NYSORA - New York School Of Regional Anesthesia - Anesthesia Teaching On The Web: A Tool For The Generations To Come
A Hadzic, J Vloka, A Hadzic, F Rand, Z Khaimova, N Hadzic, H Shih, S Mathia, G Hadzic
anesthesia, anesthesiology, critical care medicine, intensive care medicine, internet, movies, nerve blocks, nysora, regional, regional anesthesia, teaching, trauma, workshops
A Hadzic, J Vloka, A Hadzic, F Rand, Z Khaimova, N Hadzic, H Shih, S Mathia, G Hadzic. NYSORA - New York School Of Regional Anesthesia - Anesthesia Teaching On The Web: A Tool For The Generations To Come. The Internet Journal of Anesthesiology. 1999 Volume 5 Number 1.
After a relatively dormant period of several
decades, new information, research and teaching in regional anesthesia have
exploded. A number of excellent and innovative texts and inter-active
CD-ROM programs of remarkable educational value have been recently
published. But how can a busy clinician keep up with the rapid changes in
the field on a daily basis and get at information on the fly? With the
advent of the Internet, NYSORA.com offers a user-friendly guide to
regional anesthesia information via the Web. In this short review we
summarize the NYSORA website, present salient technical details on the
decision making process involved with building advanced medical Web sites,
and share our views on the value and future of Web-based teaching medical
After a relatively dormant period of several decades, new information, research and teaching in regional anesthesia have exploded. A number of excellent and innovative texts and inter-active CD-ROM programs of remarkable educational value have been recently published. But how can a busy clinician keep up with the rapid changes in the field on a daily basis and get at information on the fly? With the advent of the Internet, NYSORA.com offers a user-friendly guide to regional anesthesia information via the Web. In this short review we summarize the NYSORA website, present salient technical details on the decision making process involved with building advanced medical Web sites, and share our views on the value and future of Web-based teaching medical sites.
What is NYSORA?
NYSORA stands for
A Bit of History
The NYSORA debuted in the fall of 1996 under the name www.idamedical.simplenet.com. This was a true pioneering project since at that time this was one of the first web sites that focussed on peripheral nerve blockade. Early on, only a series of techniques that had been developed or refined by the authors were featured. The decision was made to limit the content of the site to original contributions and techniques specific to the authors’ practices rather than reproduce work that had already been published elsewhere. We continued to follow this principle as we further developed and expanded the site. As a result, we combine the information from the basic (anatomy) and clinical research and continuously assess and evaluate the details of the techniques.
The testimony to its educational value came at the authors’ scientific exhibits on peripheral nerve blocks at the 1997 ASA, IARS and PGA meetings.1,2,3 The scientific exhibits and demonstration of the website received enormous attention and proved that this pioneering project was an overwhelming success. Consequently, the rapidly growing website demanded a commitment to another re-organization and more flexible ISP (Internet Service Provider) hosting. The second generation of NYSORA emerged as a much-expanded version in December of 1997 under the name www.anesthesiaregional.com on a Yahoo server. The rising number of daily visits, incoming emails with questions on regional anesthesia, and inquires regarding the training in nerve block techniques soon demanded a new level of commitment to this regional anesthesia teaching project. At the same time, the stream of publications, continuous work on the concept of “Functional Regional Anesthesia” and the establishment of the regional anesthesia fellowship and the Center of Excellence in Regional Anesthesia at St. Luke’s-Roosevelt paralleled and fostered the development of the web-based school project. The current, third edition of the website, now located at www.NYSORA.com and hosted on a newer dedicated server, has been redesigned in order to service these demands and offers a bold frills-free tutorial on the principles and practice of peripheral nerve blocks to the ever-growing Internet-enabled Anesthesia community. The site has been substantially expanded to include more techniques, discussions on principles of practice of regional nerve blocks, local anesthetics, equipment and focused videos on techniques and responses to nerve stimulation.
NYSORA – Anatomy Dissection
The NYSORA web site is currently organized into 12 sections. These sections present the necessary information for successful implementation of practice of nerve blocks in a logical, user-friendly format. The “
Technical information (Skeleton)
NYSORA is currently hosted by the ISP Interland (www.Interland.com). We selected Interland for their fast and flexible Internet backbone connectivity in anticipation of our desire to provide video and other high bandwidth services to simultaneous visitors. This also guided our decision to host our site on a dedicated server that also provides streaming video, email, and database services. The server supports both the Windows and McIntosh platforms, and supports ASP (active server pages) and CGI (common gateway interface) services which will allow us to continue to evolve the site’s design into the very dynamic, interactive environment we envision. These services should also reduce the effort required to perform routine content maintenance.We also utilize a content search engine, Atomz, for fast cross-reference searches on subjects of interest.
Additionally, Interland provides us with site evaluation tools so that we can review visitor access to the site. They setup the industry-standard
Videos on the web
Reality or Science Fiction?
Because visual presentations are among the most useful teaching tools in regional anesthesia, it has been clear from the very beginning that NYSORA will eventually need to address the need to incorporate this media in its teaching armamentarium. While this was simply impossible or impractical back in 1996 due to the technical limitations related to the size of digital video images and slow transfer rates, the technological advances in telecommunications and digital imaging have made it possible that the modern sites of similar goals incorporate video material.
Videos Files for the Web and the Choice of Architecture
All videos featured at NYSORA were filmed in the operating rooms on actual patients using a Fuji Film, FinePix 4700 Zoom (Fuji Photo Film.,Ltd. Japan) and Sony DVCAM DSR-20/20P. The images were then digitally edited using Adobe Premiere 5.1 editing software (Adobe Systems Inc.). The exported AVI files were compressed using Media Cleaner( Pro 4 (Terran Interactive, Inc), the industry standard for dynamic media compression. The Cleaner supports REALG2, Windows Media (NetShow), QuickTime 4 and MPEG, making it an ideal tool to produce all major formats on both platforms. The two most important aspects of working with desktop video are: 1)Synchronizing, managing and playing movies and 2) aking the movies small enough to be stored and played properl.
In order to effectively handle these tasks, two special types of technology were developed:
Progressive Download vs. True Streaming
There are currently two common ways to deliver video over a network: “A progressive download” and “True streaming”. Both delivery methods are often simply called “streaming”, which can be confusing. In general, if a video is being broadcast live, or if a specialized media server or protocol is used (such as RTSP), the video is truly streaming. On the other hand, when an HTTP server is used, the file will be delivered by progressive download. “Progressive download” refers to online media which users may watch as the files are being downloaded. The user can see the part of the file that has downloaded at a given time, but cannot jump ahead to future portions that have not been transferred yet. Progressive download is especially useful for slower dial-up modem delivery of short pieces, because it allows one to create a movie with a higher data rate than a modem could play in real-time. While doing this causes the viewer some delay, it also allows presentation of a much higher quality movie. In addition, administration of progressive download material is much easier as it is placed on a standard HTTP or FTP server. In contrast, true streaming delivery always happens in realtime, and it is more suited for live events.
Based on the features comparison just described, we decided to standardize for the moment on the progressive download method for video delivery in order to accommodate the widest range of Internet access speeds. The NYSORA team can be criticized for requiring the latest software options (QuickTime 3 or 4 and RealTime 8) for the viewing of educational videos. However, from its very start in 1996, NYSORA is continuously looking into the future and has had to, at times, lock into proprietary non-backward compatible solutions for the sake of quality.
It is almost universally accepted that peripheral nerve blocks offer numerous advantages over the general and spinal/epidural anesthesia. When performed judiciously and skillfully, nerve blocks can facilitate fast-tracking, allow early mobilization, decrease hospital stay, reduce unanticipated hospital admission, and reduce health care costs at large. Similarly, with the rapidly expanding scope of ambulatory surgery, emergence of better nerve block techniques and equipment, and imminently pending development of substantially more flexible local anesthetics, nerve blocks are also rapidly becoming the anesthetic of choice for majority of patients undergoing ambulatory surgery. Because of these trends, it is imperative that the organized anesthesia societies continue to emphasize the teaching of peripheral nerve blocks.1 As the Internet makes its way into homes and operating rooms worldwide, advances in video, telecommunication and computing technologies offer an unprecedented possibility for online education in regional anesthesia. Numerous medical educational web sites are emerging as powerful online tools for a rapid access to needed medical information. Our own site monitoring tools have confirmed that the NYSORA website has already developed a group of regular visitors that browse our materials at length. We feel our site will continue to grow and educate as long we continue to routinely review, refocus, and redesign it utilizing current technologies. Our experience so far has taught us to embrace change in order to establish and maintain an effective robust educational environment on the Internet.