Cricothyrotomy surgery researchers fragmented the procedure as much as possible in
order to hold the SMEs accountable for communicating each action step. As a result, the
SMEs that explained the Open Cricothyrotomy procedure were only able to recall
58.08% of the necessary action steps, whereas the Central Venous Catheter SMEs were
able to recall 70.08% of the action steps. This is likely due, in part, to the different
approaches used by the analysts who compiled the “gold standard” for each surgical
procedure.
If feasible, future research should use the same task analysts for all SME
interviews and the creation of the “gold standards” in order to guarantee there is a
49
consistent skill level and method being applied across all CTA interviews and “gold
standards.”
Summary
Based on the information collected in this study, it is clear that the surgical
experts did not articulate all critical action or decision steps necessary to successfully
perform the Open Cricothyrotomy or Central Venous Catheter surgical procedures.
Despite the influence of the Hawthorne effect (whereby subjects improve their
performance because they are being studied), none of the experts for either surgery were
able to articulate all of the steps listed on the final “gold standard.” It is important to note
that each expert was given three opportunities to recall all necessary information. First,
during an interview conducted using CTA methods, then by reviewing and editing the
draft protocol of the procedure based on their interviews, and finally by reviewing or
editing the revised copy of the protocol. The SMEs were told to be as thorough as
possible and to describe each step and decision point during his/her respective procedure.
The purpose of this was to give the SMEs ample opportunity to include all necessary
information to perform the procedure successfully.
The fact that the SMEs were not able to communicate all of the necessary steps
for performing either of the surgical procedures is consistent with the literature, which
states that much of the information that an expert has accumulated is automated and
therefore inaccessible to the conscious mind. This also falls in line with the concept that
as people gain in knowledge and experience, they become experts and their knowledge of
the task changes from declarative (observable) to procedural (automated and inaccessible
50
to the conscious mind). The fact that many of the how-to steps become automated and
are no longer accessible to conscious awareness is what may cause an expert to omit
action steps and decision steps while teaching a procedure.
Implications
There are significant implications for informing the content of and designing the
instruction for curriculum, courses, and lessons in education and training, especially in
the medical and surgical domains. This study provides support for adopting CTA in
surgical training to increase accuracy and decrease errors. CTA does not replace the
current training methods, but adds to the completeness of the information being used.
Furthermore, training developed using the information obtained during unaided
interviews may be less effective in meeting the learner’s needs. For that reason, it may be
advantageous to use “gold standard” protocols developed using CTA strategies for
surgical skills training.
Other implications include the use of experts for surgical training simulations and
teaching practices in medical procedures. Based on the research literature, learners who
obtain training from experts are likely to forgo learning approximately 70% of the
necessary information. This can pose serious problems for patient safety. With an
estimated 234 million surgeries performed annually (Haynes et al., 2009), the
consequences for incomplete or inaccurate surgical training could be deadly.
Finally, this study has implications for the assessment of medical training. For
example, should assessment be based on whether a person performs a procedure correctly

51
or incorrectly (which could be by chance), or on whether the individual makes the right
decisions?
In short, SMEs are incapable of teaching everything they know without some
helpful elicitation strategies (Ericsson, Krampe, & Tesch-Römer, 1993). This is why
surgical residents who are trained by experts will likely experience shortcomings when
attempting to replicate learned procedures.
Conclusion
In conclusion, this study is only the first step in exploring the relationship
between the complexity of a task and the percentage of SMEs’ knowledge omissions.
Further studies in the area of task complexity and knowledge omissions could possibly
achieve an answer to this question and add to the body of knowledge.

52
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59
APPENDIX A: CTA CODING SCHEME

OA = Action

CONDITIONS
OCI = Indications
OCC = Contraindications
OSA = Accuracy
OST = Time
OR = Overarching Reason for Procedure
EM = Equipment & Materials

DECLARITIVE (information in conscious working memory)
DC = Concepts
DPR = Processes
DPN = Principles

PROCEDURAL (automated)
PDC = Classification
PDM = Modification

SENSORY CUES
SH = Hearing
SS = Seeing
ST = Touching

STEPS
A = Action
DSC = Decision Step Criteria for Deciding (“IF”)
DSA = Decision Step Alternative (“THEN”)
r = Reason for an Individual Step (not the procedure)

∆ = Uncertain (Delta Triangle)

60
APPENDIX B: CTA INTER-RATER RELIABILITY CODING SHEET

Table A1 CTA Inter-rater Reliability Coding Sheet
Code Agreement Tally Disagreement Tally Total IRR
OA
OCI
OCC
OSA
OST
R
EM
DC
DPR
DPN
PDC
PDM
SH
SS
ST
A
DSC
DSA
r
Δ

TOTAL

61
APPENDIX C: CTA GOLD STANDARD FOR THE
OPEN CRICOTHYROTOMY SURGICAL PROCEDURE

Cognitive Task Analysis Gold Standard For Open Cricothyrotomy

Last Updated: Monday, December 21, 2009
Task Analysts: Julia Campbell, Patrick Crispen, Leslie Tirapelle,
Maryann Tolano-Leveque
Procedure Title: Open Cricothyrotomy

1. Objective
Establish a definitive airway in an emergency situation (U10; V70, V72; V74; W36; X8,
Y16, Z58) as a last resort (W168)

2. Reasons
• Gain airway access in an emergency situation (U17, X32, Y22-23, Z58) when
oral tracheal intubation fails (U17; V58; X35; Y29-30; Z69, Z80, Z feedback
09/08/09)
• Risk(s) of not performing well:
• Certain mortality (W51; Y25)
• Patient may be hypoxic longer (W49; X26) and may suffer anoxic brain injury (X
feedback 09/30/09)
• Damage to vocal cords and larynx (U 254; X28)

3. Conditions
Indications:
• Loss of airway (U29, U488; V79; Y28-29; W48; Z69, Z feedback 09/08/09)
• Multiple attempts at oral tracheal intubation fails (U487; V82-84; V329-330;
V331-332; W54; X35; Y29-30; Z69, Z80, Z feedback 09/08/09)
• Facial injuries make it impossible to maintain an airway (U31; V80-81; Y39)

Contraindications:
• Able to establish an oral endotracheal airway (V95; Z Feedback 11/29/09)
• You do not know how to do the procedure (V102)
• You do not have a scalpel and a tube (V103)
• Children under10 years of age (Z83, Z feedback 09/08/09; Z feedback 10/06/09;
Z feedback 11/29/09)
• Patient has advanced directive not to be resuscitated (Y47-48)

62
APPENDIX C CONTINUED

4. Standards
• Time: From 1 minute (U63; W73; Z95) to under 5 minutes (V138; Y62; X
feedback 09/30/09)

• Vertical incision is between 1.5 to 2.5 centimeters in length (U158; X11-12;
Y114; Z281)
• Observable indications of successful procedure:
• Intubation of the trachea (W79)
• Tracheostomy tube inserted just beyond the balloon (W553)
• CO
2
return from patient (U410; W82; Y88, Z102, 103)-- CO
2
detector should
change color (V183; Y89) from purple to yellow/gold (X feedback 10/26/09, X
feedback 12/10/2009; Z feedback 11/29/09)
• Improvement in patient oxygenation (U460; W593; Y90-91)
• Audible, bilateral breath sounds (U48; W591; Y93)
• Visual confirmation of the patient’s chest rising (U49; V573; Y94-95)
• Fog in tube (U52; V573-574)

5. Equipment

Mandatory
• Blade/Knife/Scalpel (U69; V170; W93, W643, W649; X46; Y36; Z125, Z
feedback 09/08/09)
• Tube (U69): Choose one of the following based on availability (X feedback
09/30/09)
• Tracheostomy tube (U151; X149; Y65; Z126) sized 6.5 mm, 7 mm, and 7.5 mm
(V152; W94); or
• Endotracheal tube (U310; W95-96; X149; Y65; Z126; Z329) size six or smaller
(X149); or Cricothyroid cannula (X168, Y323)

Recommended
• Surgical tray (Y64)
• Tracheostomy Kit (U75; V171; Y76, Z129) / cricothyrotomy kit (V375; W91)
• Tracheostomy tube or endotracheal tube (V182; V758; X149, Y65, Z126, Z329)
• Cricothyroid cannula (V180; X168, Y323)
• Connecting piece from tracheostomy to ventilator (Y66)
• Tracheostomy hook (U73; V173, V feedback 11/13/09; W128; X50; Z67)
• Trachea tape (W576; X feedback 09/30/09); Y166)

63
APPENDIX C CONTINUED

• Tracheostomy collar (V177; X feedback 09/30/09)
• 10 cc Syringe (V163; Y321)
• Airway extender / extension tubing (V181; V feedback 11/13/09)
• 3-0 nylon (X feedback 12/10/09) sutures (U420; V176-177; W424; X87, X
feedback 09/30/09; Y242; Z131) and cutting needle (X feedback 12/10/09)
• 4x4 gauze (W547; X85; Y67; Z135)
• Clamp (Z132) or Kelly hemostat (U73; V175; W129; Y76; Z309)
• Small retractor (X49; W131) – optional (X83)
• Chlorhexidine (U146, X feedback 10/26/09) or betadine (U146)
• Drapes (Z184)
• Rolled towel (V164; Y183; Z172)
• Lighting (X195, Z137)
• Suction (W220; Y67)
• Universal barrier precautions
• Eyewear (V444; U585; W257; Z187)
• Hat (Z187)
• Mask (W257; Z187)
• Gown (V444; U590, W257; Z188)
• Sterile gloves (V416; U590, W257; X feedback 10/26/09, Z feedback 10/06/09)
• Pulse oximeter (Z118)
• CO2 detector (U575; V184, V feedback 11/13/09; W82; Y87)
• Bronchoscope (U56; Y421; Z108)
• Stethoscope (X feedback 10/26/09)
• Chest x-ray (U51; V feedback 11/13/09; W595)
• Recommended: Assistant to provide retraction/apply pressure (U259; V410;
W128; X47; Y359; Z168)
• Ambu bag (U564)
• Ventilator / oxygen source (U379; V182, V727; W570-571)/ airway team (V411)

6. Task List

1. Prepare equipment, patient, and self (U75, U84; U590; V164-183;
V378-79; W186; X62; Y101-102, Y391-393; Z14, Z148)
2 Make incisions and open airway (U159; V458; W396; X62; Y119-
123; Z156)
3. Place tube in airway (U293, U317; V534; W186; X71; Y124;
Z157)
4. Confirm placement and secure the tube (U381; V676; W424,
W186; X165; Y238-243; Z160)

64
APPENDIX C CONTINUED

7. Procedure Steps

Task 1: Prepare equipment, patient, and self (U75, U84; U590; V164-183;
V378-79; W186; X62; Y101-102, Y391-393; Z14, Z148)

Actions and Decisions

1.1 Locate cric/tracheostomy kit (V374), blade (X62; Y101; Z feedback 9/8/09) and
tubes (X82; V378-379; Z feedback 9/8/09) -- tracheostomy tube (U151; X149;
Y65; Z126) sized 6.5 mm, 7 mm, and 7.5 mm (V152; W94); or endotracheal tube
(U310; W95-96; X149; Y65; Z126; Z329) size six or smaller (X149)

1.2 Select tube (U197; W105)

IF you have only tracheostomy tubes THEN select the tracheostomy tube and go
to step 1.3.
IF you only have endotracheal tubes THEN select the endotracheal tube and go to
step 1.4
IF you have both tracheostomy and endotracheal tubes THEN select the
tracheostomy tube and go to step 1.3 (Z feedback 11/29/09)

1.3 Prepare and test tracheostomy for working cuff (Y325) by attaching balloon to
10cc syringe (V456), blowing-up cuff, and deflating cuff (Y320-322). Pull inner
cannula out of the tracheostomy tube and put the obturator into the tracheostomy
appliance (U298-299; Z338; Z feedback 10/06/09). Go to step 1.4

1.4 Assemble CO2 monitor onto bag (V566; Y352)

1.5 Obtain assistance if possible (U259; V410-412; Y47; Z150, 168)

1.6 Position lights (Z171)

1.7 Position patient (Y102; Z177, 248) into supine position (U164; Y188; Z177, 248)
with patient’s arms at their side (V392-393)

IF patient is at risk of C-Spine injuries, THEN provide C-spine immobilization to
secure patient neck from moving (V104-106; Y104-106, Y408-410; Z feedback
10/06/09) or keep patient in a neutral position (U103). Go to step 1.8.

65
APPENDIX C CONTINUED

IF patient has no C-spine injuries, THEN place a rolled towel underneath patient
shoulders to open up neck (V164-165; V169-170, V feedback 11/13/09;Y183-
184; Z172)

1.8 Prepare self by donning universal safety precautions (U585, U593; V441; V444;
V834; W252; Z187); scrubbing hands is unnecessary because of time constraints
(Z444)

1.9 Prepare the neck (U150; V feedback 11/13/09; Z171) with chlorhexidine or
betadine (U152, X feedback 10/26/09) and drape the patient (Z184). Local
anesthetic is unnecessary (Z477).
1.10 Position self for the procedure (Y391-393, 396).
IF you are right-handed, THEN position yourself to the patient’s right side (Y391-
393).

IF you are left-handed, THEN position yourself to the patient’s left side (Y396).

Task 2: Make incisions and open airway (U159; V458; W396; X62; V458;
Y119-123; Z156)

Actions and Decisions

2.1 Use non-dominant hand to hold the trachea still (U157; W380-381; X103; Y108-
109)

2.2 Identify the location to make the incision (U99; X63; Y132-133) by using the
dominant hand to palpate through the skin (Z266) and feel for cricothyroid
membrane and thyroid cartilage (Adam’s Apple) (U118, U111, U117; V452-454;
V feedback 11/13/09; w feedback 11/14/2009; Y111-112), either by going
inferior to the Adams’s apple (X95) or by going three or four fingers up from the
sternal notch (U119, U121; W3640366; X96)

2.3 Make a vertical incision 1.5 cm to 2.5 cm in length in the area between the thyroid
cartilage and cricothyroid cartilage (U158; V458, V465-466; V473; W396; X111;
X feedback 09/30/09; Y114, 208; Z281) centered over the top of the cricothyroid
membrane (Z266). Bluntly dissect down past the soft tissue (X113) to expose
thyroid cartilage and cricothyroid cartilage (Y213-215)

2.3.1 IF patient is obese THEN make a longer incision (Y203-204; X feedback
10/26/09; Z feedback 10/06/09) and go to step 2.3.2
IF the patient is not obese THEN go to step 2.3.2
66
APPENDIX C CONTINUED

2.3.2 IF you do not have an assistant (W468) THEN make the incision long enough that
it opens up on its own (W469) and go to step 2.3.3
IF you do have an assistant THEN go to step 2.3.3.

2.3.3 IF there is bleeding and you cannot see (W449) any landmarks such as the trachea
(X feedback 12/10/09) THEN use palpation (W451, W549) or gauze (W548) but
continue to step 2.4 (W547)
IF there is no bleeding THEN go to step 2.4

2.4 Retract the area (V475-476; W400, W474; X114-115; Y233).
IF you have an assistant (W399) THEN have the assistant hold the skin flaps open
(W400) using a Kelly (V475-476) or you can push the skin flaps open with the
blunt end of your knife (V482)

IF you do not have an assistant (W468) THEN push straight back with your
nondominant hand (X feedback 12/10/09) to open the incision (W474)

Once through the skin and soft tissues, use your finger to feel again to confirm
cricothyroid membrane location (U202; V491-492; W404; Z283; Z feedback
10/06/09)

IF the incision is not over the cricothyroid membrane or the incision is too small
(W452) THEN extend the incision before continuing to step 2.6 (U279; W453-
454)

IF this incision is in the correct location THEN go to step 2.6

2.6 Make a transverse [horizontal] incision across cricothyroid membrane (U204;
V493, V496; W404, W431, W433; Y120, Y223) or penetrate the cricothyroid
membrane with your blade (X116; Z feedback 11/29/09) or the tip of a Kelly
clamp (U feedback 11/15/2009)

2.7 Spread the cricothyroid opening 5-10 mm to fit tube by inserting and twisting the
blunt end of scalpel, inserting and expanding a Kelly inside of the opening
(W405; X116; Y121-123; Z feedback 09/08/09; Z feedback 10/06/09), or
inserting your finger (W406; V496)

Standard: Incision location is correct if you encounter a gush of air (U210, Z307)
and/or observe a small opening (Z308).

67
APPENDIX C CONTINUED

IF you get bleeding (X135), THEN apply pressure to stop the bleeding (X136) but
continue to step 2.8 (X140)

IF you do not get bleeding THEN continue to step 2.8

2.8 IF you are placing a tracheostomy tube THEN go to Task 3A.
IF you are placing an endotracheal tube THEN go to task 3B

Task 3A: Place tracheostomy tube in airway (U293; U317; V534; W186; X71;
Y124; Z157)

Actions and Decdisions

3.1 Optional but recommended: Lift the airway up to facilitate the insertion of the
appliance by inserting the trachea hook from above or below (Z feedback
11/29/09), turning the hook towards the lower part of the tracheal incision, and
pulling the hook up towards yourself (U247; V518-519; V524-525; Z362). If you
do not have a trachea hook, you can make one by bending a large bore IV needle
(V545-546)

3.2 Approach the hole perpendicularly (V534-535), place the tube inside opening
(U185; V534-535; W408; X71; Y234; Z341), twist the tube downwards (V534-
535; X152) and insert the entire length of tube (X feedback 09/30/09) to just
beyond the balloon (W553).

IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and repeat step 3.2 (V611-613, V619, V feedback
11/13/09)

IF the tube insertion is successful THEN go to step 3.3

3.3 Hold the tube (U373), remove the obturator (U347; Z342), inflate the cuff to
inflate the balloon (U304, U347; V feedback 11/13/09; W409) and place the inner
cannula into the tube (U372; Z342)

Task 4A: Confirm placement and secure the tube (U381; V676; W424, W186;
X165; Y238-243; Z160)

Actions and Decisions

4.1 Connect bag and CO2 monitor to patient (W409; Y238) and bag patient while
ventilator is set up (U380; Y239-241),
68
APPENDIX C CONTINUED

4.2 Check for CO2 return (U49; V185, V601; W feedback 11/14/2009; Y239).

IF you are not getting CO2 (W600) THEN make sure the patient did not die
(W600) recheck the tube’s position (W605), extend your incision (W607), look
back into the incision (W607) and make sure you have identified your landmarks
(W607)

IF you are getting C02 THEN go to step 4.3

4.3 Ventilate the patient (V561-563; W570; Y239; Z feedback 11/29/09).

4.4 Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels (W593; Z103)

Check for bilateral breath sounds with stethoscope (U48; W591; X feedback
09/30/09; X feedback 10/26/09) and confirm that chest is rising and falling (U49;
V602)

Optional: Conduct a bronchoscopy (U 50; Z102; Y feedback 10/06/09) or chest x-
ray (U51; V feedback 11/13/09; W595)

4.5 Suction area out once saturation levels have increased (mid 90’s) (Z374, Z
feedback 09/08/09).

4.6 Place a tracheostomy collar around the neck (U676-682; X feedback 09/30/09)
and then suture the collar (U418; V676-682; W583; X167; Y242; Z382) with 3.0
or larger nylon sutures (U418) on a cutting needle (X feedback 12/10/09)

4.7 STOP

Task 3B: Place endotracheal tube in airway (U317)

3.1 Optional but recommended: Lift the airway up to facilitate the insertion of the
appliance by inserting the trachea hook from above or below (Z feedback
11/29/09), turning the hook towards the lower part of the tracheal incision, and
pulling the hook up towards yourself (U247; V518-519; V524-525; Z362). If you
do not have a trachea hook, you can make one by bending a large bore IV needle
(V545-546)

3.2 Approach the hole perpendicularly (V534-535), place the tube inside opening
(U185; V534-535; W408; X71; Y234; Z341), twist the tube downwards (V534-
535; X152) and insert the tube between 5 cm (U317) to 10 cm (x feedback
69
APPENDIX C CONTINUED

09/30/09) with the balloon barely below the level of the incision (U318; W
feedback 11/14/2009)

IF the tube does not go in easily or you get a lot of subcutaneous emphysema
THEN remove the tube and repeat step 3.2 (V611-613, V619)

IF the tube insertion is successful THEN go to Task 4B

Task 4B: Confirm placement and secure the tube (U381; W424, W186; X165;
Y238-243; Z160)

Actions and Decisions

4.1 Connect bag and CO2 monitor to patient (W409; Y238) and bag patient while
ventilator is set up (U380; Y239-241),

4.2 Check for CO2 return (U49; V185, V601; W feedback 11/14/2009; Y239).

IF you are not getting CO2 (W600) THEN make sure the patient did not die
(W600), recheck the tube’s position (W605), extend your incision (W607), look
back into the incision (W607) and make sure you have identified your landmarks
(W607)

IF you are getting C02 THEN go to step 4.3

4.3 Ventilate the patient (V561-563; W570; Y239; Z feedback 11/29/09).

4.4 Confirm successful placement with the following indicators:
Look for increased oxygen saturation levels (Z103) and fogging of the tube (U52;
V602).

Check for bilateral breath sounds with stethoscope (U48; X feedback 09/30/09; X
feedback 10/26/09) and confirm that chest is rising and falling (U49; V602)

Optional: Conduct a bronchoscopy (U 50; Z102; Y feedback 10/06/09) or chest x-
ray (U51; V feedback 11/13/09; W595)

4.5 Suction area out once saturation levels have increased (mid 90’s) (Z374, Z
feedback 09/08/09).

70
APPENDIX C CONTINUED

4.6 Suture the tube (U418; U423; W424; X167; Y242; Z382) or tape it to the neck
(U423, W576; X166, X169)

4.7 STOP

Other Information:
8. Conditions & Cues
• Emergency situation (U37, X32, Y22-23, Z58) when nasal tracheal intubation and
oral tracheal intubation fails (X35; Y29-30; Z34, Z69, Z80, Z feedback 09/08/09)
• Usually performed in a hospital but can be performed anywhere with a tube and
scalpel (U?)
9. Prerequisite Skills / Knowledge
• Standard knowledge and skill set of ED residents and surgical residents (U524;
V?; X178; Z34, Z53) and critical care physicians (Y feedback 10/26/09)
• Interns can perform this task under supervision (W631)

10. Concepts
• A tube secured in the trachea is a definitive airway. A cricothyrotomy is one
of those devices, and the other two being orotracheal intubation and a
tracheostomy (V320-322).
• How difficult is to visualize the landmarks (X203)
• The cricothyroid membrane is not as pretty as on a mannequin (X206) and is a
solid structure (U250)
• How all the equipment works (Z446)
• A tracheostomy tube is shorter, has less chance of being dislodged, and is
easily attached to the skin (U428). It is also curved (V525-526)
• An endotracheal tube is best for obese patients because the tracheostomy tube
may not be long enough (U308), although it is very rare that the tube is not
long enough (Z feedback 11/29/09)
• An ET tube causes you to intubate about 12 cm from where you would
intubate with a tracheostomy tube (U315)
• Cricothyrotomy may be taken out and replaced with a tracheostomy, because
having a tube on the cricothyroid cartilage can cause subglottic stenosis
(V743-745; Z215)

71
APPENDIX C CONTINUED

• Ventilatory management depends on why you place the airway in the first
place (V707-708). Some patients need oxygenation, not ventilation. Some
people just need ventilation, not oxygenation. Some people need both (V713-
715). Setting the ventilator mode depends on the primary problem (V731-
732).
• When placing the tracheostomy tube, you have to approach the hole
perpendicularly (V530) because if you place it directly in, you’re going to run
into the patient’s chest (V527-528)
• ATLS (W252)
• 02 stats below 90 are significant (W266)

11. Process Knowledge
• Assembling cricothyrotomy equipment (Y317-321)
• Locating cricothyroid membrane using landmarks and touch (U537; W355;
X63; Y132-133; Z266)
• CO2 monitor changing from purple to gold/yellow is a sign of CO2 return (X
feedback 10/26/09, X feedback 12/10/2009; Z feedback 11/29/09)

12. Principles
If tube is too deep, only one side of breath sounds will be heard and the only the
side of the breath sounds will rise. The majority of time the tube will end up in
the right side. Simply pulling the tube back 1-2 cm will do. (Z feedback
12/10/09)

13. Sensory Mode Information
Touch
• Feeling for the trachea and cricothyroid membrane location (U87,
U202; V486, V491-492; W363-364, W366, W485; X184; Z283)
Visual
• When you insert the endotracheal tube correctly, it will look like the
tube is not completely in (X154, X feedback 09/30/09)
• Detecting CO2 monitor colors (U49, U575; V184-185; ?89)
• Watching gush of air and blood (U211)
• Watching chest rise and fall (U49, U573; V602)
72
APPENDIX C CONTINUED

• Watching patients’ color change (U577; W277)
• View chest x-ray to confirm placement (U50, U579; V feedback
11/13/09; W596)
• See fog in tube (U52; V602)
• Seeing if tube is in trachea using bronchoscope (U56; Z102; Y
feedback 10/06/09)
• Seeing the thyroid membrane or the thyroid cartilage (V454-455;
W401, W664)
Audible
• Breath sounds (U48, U573; V830; W591; Y93)
• The pulse ox monitor has a sound to when the patient’s not
oxygenating (V871-873)

14. Safety Factors
• Wear barrier precautions (U585, U590; V441, V444, V834; X192)
• Cutting into a vein can cause moderate hemorrhaging (Z404, feedback
09/08/09)

15. Environmental Considerations
• Ensure sufficient lighting (Z137)

16. References
None.

17. Problems
• Deciding when to do this procedure (Y32). Novices decide that the patient needs
an airway too late (V356; W533) – or perform the procedure too slowly (W533) –
because they start looking for other causes, and really those causes don’t matter.
They fail to realize that A is A, because airway comes first (V362-363).
• Lack of experience (V102; Y41-42) or equipment (V103)
• Attempting to insert wrong size tube (X159)
• If the neck is short or the patient is obese it is more difficult to locate the anatomy
(U119)
• Hematoma or a neck injury may distort the anatomy (U126)
73
APPENDIX C CONTINUED

• Bleeding (W529)
• Misidentifying landmarks (U136; W527)
• Too small of an incision into the membrane (V589)
• Too large of an incision which can transect the larynx (U228)
• Letting go of the anatomy with the non-dominant hand and losing site of where to
place the tube (U243)
• Inserting the tube into the wrong passage (U335)
• Putting an endotracheal tube in too far (U337; W556) and pushing it into the right
main bronchus causing the left lung not to be ventilated (U342)
74
APPENDIX D: PROCEDURE STEPS FOR THE
OPEN CRICOTHYROTOMY SURGICAL PROCEDURE

Table A2 Procedure Steps for the Open Cricothyrotomy Surgical Procedure
Step Type:
Decision (D)
Action (A)
SMEs that
reported this
(6 possible)
Task 1: Prepare equipment, patient, and self
1.1 Locate cric/tracheostomy kit, blade and tubes --
tracheostomy tube sized 6.5 mm, 7 mm, and 7.5 mm; or
endotracheal tube size six or smaller
A 6
1.2 Select tube D 1
1.3 Prepare and test tracheostomy for working cuff by
attaching balloon to 10cc syringe, blowing-up cuff, and
deflating cuff. Pull inner cannula out of the
tracheostomy tube and put the obturator into the
tracheostomy appliance. Go to step 1.4
A 4
1.4 Assemble CO2 monitor onto bag. A 2
1.5 Obtain assistance if possible A 4
1.6 Position lights A 1
1.7 Position patient into supine position with patient’s
arms at their side
D 4
1.8 Prepare self by donning universal safety precautions;
scrubbing hands is unnecessary because of time
constraints
A 4
1.9 Prepare the neck with chlorhexidine or betadine and
drape the patient (Z184). Local anesthetic is
unnecessary.
A 4
1.10 Position self for the procedure (Y391-393, 396). D 1
Task 2: Make incisions and open airway
2.1 Use non-dominant hand to hold the trachea still A 4
2.2 Identify the location to make the incision by using
the dominant hand to palpate through the skin and feel
for cricothyroid membrane and thyroid cartilage
(Adam’s Apple), either by going inferior to the Adams’s
apple or by going three or four fingers up from the
sternal notch
A 6
2.3 Make a vertical incision 1.5 cm to 2.5 cm in length
in the area between the thyroid cartilage and
cricothyroid centered over the top of the cricothyroid
membrane. Bluntly dissect down past the soft tissue to
expose thyroid cartilage and cricothyroid cartilage
A 6

75
APPENDIX D CONTINUED

Table A2, Continued
Step Type:
Decision (D)
Action (A)
SMEs that
reported this
(6 possible)
IF patient is obese THEN make a longer incision and go
to step 2.3.2. IF the patient is not obese THEN go to
step 2.3.2
D 2
IF you do not have an assistant THEN make the incision
long enough that it opens up on its own and go to step
2.3.3. IF you do have an assistant THEN go to step
2.3.3.
D 1
IF there is bleeding and you cannot see any landmarks
such as the trachea THEN use palpation or gauze but
continue to step 2.4. IF there is no bleeding THEN go to
step 2.4
D 2
2.4 Retract the area.
IF you have an assistant THEN have the assistant hold
the skin flaps open using a Kelly or you can push the
skin flaps open with the blunt end of your knife. IF you
do not have an assistant THEN push straight back with
your nondominant hand to open the incision
D 3
2.5 Once through the skin and soft tissues, use your
finger to feel again to confirm cricothyroid membrane
location.
A 4
IF the incision is not over the cricothyroid membrane or
the incision is too small THEN extend the incision
before continuing to step 2.6. IF this incision is in the
correct location THEN go to step 2.6
D 2
2.6 Make a transverse [horizontal] incision across
cricothyroid membrane or penetrate the cricothyroid
membrane with your blade or the tip of a Kelly clamp
A 6
2.7 Spread the cricothyroid opening 5-10 mm to fit tube
by inserting and twisting the blunt end of scalpel,
inserting and expanding a Kelly inside of the opening,
or inserting your finger
A 5
IF you get bleeding, THEN apply pressure to stop the
bleeding but continue to step 2.8. IF you do not get
bleeding THEN continue to step 2.8
D 2

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APPENDIX D CONTINUED

Table A2, Continued
Step Type:
Decision (D)
Action (A)
SMEs that
reported this
(6 possible)
2.8 IF you are placing a tracheostomy tube THEN go to
Task 3A. IF you are placing an endotracheal tube THEN
go to task 3B.
N/A
(This is neither
a decision or
action, but is
necessary to
guide the
resident to the
next
appropriate
step)
N/A
Task 3A: Place tracheostomy tube in airway
3.1 Optional but recommended: Lift the airway up to
facilitate the insertion of the appliance by inserting the
trachea hook from above or below, turning the hook
towards the lower part of the tracheal incision, and
pulling the hook up towards yourself. If you do not
have a trachea hook, you can make one by bending a
large bore IV needle
A 3
3.2 Approach the hole perpendicularly, place the tube
inside opening, twist the tube downwards and insert the
entire length of tube to just beyond the balloon.
A 6
IF the tube does not go in easily or you get a lot of
subcutaneous emphysema THEN remove the tube and
repeat step 3.2. IF the tube insertion is successful THEN
go to step 3.3
D 1
3.3 Hold the tube, remove the obturator, inflate the cuff
to inflate the balloon and place the inner cannula into
the tube
A 4
Task 4A: Confirm placement and secure the tube
4.1 Connect bag and CO2 monitor to patient and bag
patient while ventilator is set up
A 3
4.2 Check for CO2 return D 1
4.3 Ventilate the patient A 4
4.4 Confirm successful placement with the following
indicators:

77
APPENDIX D CONTINUED

Table A2, Continued
Step Type:
Decision (D)
Action (A)
SMEs that
reported this
(6 possible)
Look for increased oxygen saturation levels A 2
Check for bilateral breath sounds with stethoscope and
confirm that chest is rising and falling
A 4
Optional: Conduct a bronchoscopy or chest x-ray A 5
4.5 Suction area out once saturation levels have
increased (mid 90’s).
A 1
4.6 Place a tracheostomy collar around the neck and
then suture the collar with 3.0 or larger nylon sutures on
a cutting needle
A 6
4.7 STOP
Task 3B: Place endotracheal tube in airway
3.1 Optional but recommended: Lift the airway up to
facilitate the insertion of the appliance by inserting the
trachea hook from above or below, turning the hook
towards the lower part of the tracheal incision, and
pulling the hook up towards yourself. If you do not have
a trachea hook, you can make one by bending a large
bore IV needle
A 3
3.2 Approach the hole perpendicularly, place the tube
inside opening, twist the tube downwards and insert the
tube between 5 cm to 10 cm with the balloon barely
below the level of the incision.
A 6
IF the tube does not go in easily or you get a lot of
subcutaneous emphysema THEN remove the tube and
repeat step 3.2. IF the tube insertion is successful THEN
go to Task 4B
D 1
Task 4B: Confirm placement and secure the tube
4.1 Connect bag and CO2 monitor to patient and bag
patient while ventilator is set up
A 3
4.2 Check for CO2 return D 1
4.3 Ventilate the patient A 3
4.4 Confirm successful placement with the following
indicators:
A 3
Look for increased oxygen saturation levels and fogging
of the tube
A 3
Check for bilateral breath sounds with stethoscope and
confirm that chest is rising and falling
A 3

78
APPENDIX D CONTINUED

Table A2, Continued
Step Type:
Decision (D)
Action (A)
SMEs that
reported this
(6 possible)
Optional: Conduct a bronchoscopy or chest x-ray A 5
4.5 Suction area out once saturation levels have
increased (mid 90’s)
A 1
4.6 Suture the tube or tape it to the neck A 6
4.7 STOP

79
APPENDIX E: CTA GOLD STANDARD PROTOCOL
FOR THE CENTRAL VENOUS CATHETER SURGICAL PROCEDURE

Central Venous Catheter Placement Gold Standard Protocol

Procedure Title: Central Venous Catheter Placement
Experts: Surgeons A, B, C, D, E, F
Task Analysts: Craig Bartholio, Joon Kim, Eko Canillas
Interview Location: USC Keck Medical Center
Interview Date: November 2009

1. Objective
(Write the overall terminal (end) performance objective of this procedure, using an
“action” verb that describes what a resident does.)
• Perform central venous catheter placement to provide central venous access to
quickly administer drugs, fluids, or bloods to a patient quickly and to monitor the
patient.

2. Reasons
(What is the risk for not performing well? What are the benefits to the trainees if they do
a good job?)
The risks of not inserting a central venous catheter properly could be:
• Inadvertent carotid injury (IJ site)
• Inadvertent pneumothorax
• Artery is inadvertently cannulated (subclavian site)
• Ectopic beats
• Widening of the mediastinum
• A hematoma
• Death
• Damage to vein
• Air embolus
• Sepsis
• Bleeding
• Physical damage to the area itself
• Tran section of the vein
• Allergic reaction
• Infection
• Tearing the vein
• Getting into the femoral artery by mistake
• Guide wire becoming embolized

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APPENDIX E CONTINUED

The benefits of inserting a central venous catheter properly are:
Venous access to provide fluids and drugs
Access to central circulation to allow for hemodynamic monitoring
Deliver blood and nutrition

3. Conditions
Indications: (List the symptoms or particular circumstances that indicate the
advisability or necessity of the specific medical treatment or procedure.)
• Need long-term IV access
• Need multiple IV medications
• Need IV medications in a continuous drip
• Need large volume resuscitation
• Need intravenous nutrition
• No peripheral IV access and needs IV resuscitation
• Inadequate peripheral access for fluid/drug administration
• Hemodynamic monitoring
• Cardiac arrest
• Loss of blood and fluid
• Anticipating blood loss
• Limited venous access
• Need to prepare for Swan Ganz catheter placement
• Rapid fluid/blood resuscitation
• Need to monitor central venous pressure
• Need direct access into central circulation system
• Need to use Swan Ganz catheter
• Hypotensive
• Deliver medication only compatible with central lines

81
APPENDIX E CONTINUED

Contraindications: (List the symptoms or conditions that make the particular
treatment or procedure inadvisable.)
• In emergency situations, there’s almost none
• Patient has coagulopathy
• Patient has no thrombosis of a vessel
• Patients using thrombolytics or has history of prior thrombotic disease in central
vein
• Patients using blood thinner medication such as Heparin
• Surgeon doesn’t know the anatomy or distorted anatomy
• Trauma to the area (i.e. broken clavicle, fractures, burns)
• History of lymphedema in the ipsilateral extremity
• Skin infection on the site
• Patient has c-spine precautions (may be relative contraindication to IJ due to
positioning restrictions)
• Peripheral access is available

4. Standards
(Are there any time limits, efficiency, or quality standards that must be met when
performing this procedure? What are the observable indications of a successful
procedure?)
• Time approximately 5 minutes to 8 minutes / 10 minutes.
• Time from needle stick to catheter placement: 2 minutes
• Observable indications of success: Chest x-ray should show:
1. The catheter is above the hear heart in a straight line coming down into the
entrance of the heart
2. Clear lung fields
3. Easily draw blood back from the catheter
4. Easily flush fluid into the catheter

• Lung markings all the way out the periphery
• Catheter flushes easily
• Subclavian is the first choice, followed by IJ and then femoral
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APPENDIX E CONTINUED

5. Equipment
(What supplies and materials must be available to perform the task?)
• X-ray
• Personal protective gear
o Cap
o Gown
o Sterile Gloves
o Mask
o Eye protection
o Full sheet drape
o Stethoscope
o Sterile Prep
• Chlorhexidine
• Ultrasound machine
• General anesthesia/one percent lidocaine
• Anesthetic needle
• Central Line Kit
o Introducer needle
o Guide wire
o Central Venous Catheter
 Cordis central venous catheter-large lumen for large volume fluid
or blood administration
 Triple lumen- when large volume is no longer needed, when
patient needs multiple medications
 Swan Ganz Catheter
o Syringe
o Tubing
o Finder needle/20 gauge needle
o Brown port
o Dilator
83
APPENDIX E CONTINUED

• Cardiac monitor
• Scalpel
• Sterile saline
• Sutures
• Sterile Dressing
• Infusion bag
• Antibiotic ointment
• Transducer
• Three-way stop cocks
• Pressure bag
• Sterile towels
• Extra towels
• Large sheet
• Table to place equipment
• *Luer-lock
• 2-0 nylon suture
• Non-scrubbed assistant
• External lighting
• Extra kit
• Antibiotic-coated disk
6. Task List
1. Prepare the surgeon and prepare equipment
2. Decide and select the anatomic site and catheter type
3. Prepare the patient and surgeon
4. Insert finder needle into a large vein
5. Place introducer needle into the vein
6. Introduce guide wire through the needle
7. Direct the central venous catheter over the wire into the vein
8. Remove the wire and remove all needles
9. Verify placement of CVC
10. Affix catheter to the skin
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APPENDIX E CONTINUED

7. Procedure for Central Venous Catheter Placement

Task 1: Prepare the surgeon and prepare equipment

Step 1.1: Select type of catheter to use

IF for a general resuscitation and if patient is stable, THEN you can use a
single-lumen or a double-lumen catheter

IF administering multiple medications over time or IF you have a sick
patient that needs TPM (TPN; total parental nutrition) therapy or need to
give antibiotic therapy or need to give fluid therapy,THEN use triple-
lumen catheter.

IF you need to place a Swan-Ganz catheter to closely monitor the fluid
and hemodymanic parameters of a patient or temporary pacemaker in the
heart, THEN use a single-lumen with large port

IF Swan Ganz is required, or if patient is unstable or if patient requires
large volumes of blood/saline, THEN use cordis.

IF patient is stable and requires medications that can only be given
through a large bore vein, THEN use triple or double lumen

IF it is life or death situation, use whatever central line kit is available

IF you have more time, THEN select a central line kit that is more
complete

IF you are going to perform the procedure, THEN you should be
responsible for getting all the stuff

Step 1.2: Put on a cap, gown, and gloves, and mask, protect yourself with universal
precautions

Step 1.3: Check equipment is in kit and working together properly test the
equipment by flushing it with saline, ensure wire moves back and forth on
the roll, and ensure knife comes in and out of protective sheath. Select
largest-bore needle in set and place on syringe. Place equipment on table
or patient.

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APPENDIX E CONTINUED

Step 1.4: Communicate to the patient what you are going to do.

IF the patient is awake, THEN explain to the patient what you are going to
do and administer local anesthesia to help them with comfort and acute
pain before proceeding to step 1.5
OR
IF the patient is unconscious, THEN proceed directly to step 1.5

Step 1.5: Drape the patient from head to toe.

Step 1.6: Take sterile precautions by prepping the site with chlorhexidine

Step 1.7: Prep the area as if this was a surgical procedure.

Step 1.8: Prep the whole area as wide as possible so you have lots of space so you
can see the stuff above, to the sides, and below.

Task 2: Select the anatomic site.

Step 2.1:

Internal Jugular
IF:
1. Can’t find the subclavian vein
2. Impossible to cannulate the subclavian vein
3. Patient has long neck, or
4. It is a non-emergency situation, or
5. Patient has damage to the right side of body, or
6. There is no scar tissue indicating previous line placement, or
7. You can distinguish several landmarks. Landmarks are
anatomic structures that help guide you to the correct location
and keep you away from areas of dangers.
8. Can’t pass the wire.
9. Comfortable with high lines.
THEN:
choose internal jugular and place the patient on his or her back in a
head down position and turn their head away from the side you are
working, Trendelenburg position.

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APPENDIX E CONTINUED

Subclavian
IF:
1. patient’s internal jugular is unavailable, or
2. it is an emergency situation, or
3. patient is obese, or
4. patient’s neck is small, or
5. patient has damage to the left side of body, or
6. there is no scar tissue indicating previous line placement
7. c-spine injury or IF bleeding in belly
8. comfortable with high lines
THEN:
Choose subclavian and place patient in head down position and
have assistant to help hold down their arm

If the patient already has a pneumothorax on one side, THEN
choose that side to place the catheter

IF placing Central Venous Catheter in the subclavian vein, THEN
position the patient in a supine position.

IF placing Central Venous Catheter in the subclavian, THEN
position the patient in a slight Trendelenburg, head down position
with their arm at their side.

IF know it is going to be a difficult stick, THEN extend the arm to
allow better access. May put a restraint on the extended arm.

Femoral
IF:
1. both internal jugular and subclavian are unavailable or
2. the situation is life or death or learners would know at the
minimum that the situation is critical and it is extremely
important to obtain IV access
3. patient needs immediate IV access and there are
contraindications to the head and chest
4. patient is hypotensive and no suspicion of intra-abdominal
bleeding
THEN:
Choose femoral and place patient supine or head down

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APPENDIX E CONTINUED

Procedure for the Internal Jugular Location (A)

Task 3A: Prepare the patient

Step 3A.1: If the patient is awake, describe the procedure to the
patient and obtain consent

Step 3A.2: Verify no injury to neck and explain risks and benefits

Step 3A.3: Sterilely prep the area of CVC placement

Step 3A.4: Prepare yourself with universal barrier precautions

Step 3A.5: Drape bed with large sheet

Step 3A.6: Decide whether or not to administer local anesthesia.

IF the patient is conscious or it’s an elective procedure or feeling pain,
THEN administer local anesthetic.

IF the procedure is an emergency, THEN skip to Step 3A.9

Step 3A.7: The area of skin over the site needs to be anesthetized with local
anesthetic, which is typically one percent lidocaine.

Step 3A.8: Anesthesia is injected through a smaller needle by raising a skin wheel just
under the skin and then more widely infiltrating the skin and subcutaneous
tissue over the central line site.

Step 3A.9: Decide how to position the patient.

IF placing Central Venous Catheter in the internal jugular vein, THEN
position the patient in a supine position or prone and in a slight
Trendelenburg head down position with their arm at their side and the
head turned away from the side of the cannulation.

Step 3A.10: Prepare the equipment to be used.

IF you are going to perform the procedure, THEN you should be
responsible for getting all the equipment.

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APPENDIX E CONTINUED

Step 3A.11: Decide if ultrasound will be used

IF ultrasound is going to be used, THEN skip to Step 3A.14.

IF ultrasound is not going to be used, THEN proceed by using
anatomical landmarks.

Step 3A.12: Sterilize the ultrasound machine with sterile drape.

Step 3A.13: Using Landmarks to locate vessel

• Feel for the carotid pulse, located between the two bellies of
the sternocleidomastoid muscle and lateral to the thyroid.
• IF you cannot feel the carotid pulse, THEN choose locations
that are lateral to the course of the carotid artery
• Two heads of the sternocleidomastoid muscle are the clavicle
head and the manubrial head.
• One head of the muscle attaches to the manubrium, one head
attaches to the clavicle and there’s a gap between these two
heads.
• Distal from the clavicle or superior from the clavicle, the two
heads join again, making a crotch where the internal jugular
vein can be cannulated. Skip to Task 4A.
• IF you are right handed, THEN performing the lines on the
patient’s right side is ergonomically easier.
• IF you are left handed, THEN performing the line son the
patient’s left side is ergonomically easier.
• IF patient already has traumatic penumothorax or a chest tube
on the left side, THEN use that side for the CVC placement.
• IF there is a gunshot would to the arterial or venous vessel(s)
on one side, THEN go to the other side.

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APPENDIX E CONTINUED

Step 3A.14: Place ultrasound probe near the head of the clavicle and march your way
to the neck. Position the probe so that the vein is in the center of the
screen.

• Use the anatomical landmarks as a guide. Aim for the split of
the sterna and clavicular head of the stemocleidomstoid muscle
• The ultrasound probe is placed at the site and the internal
jugular vein can be distinguished from a carotid artery.
• The artery typically appears completely round.
• The artery, when compressed with the ultrasound probe, the
artery will remain patent.
• The internal jugular vein is more lateral and larger and oblong
in shape.
• The internal jugular vein will change in size with the patient’s
respiration.
• The internal jugular vein is easily compressible.

Task 4A: Insert the finder needle into the vein.

Step 4A.1: Decide between using plastic angiocath or metal needle

Step 4A.2: Assemble syringe

Step 4A.3: Check that needle will accommodate guide wire by passing the
wire through the needle

Step 4A.4: The finder needle, a twenty-gauge needle, can be affixed to a 10cc syringe
and used to cannulate the internal jugular vein.

Step 4A.5: The site of entrance is at the crotch of the sternocleidomastoid muscle
heads.

Step 4A.6: The angle of insertion is fairly steep, almost a ninety degree angle states
“45-80 degree angle) into the patient’s neck at this site towards the
ipsilateral nipple and away from the carotid artery.

Step 4A.7: Tighten the skin and flatten the needle and advance the needle aiming for
the vessel.

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APPENDIX E CONTINUED

Step 4A.8: Provide continuous aspiration on the syringe.

Step 4A.9: IF there is flash or flow of blood, THEN disconnect syringe from the
needle.

IF there is no flash or flow of blood or IF you get air back (B618), THEN
pull syringe back out and try again.

Step 4A.10: Repeat infuse-drawback sequence until you see a nice drawback of dark
venous blood coming into your needle.

IF unsuccessful after three attempts, THEN abort procedure or have
someone else perform.

Task 5A: Insert introducer needle into the vein.

Step 5A.1: The larger introducer needle, which has already been affixed to a syringe,
is introduced into the skin at the very same site and angle as the finder
needle, but go in a millimeter or so further.

Step 5A.2: Slide the introducer needle right along the finder needle, metal to metal,
into the same site.

Step 5A.3: There should be a return venous blood into the second syringe.

• Venous blood tends to be darker than arterial blood.
• The patient that’s on high concentration oxygen may have
fairly red venous blood.
• Steady flow of dark blood from the needle is more likely a
venous cannulation.

IF pulsating and bright red (blood) or spurting may indicate arterial
cannulation, THEN remove needle and redirect.

IF you get a flash of venous blood, THEN remove the syringe and proceed
to Step 5A.4.

IF you are unsure of which line your needle is in, THEN the safest thing is
to pull out and do it again with the use of a pressure transducer.

IF you have entered the artery, THEN pull the needle out, apply pressure
for a couple minutes and try again on the same side without re-prepping.
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APPENDIX E CONTINUED

Step 5A.4: Once the vein is cannulated, then it’s very important to maintain the
position of the needle, firmly hold hub of the needle to keep it in position
with non-dominant hand.

Step 5A.5: Remove syringe from the needle.

• Continued venous bleeding from the needle is a good sign that
it is still in position, that it’s still in the vein.

Step 5A.6: Place thumb over hub of the needle to avoid any air being introduced into
the vein.

• Placing thumb over hub of needle helps avoid air embolus for
patients with low venous pressure or nearly negative venous
pressure.

IF you are right handed, THEN you will hold the hub with your left hand.

IF you are left handed, THEN you will hold the hub with your right hand.

Task 6A: Introduce guide wire through the needle.

Step 6A.1: Take the guide wire from the tray.

Step 6A.2: Introduce the guide wire through the needle.

• Always maintain one hand on guide wire.
• The guide wire should pass very easily, should require no force
at all to advance it into the vein starting with the flexible side.
• “the guide wire typically goes in about twenty centimeters.
• “insert ½ to 2/3 of the wire” goes in.
• “Insert wire to the length of the needle and a little past, about
5-10cm.
• Insert length of wire but leave approximately 7’’ out
• Look and listen to the monitor
• You don’t want to introduce the entire wire to avoid losing the
wire inside the patient or cause arrhythmia.

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APPENDIX E CONTINUED

Step 6A.3: IF the wire is entering smoothly without causing an arrhythmia, THEN
continue to Step 6A.4
Or
IF the wire going in smoothly causes arrhythmia, THEN withdraw the
wire several centimeters to cease the irregular heart beat before continuing
to Step 6A.4
Or
IF the wire is not going in smoothly, THEN remove the wire and needles
as one unit [Never remove the wire back through the needle] and return to
return to Task 5A

Step 6A.4: Remove the needle leaving only the guide wire in place and place a clamp
on the end of the guide wire.

Step 6A.5: Make an incision with a scalpel to enlarge the skin to allow passage of the
dilator over the wire into the internal jugular.

 Lay the dull edge of scalpel on the wire.
• Stab the length of the scalpel blade.
• Pull the scalpel out.
• Rotate the scalpel blade 180 degrees.
• Stab the length of the scalpel blade, avoid leaving bridge of
skin between needle and cut.
• Incision should be made just wide enough to allow passage of
the catheter, an additional three millimeters.
• In the internal jugular position, the dilator does not need to be
as vigorously introduced as in the subclavian site because
there’s minimal connective tissue over the internal jugular
vein.
• If the dilator is vigorously introduced, it could result in tearing
of the vein.

Task 7A: Direct the central venous catheter over the wire into the vein.

IF you are putting in a percutaneous introducer, THEN you do
not need to use a dilator because the introducer and dilator are
preloaded as one.

IF you are using a multi-lumen catheter, THEN use the dilator
first, pull that out and then put the catheter in.

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APPENDIX E CONTINUED

Step 7A.1: Direct the dilator over the wire.

IF you are using a triple lumen catheter, THEN open the brown port
and make sure the wire comes out of the brown port.

Step 7A.2: Slide dilator and catheter all the way down to the hub at the skin by
controlling the wire with one hand advancing the dilator and catheter with
free hand.

IF you cannot push the dilator through, THEN you have left a skin bridge,
so cut down on it to make sure that you cut the skin.

Step 7A.3: The catheter and wire should not move together, but pull
the wire out a little while the dilator is in so you can capture it on the
other side.

IF you have time, THEN prep the catheters by priming the lines with
saline.

Step 7A.4: Remove the dilator while holding the wire in place.

Step 7A.5: Remove cap on the brown port of the central venous catheter to allow
passage of the wire through the catheter.

Step 7A.6: The wire should be controlled at the brown port the entire time
the catheter is advanced over the wire.

Step 7A.7: Close dilator ports and entry points on the catheter.

Task 8A: Remove the wire.

Step 8A.1: Remove wire and dilator in one motion and blood will immediately come
up to the catheter

Step 8A.2: IF the removal is smooth and without resistance, THEN continue to Step
9A.

Task 9A: Verify placement of CVC

Step 9A.1: A syringe is placed on the brown port and aspirated to verify that the
catheter is in position in a vein.
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APPENDIX E CONTINUED

Step 9A.2: A syringe is attached to all three ports.

Step 9A.3: The air from each port is aspirated.

Step 9A.4: If you get dark blood flow, THEN continue to Step 9A.5

But
IF the blood is bright red or determined to be arterial blood, THEN leave
in place and call a vascular surgeon

IF unsure, or getting pulsatile flow, THEN hook the transducer to the
barrel of the needle and look at waveform
OR send blood for blood gas
OR hook up IV bag to needle and lower below level of bed.

Step 9A.5: Each port is flushed with a small amount of sterile saline, one to two cc’s
per port.

Step 9A.6: The caps are replaced for all lines with luer lock

Task 10A: Affix catheter to the skin.

Step 10A.1: Affix the central venous catheter to the skin using two interrupted sutures
through the skin to the tabs on the hub of the catheter.

Step 10A.2: Place antibiotic-coated disc right on the insertion site.

Step 10A.3: Put some sterile ointment and dressing over the wound.

Step 10A.4: Remove the drapes.

Step 10A.5: Place patient in a comfortable position.

Step 10A.6: A chest x-ray is ordered to verify proper placement of the catheter.

Step 10A.7: IF you see blood or air, THEN notify the patient that they may need a
chest tube or further observation
OR

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APPENDIX E CONTINUED

IF you see that the catheter is in the wrong place or inside the right atrium,
THEN start over.
OR
IF catheter is correctly placed and shown to go downward and no show of
air or blood, THEN proceed.

Step 10A.8: Count all the equipment, including the wire.

Procedure for the Subclavian location (B)

Task 3B: Prepare the patient.

Step 3B.1: Obtain Consent.

Step 3B.2: Make sure wires are out of the way.

Step 3B.3: Lower the bed guardrails and position the bed at a height that is
appropriate for you.

Step 3B.4: Remove patient’s gown in area of procedure.

Step 3B.5: Place a roll of towels underneath the shoulder to open up the area.

Step 3B.6: Decide whether or not to administer local anesthetic.

IF the patient is conscious or can feel pain, THEN administer local
anesthetic.

IF it is an emergency situation, THEN you can skip giving a local
anesthetic

IF it is an elective situation, THEN you administer a local anesthetic

Step 3B.7: The area of skin over the site needs to be anesthetized with local
anesthetic, which is typically one percent lidocaine.

Step 3B.8: Take a 10cc syringe and the very thin needle with lidocaine and you may
want to draw up more than what comes in the kit.

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APPENDIX E CONTINUED

Step 3B.9: It’s introduced or injected through a smaller needle, and that’s done by
raising a skin wheel just under the skin and then more widely infiltrating
the skin and subcutaneous tissue over the central line site. Localize the
skin and anesthetize the skin.

Step 3B.10: Use this needle to localize the vessel.

Step 3B.11: Identify the anatomic landmarks around the delta-pectoral group
(Deltapectoral groove), about one or two finger breadths below the
clavicle and numb the location with Lidocaine.

Step 3B.12: Picture in your mind that the subclavian vein is running beneath the
clavicle.

Step 3B.13: Identify the sternal notch and the clavicle.

Task 4B: Insert needle into the subclavian vein.

Step 4B.1: Palpate the sternal notch; place the tip of left index finger in the sternal
notch.

Step 4B.2: Palpate the clavicle. Identify the point at the distal two thirds of the
clavicle, and place thumb just inferior to the clavicle at that position of the
thumb on left hand.

Step 4B.3: Pop through and move slightly forward, drawback to make sure you’re not
getting blood.

• The downward pressure depends on the thickness of the
patient’s subcutaneous tissue.
• Sometimes the clavicle is pretty deep and it does require a lot
of pressure to get underneath the clavicle.
• If the patient is obese it requires pretty firm palpation.
• Push needle forward until you hit the vein. If you hit the
clavicle, pull back 1-2 cm, angle needle down, and move
forward to the vein.
• Subclavian vein sits underneath the clavicle.

Step 4B.4: Push some local in and let that infuse for a second, then draw back. Repeat
infuse-drawback sequence until you see a nice drawback of dark venous
blood coming into your needle.
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APPENDIX E CONTINUED

Step 4B.5: Pull thin needle right back out.

Step 4B.6: Switch to the big needle.

Step 4B.7: With right hand take empty syringe with the introducer needle. Select spot
on the skin that is two centimeters inferior and approximately one
centimeter lateral to that position on the clavicle.

Step 4B.8: Introduce the needle at 45 degrees into the skin with the needle in a plane
parallel to the floor to avoid inadvertent puncture of the apex of the lung.

Step 4B.9: Use the big needle under suction and follow the path of the thin needle
until you get a nice drawback and go in a millimeter or so further.

Step 4B.10: The needle is advanced until it strikes the inferior surface of the clavicle.

• The advancement of the needle should be fairly gentle.

Step 4B.11: Using a downward pressure on the skin with left thumb, guide the
introducer needle under the clavicle by (serially marching?) it down the
flat portion of the clavicle until I can feel it pass underneath.

Step 4B.12: The syringe is aspirated.

Step 4B.13: The needle is advanced towards left index finger in the sternal notch.

Step 4B.14: Return of venous blood in the syringe should signify cannulation of the
subclavian vein.

• Venous blood tends to be darker than arterial blood.
• The patient that’s on high concentration oxygen may have
fairly red venous blood.
• Pulsating and bright red (blood) may indicate that’s an arterial
cannulation.
• Steady flow of blood from the needle is more likely a venous
cannulation.

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APPENDIX E CONTINUED

IF you don’t get a flash of blood, or blood, THEN withdraw needle,
reposition needle and reinsert needle.

IF you have placed your needle into the subclavian artery, THEN
withdraw needle and hold pressure with a 4 by 4 for 5 minutes while
maintaining pressure. Then repeat the procedure using the other side.

IF there is evidence of ongoing blood loss, THEN call for a surgical
consultation.

IF the blood is dark and the patient is not hypotensive, THEN assume you
are in the vein.

If you are not completely in the vein, THEN the subsequent (CVC
placement) steps will not work very well and you can tear the vessel.

Step 4B.15: Once the vein is cannulated, then it’s very important to maintain the
position of the needle, firmly hold hub of the needle to keep it in position
with non-dominant hand.

IF you are right handed, THEN you will hold the hub with your left hand.

IF you are left handed, THEN you will hold the hub with your right hand.

Step 4B.16: Keep needle as still as possible.

Step 4B.17: Remove syringe from the needle.

• Continued venous bleeding from the needle is a good sign that
it is still in position, that it’s still in the vein.

IF your needle is in the vein, THEN the blood will be a nice slow dripping
of dark venous blood.

IF your needle is in the artery, THEN you see that pulsatile, arterial red
blood.
IF you are unsure of which line your needle is in, THEN you can plug in
an A-line transducer to verify if it is arterial pressure wave.

IF you are unsure of which line your needle is in, THEN the safest thing is
to pull out and do it again with the use of a pressure transducer.
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APPENDIX E CONTINUED

IF you have entered the artery, THEN pull the needle out, apply pressure
for a couple minutes and then try again on the same side without re-
prepping.

Step 4B.18: Place thumb over hub of the needle to avoid any air being introduced into
the vein

• Placing thumb over hub of needle helps avoid air embolus for
patients with low venous pressure or nearly negative venous
pressure.

Task 5B: Introduce guide wire through the needle.

Step 5B.1: Take the guide wire from the tray.

Step 5B.2: Introduce the guide wire through the needle.

• The guide wire should pass very easily, should require no force
at all to advance it into the vein.
• The guide wire typically goes in about twenty centimeters.
• Insert ½ to 2/3 of the wire through the introducer needle.
• Insert the wire through the needle leaving approximately seven
inches out while looking and listening to the monitor. It
monitors a cardiac rhythm strip, BP, HR, RR, and O2 sat.
• The wire needs to go the length of the needle and a little past,
about 5-10 centimeters.
• You don’t want to introduce the entire wire.
• You want to avoid losing the wire inside the patient.

IF the wire doesn’t go through, THEN the needle has slipped out of the
vessel. Put the wire aside, get your syringe back on, and try to find it
(vein) again.

• Always maintain one hand on guide wire.

IF the wire is going in smoothly but causes irregular heart beat, THEN
remove the wire several centimeters to cease the irregular heart beat.

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APPENDIX E CONTINUED

IF the wire is not going in smoothly, THEN remove the wire and needles
as one unit [never remove the wire back through the needle] and go to task
4.

IF the patient is developing arrhythmias, THEN pull the needle back a bit.

IF the guide wire induces arrhythmia, THEN remove the guide wire.

IF resistance, THEN remove the wire by bringing it back into the housing,
Put syringe back on and confirm that there is still blood flow and try
passing the wire again.

IF the wire cannot go in or gets stuck, THEN do not force it. Take it out,
get a nice clean pull of blood and then re-feed the wire.

IF you persist with a stuck wire, THEN you may shred the wire and
embolize a bit of the wire. Just pull the whole thing out.

Step 5B.3: If the patient is on a cardiac monitor, the guide wire may cause some
ectopy that can be seen on the screen, which is an indicator that the wire is
in the right place.

Step 5B.4: Remove the needle leaving only the guide wire in place.

Step 5B.5: Take hold of the wire in one hand.

Step 5B.6: Take hold of the introducer needle in your other hand.

Step 5B.7: Slide the introducer needle off the wire without pulling the wire back.

Step 5B.8: Put a clamp on the end of the guide wire.

Step 5B.9: Make an incision with a scalpel to enlarge the skin to allow passage of the
dilator over the wire into the subclavian vein.

Step 5B.10: Lay the dull or sharp edge of a scalpel on the wire.

Step 5B.11: Stab the length of the scalpel blade, 1/4 inch incision.

Step 5B.12: Pull the scalpel out.

Step 5B.13: Rotate the scalpel blade 180 degrees.
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APPENDIX E CONTINUED

Step 5B.14: Stab the length of the scalpel blade.

• In the subclavian position, this is an important step because the
connective tissue around the clavicle is substantial, and there’s
some periosteum around the clavicle that needs to be dilated to
allow passage of the central venous catheter.

• Incision should be made just wide enough to allow passage of
the catheter, an additional three millimeters.

The incision is just a couple millimeters but it has to be wide enough.
The cut is right on top of the wire.

Step 5B.15: Make sure there is no skin bridge between the needle and the cut.

Step 5B.16: Pull the needle out.

Step 5B.17: Direct the dilator over the wire and then remove the dilator.

IF you are putting in a percutaneous introducer, THEN you do not need to
use a dilator because the introducer and dilator are preloaded as one.

IF you are using a multi-lumen catheter, THEN use the dilator first, pull
that out and put the catheter in.

The dilator is a rigid plastic tube that dilates the tract and facilitates
insertion of the less rigid catheter.

IF you feel resistance or it’s not coming out, THEN decide whether to
leave it and call somebody with more experience.

IF you feel resistance or it’s not coming out, THEN remove it and hold
pressure for five minutes as long as you’re pretty sure it’s not in the artery,
then return to task 3.

Step 5B.18: Never let go of the wire.
Wire could get embolized if you let go of the wire.
Step 5B.19: As you hold the wire [near the skin], you push the dilator over top, grab
the wire on this end [top], push the dilator in.
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APPENDIX E CONTINUED

IF you cannot push the dilator through, THEN you have left a skin bridge,
so cut down on it to make sure that you cut the skin bridge.

Step 5B.20: Pull the wire out a little while the dilator is in so you can capture it on the
other side.

People jam the wire in too far.
IF you have time, THEN prep the catheters by priming the lines with
saline.
The blood just pushes the saline out.

Task 6B: Direct the central venous catheter over the wire into the vein.

Step 6B.1: Remove cap on the brown port of the central venous catheter to allow
passage of the wire through the catheter.

Step 6B.2: Thread the wire through the dilator and catheter until it comes out of the
end.

Step 6B.3: The catheter should slide easily over the wire until, in most adults; the
catheter hub is at the skin.

Step 6B.4: Slide dilator and catheter all the way down to the hub by controlling the
wire with one hand and advancing the dilator and catheter with free hand.

Step 6B.5: Close dilator ports and entry ports on the catheter.

• The catheter and wire should not move together.

• The wire should be controlled at the brown port the entire time the
catheter is advanced over the wire.

IF inserting a triple lumen, THEN take the following steps:

• Take Dilator from the kit and unclamp guide wire.
• Hold guide wire at the skin and pass the introducer needle with the
dilator over the guide wire.
• As guide wire sticks out of the end of the dilator, put clamp back
on.
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APPENDIX E CONTINUED

• Hold guide wire steady in one position and advance the dilator.
• Run it back and forth a few times to establish track to pass
catheter.
• Pull back on dilator and keep finger on tip of where guide wire
enters skin.
• Take off clamp, take off guide wire, and take off introducer needle.
• Put triple lumen over guide wire and feed it out, making sure that
there is guide wire coming out of the end of catheter.
• Put clamp back on the guide wire.

IF catheter induces arrhythmia, THEN remove catheter.

Step 6B.6: Hook up various lines.

Task 7B: Remove the wire.

Step 7B.1: Once the catheter is in place, remove the wire.

Step 7B.2: Remove wire and dilator in one motion.

Task 8B: Verify placement of CVC by aspiration and by chest x-ray.

Step 8B.1: A syringe is placed on the brown port and aspirated to verify that the
catheter is in position in a vein.

IF you get dark blood flow, THEN go to task 9

IF you don’t get dark blood flow, THEN leave it and call vascular surgery.

Step 8B.2: A syringe is attached to all three ports.

Step 8B.3: The air from each port is aspirated.

Step 8B.4: Each port is flushed with a small amount of sterile saline, one to two cc’s
per port.

Step 8B.5: The caps are replaced.

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APPENDIX E CONTINUED

Step 8B.6: A chest x-ray is ordered to verify proper placement of the catheter
confirming that it’s sitting in the SVC outside of the right atrium.

• Make sure it is not going upwards instead of downwards.
• The chest x-ray ideally shows a central venous catheter with the tip
just at the superior venacaval right arterial junction.
• It should NOT show a pneumothorax on the side of the central
line.
• It should NOT show any widening of the mediastinum.
• It should NOT show hematoma indicating arterial injury.
• It should NOT show extravasations of blood into the right chest.

IF you see blood or air, THEN notify the patient that they may need a
chest tube or further observation.

IF you see that the catheter is in the wrong place, THEN start over.

Task 9B: Affix catheter to the skin.

Step 9B.1: Affix the central venous catheter to the skin using two interrupted sutures
through the skin to the tabs on the hub of the catheter.

Step 9B.2: Attach catheter with Luer-lock.

Step 9B.3: Place an antibiotic-coated disc right on the insertion site.

Step 9B.4: Put some sterile ointment and plastic occlusive dressing over the wound.

• Remove the drapes.
• Place patient in a comfortable position.

Step 9B.5: Count all the stuff.

Step 9B.6: Make sure you still have that wire.

Procedure for the Femoral Vein location (C)

Task 3C: Prepare the patient.

Step 3C.1: Get Consent.
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APPENDIX E CONTINUED

Step 3C2: Explain risks and benefits of the procedure.

Step 3C3: Get rid of clothing in that area.

Step 3C.4: Decide whether or not to administer local anesthetic.

IF the patient is conscious OR can feel pain, THEN administer local
anesthetic.

Step 3C.5: Drape the patient.

Step 3C.6: Anesthetize area over the skin using a local anesthetic of typically one
percent lidocaine.

Step 3C.7: Introduce or injected through a smaller needle by raising a skin wheel just
under the skin and then more widely infiltrating the skin and subcutaneous
tissue over the central line site.

Step 3C.8: Decide how to position the patient.

IF placing Central Venous Catheter in the femoral vein, THEN position
the patient in a supine position.

• Place the patient in a flat position.

IF placing Central Venous Catheter in the femoral vein, THEN position
the patient in a slightly frog-leg position, externally rotated, slightly
flexed.

IF placing Central Venous Catheter in the femoral vein, THEN position
patient in prone.

IF no fracture to the pelvic area, THEN extend legs or rotate out to open
up that space.

Step 3C.9: Identify anatomic landmarks using Nerve-Artery-Vein-Empty
Space-Lymphatic’s from lateral to medial.

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APPENDIX E CONTINUED

Step 3C.10: Palpate the groin and femoral artery to locate vein.

• The femoral artery is just inferior to the inguinal ligament. The
vein is 1 finger breath medial to this palpable pulsation. Stay
below the inguinal ligament.
• Feel for the pulse, go medial to that (about 1 centimeter) and
work your way away from the artery, from the pulse.

Step 3C.11: The needle will enter at this point.

Task 4C: Select needle and insert needle into a large vein.

• Insert the needle into the vein using the ultrasound to guide
you.

Step 4C.1: Take a 10cc syringe and the very thin needle with lidocaine and you may
want to draw up more than what comes in the kit.

Step 4C.2: Use this needle to localize the vessel.

Step 4C.3: Localize the skin and anesthetize the skin.

Step 4C.4: Tighten skin and flatten out needle to introduce introducer needle at
approximately a forty-five degree angle to 75 degree angle, pointed in the
cephalad direction with a bit of negative pressure on syringe. Pop through
and move slightly forward.

Step 4C.5: Continuous aspiration on the syringe until there’s a return of venous
blood.

IF spurting of blood occurs, THEN hold pressure for several minute. The
femoral artery is compressible.

Step 4C.6: The needle is advanced.

• Aim towards the umbilicus.

Step 4C.7: Push some local in and let that infuse for a second, then draw back.
Repeat infuse-drawback sequence until you see a nice drawback of dark
venous blood coming into your needle.

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APPENDIX E CONTINUED

Step 4C.8: Pull thin needle right back out.

Step 4C.9: Switch to the big needle.

Step 4C.10: Use the big needle under suction and follow the path of the thin needle
until you get a nice drawback and go in a millimeter or so further.

IF you are not completely in the vein, THEN the subsequent [CVC
placement] steps will not work very well and you can tear the vessel.

Step 4C.11: Remove syringe from the needle.

• Continued venous bleeding from the needle is a good sign that
it is still in position, that it’s still in the vein.

IF your needle is in the artery, THEN you see that pulsatile, arterial red
blood.

IF you are unsure of which line your needle is in, THEN you can plug in
an A-line transducer to verify if it is arterial pressure wave.

IF you are unsure of which line your needle is in, THEN the safest thing is
to pull out and do it again with the use of a pressure transducer.

IF you have entered the artery, THEN pull the needle out, apply pressure
for a couple minutes and then try again on the same side without re-
prepping.

Step 4C.12: Hold the hub of the needle.
IF you are right handed, THEN you will hold the hub with your left hand.

IF you are left handed, THEN you will hold the hub with your right hand.

Step 4C.13: Keep needle as still as possible.

Step 4C.14: Place thumb over hub of the needle to avoid any air being introduced into
the vein.

Placing thumb over hub of needle helps avoid air embolus for patients
with low venous pressure or nearly negative venous pressure.

108
APPENDIX E CONTINUED

Task 5C: Introduce guide wire through the needle.

Step 5C.1: Take the guide wire from the tray.

Step 5C.2: Introduce 1/2 to 2/3 of guide wire through the introducer needle and
stabilize the introducer needle.

• The guide wire should pass very easily, should require no force
at all to advance it into the vein.
• The guide wire typically goes in about twenty centimeters.
• The wire needs to go the length of the needle and a little past,
about 5-10 centimeters.
• You don’t want to introduce the entire wire.
• You want to avoid losing the wire inside the patient.

IF the wire doesn’t go through, THEN the needle has slipped out of the
vessel. Put the wire aside, get your syringe back on, and try to find it
(vein) again.

IF the wire cannot go in or gets stuck, THEN do not force it. Take it out,
get a nice clean pull of blood and then re-feed the wire.

IF you persist with a stuck wire, THEN you may shred the wire and
embulize a bit of the wire. Just pull the whole thing out.

IF resistance, THEN remove the wire by bringing it back into the housing.
Put syringe back on and confirm that there is still blood flow and try
passing wire again.

Step 5C.3: Remove the needle and all needles leaving only the guide wire in place.

Step 5C.4: Put clamp on the end of the guide wire.

Step 5C.5: Make quarter-inch incision with dull side of 15-blade scalpel along side,
on top of guide wire to enlarge skin to allow passage of the dilator over
the wire into the femoral vein.

Incision should be made just wide enough to allow passage of the catheter,
an additional three millimeters.

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APPENDIX E CONTINUED

Make sure there is no skin bridge between the needle and the cut.
The dilator is a rigid plastic thing that dilates the tract and the skin up a
little bit.

Step 5C.6: Never let go of the wire.

Wire could get embulized if you let go of the wire.

Step 5C.7: As you hold the wire [near the skin], direct the dilator over the wire and
then remove dilator.

IF you cannot push the dilator through, THEN you have left a skin bridge,
so cut down on it to make sure that you cut the skin bridge.

Step 5C.8: Pull the wire out a little while the dilator is in so you can capture
it on the other side.

People jam the wire in too far.
IF you have time, THEN prep the catheters by priming the lines with
saline.
The blood just pushes the saline out.

Task 6C: Direct the central venous catheter over the wire into the femoral vein.

Step 6C.1: Remove cap on the brown port of the central venous catheter to allow
passage of the wire through the catheter.

Step 6C.2: Insert catheter which should slide easily over the wire until, in most
adults; the catheter hub is at the skin.

The catheter and wire should not move together.

Use one hand to control wire and the other free hand to advance dilator
and catheter.

The wire should be controlled at the brown port the entire time the
catheter is advanced over the wire.

IF unsure, or getting pulsatile flow, THEN hook the transducer to the
barrel of the needle and look at waveform OR send blood for blood gas
OR hook up IV bag to needle and lower below level of bed.
110
APPENDIX E CONTINUED

Task 7C: Remove the wire in one motion.

Step 7C.1: Remove the wire once catheter is in place.
Blood will immediately come up to the catheter.

IF you feel resistance or it’s not coming out, THEN decide whether to
leave it and call in somebody with more experience.
OR
IF you feel resistance or it’s not coming out, THEN remove it and hold
pressure for five minutes. If sure, not in the artery, then return to step one

Task 8C: Verify placement of CVC in femoral vein by aspiration.

Step 8C.1: Place syringe on catheter brown port and aspirate to verify catheter is in
proper position in femoral vein.

Step 8C.2: Pull blood out so you get a drawback and you can infuse saline back in.

Step 8C.3: Attach syringe to all three ports.

Step 8C.4: Aspirate each port.

IF you get dark blood flow, THEN continue to Step 8C.4
OR
IF you don’t get dark blood flow, THEN leave it and call vascular surgery.

Step 8C.5: Flush each port with a small amount of sterile saline, one to two cc’s per
port.

Step 8C.6: Replace caps.

Task 9C: Affix catheter to the skin.

Step 9C.1: Affix the central venous catheter to the skin using two interrupted
sutures through the skin to the tabs on the hub of the catheter.

Step 9C.2: Place an antibiotic-coated disc right on the insertion site.

Step 9C.3: Place a plastic occlusive dressing.

Step 9C.4: Put some sterile ointment and dressing over the wound.
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APPENDIX E CONTINUED

Step 9C.5: Remove the drapes.

Step 9C.6: Place the patient in a comfortable position.

Step 9C.7: Count all the stuff.

Step 9C.8: Make sure you still have that wire.

Abstract (if available)

Abstract This study used cognitive task analysis (CTA) knowledge elicitation strategies to find the percentage and type of information that experts omit when describing how to perform a surgical procedure. CTA is a method by which a trained analyst can extract and capture information that has been automated and is non-conscious to an expert. This information includes critical decision points and judgments involved in the expert’s performance of the procedure. Based on the current research literature, the hypothesis for this study was that surgical experts would omit approximately 70% of the critical decision steps necessary to perform the Open Cricothyrotomy and Central Venous Catheter surgical procedures. More specifically, this study sought to determine if there is a difference in knowledge omissions based on the experts’ prior knowledge of the procedures.

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Asset Metadata

Creator Tolano-Leveque, Maryann (author)

Core Title Using cognitive task analysis to determine the percentage of critical information that experts omit when describing a surgical procedure

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Counseling Psychology)

Publication Date 07/28/2010

Defense Date 03/08/2010

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag central venous line placement,cognitive task analysis,CTA,decision steps,Dr. Richard Clark,education,gold standard,Keck School of Medicine,knowledge omissions,Maryann Tolano-Leveque,OAI-PMH Harvest,open cricothyrotomy,Psychology,subject matter experts,Surgery,surgical training,teaching,University of Southern California,USC

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Clark, Richard E. (committee chair), Sullivan, Maura E. (committee member), Yates, Kenneth A. (committee member)

Creator Email mtolano@mtsac.edu,mtolano18@aol.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m3226

Unique identifier UC1438898

Identifier etd-TolanoLeveque-3844 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-351724 (legacy record id),usctheses-m3226 (legacy record id)

Legacy Identifier etd-TolanoLeveque-3844.pdf

Dmrecord 351724

Document Type Dissertation

Rights Tolano-Leveque, Maryann

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu