The Modules for ISLS/PNLS Combined Course as International Version: Report of Workshop in 9 International Conference of Cerebrovascular Surgery.

In Japan, there are two simulation based training systems for neurosurgical diseases, that are ISLS (Immediate Stroke Life Support) and PNLS (Primary Neurosurgical Life Support). Workshop on "First ISLS International Version Trial Task Force" came to a successful conclusion on November 12, 2009, in Nagoya, Japan. More than 30 international participants attended this workshop, organized by the Department of Neurosurgery, Fujita Health University. This report summarizes the modules for ISLS/PSLS combined course as international version from the workshop.

Introduction

The goal of care for neurosurgical emergency diseases, including stroke, is to minimize brain damage and maximize patient recovery. Appropriate general managements should be needed before surgical treatment. It is, therefore, necessary to perform training to learn these management. There are two simulation based training system for neurosurgical diseases in Japan. One is interdisciplinary stroke training system, which is called as ISLS (Immediate Stroke Life Support) course[12]. The other is training system for neurosurgical emergency, which is termed as PNLS (Primary Neurosurgical Life Support) course[34]. ISLS course has been developed and performed by Japan Congress of Neurological Emergencies (JNE) and Japanese Association for Acute Medicine (JAAM) since 2005, and PNLS course has been developed and performed by Japan Society of Neurosurgical Emergency (JSNE) since 2008. We performed first international version of ISLS/PNLS combined course with the 9th International Conference of Cerebrovascular Surgery on November 12, 2009, organized by the Department of Neurosurgery, Fujita Health University. More than 30 international participants attended this workshop.

Design of ISLS/PSLS Combined Course as International Version

We designed subjective behavior objects as international version of ISLS/PSLS combined course, such as 1) evaluation of consciousness level using coma scale, 2) evaluation of neurological conditions using stroke scale, 3) learning early systemic management for cerebral herniation, 4) learning of the treatment algorithm of ISLS/PNLS. (Table 1).

Table 1

Three skill modules of ISLS/PSLS combined course as international version.

Module A: Coma Scale

In this module, participants could learn to evaluate consciousness level using Glasgow Coma Scale (GCS)[56] and Emergency Coma Scale (ECS)[178]. The GCS is internationally accepted when discussing patient's consciousness level with other professionals. However, the GCS has the disadvantages of complexity especially category of best motor response[8]. We introduced “Ajimi” performance to understand the category of best motor response[9]. The ECS was designed by Ohta in 2003 and developed by the JNE and JNES[8]. The ECS consists of three major categories depending on the severity of consciousness disturbance (Table 2) . Category 1 and 2 have two subcategories, and category 3 has five subcategories based on the category of best mortar response of GCS. Many participants have commented about the usefulness of it. The ECS could be understood for beginners in evaluating consciousness level and useful for staff education[7].

Table 2

The Emergency Coma Scale (Ohta)

Module B: Stroke Scale

The National Institute of Health (NIH) stroke scale is a standardized method used by physicians and other health care professionals to measure the level of impairment caused by a stroke[1011]. The NIH stroke scale could measure several aspects of neurological function, including 1) consciousness, 2) gaze, 3) vision, 4) facial palsy, 5) arm movement, 6) leg movement, 7) ataxia, 8) sensation, 9) language, 10) dysarthria, and 11) extinction (Table 3) . A maximal score of 42 represents the most severe stroke. Participants learned how to evaluate neurological conditions using NIH stroke scale with simulated patients (Figure 1). Interestingly, although some participants were not familiar with NIH stroke scale until workshop, they have commented about the usefulness of it. The NIH stroke scale could be understandable for medical staff in evaluating neurological conditions and also useful for staff education in the same as coma scale.

Table 3

NIH stroke scale[1011]

Figure 1

The scenery of workshop (First ISLS/PNLS International Version Trial Task Force) in 9th International Conference of Cerebrovascular Surgery (November 12, 2009). Participants leaned the NIH stroke scale with simulated patient.

Module C: Systemic Management

This module introduced initial management for impaired respiratory and circulatory function in patients by slides. Participants could learn to stabilize airway obstruction, breathing disturbance and extensive hypertension and to evaluate cerebral herniation. Emergency medical staff should assess the patient with suspected stroke within 10 minutes of arrival in the hospital. General care includes assessment and support of airway, breathing, and circulation. The American Heart Association Guidelines indicate that emergency medical staff should administer oxygen to hypoxemic patients, confirm intravenous access and obtain blood samples[12]. We design algorithm of ISLS/PNLS for neurosurgical emergency patients (Figure 2). It is emphasized that stabilization of respiratory and circulatory function has priority over evaluation of cerebral herniation. Key points in management include the assessment of oxygenation, blood pressure, consciousness level, and the papillary examination before CT (computed tomography) scan. Treatment strategies are directed toward maintaining adequate oxygenation and perfusion, and then treating cerebral herniation. All the workshop participants confirmed these points.

Figure 2

ISLS/PNLS algorithm for neurological emergency patients. Reference in the American Heart Association Guidelines[12]. EMS: emergency medical services, ABC: airway, breathing, and circulation, IV: intravenous, CT: computed tomography.

Module D: Group Work Using Clinical Map

We desigened and performed a group work, which was a system/structure oriented case debriefing to summarize ISLS/PNLS course. The group work was performed using a clinical map[1314] as a desk work of simulation for initial management for a stroke or neurosurgical emergency patients.

Structure of a clinical map

We produced a clinical map of an initial treatment for a patient of severe hemorrhagic stroke with cerebral herniation. The clinical map has a structure like a clinical path and provides a procedure and contents of an initial treatment of stroke in chronological order according to the algorithm of ISLS/PNLS. Its horizontal axis means the algorithm and vertical axis means physical findings, examinations, imaging, treatment and other clinical items.

How to use a stroke clinical map for group work

Initially participants were given a frame and elements which were divided from a clinical map. Participants need to fill an empty frame by putting pieces of elements to complete the clinical map. A facilitator observed their performance and helped their work (Figure 3) .

Figure 3

The scenery of a group work using a clinical map in module D. Participants enjoyed the group work.

Conclusions

The workshop was held as the project of the first ISLS/PNLS international version task force. The participants’ comments indicated that a sufficiently high standard of knowledge was obtained in this workshop. This workshop could contribute to the spread of ISLS and PNLS course not only Japan but also throughout the world.