A paediatric radiology themed escape room session and 8-question single best answer (SBA) test was devised by the senior author (S.S.), a paediatric radiologist (10 years of radiology experience, 5 in paediatric radiology). Both the SBA test and escape room were constructed with specific learning objectives in mind, mapped to outcomes from the Royal College of Radiologists (RCR) [20 ] and European Society for Radiologists (ESR) [21 ] undergraduate radiology curriculums. These objectives included delivering knowledge on (1) radiation protection, (2) fracture detection on paediatric radiography and (3) emergency findings on paediatric chest radiographs (e.g. consolidation, pneumomediastinum, pneumothorax) (see Additional file 1: Figure A1). A copy of the SBA test, with answers in the caption, is also provided in Additional file 1: Figure A2.
The escape room consisted of four radiological ‘puzzles’ (relating to the objectives above), that could be solved in any order (Figs. 1, 2, 3 and 4). After solving each of these puzzles, a three-number combination code would be revealed allowing participants to unlock one of four tin containers in the room (Fig. 5). Within each container was a note, upon which a single number and crossword clue were written. Only by unlocking all four containers (i.e. by solving all four puzzles) could the combination of numbers on the notes provide a code to unlock a briefcase containing a crossword puzzle. In order to ‘unlock’ the room, participants would need to solve the crossword to reveal a secret word, which they shout in unison in order to escape (Fig. 6). A layout of the room is shown in Fig. 7.

‘Read the signs’: an example of one of the puzzles in the escape room. a A poster detailing three different paediatric radiographs with abnormalities is placed on one of the walls of the room. The students need to find a hidden folder of ‘radiology signs’ somewhere in the room containing 20 different imaging signs and match the images on the poster to that in the folder to solve the three number combination code. b An example of one of the pages in the clear plastic presentation folder matching the second image on the poster. In this example, the second number for the combination code would be ‘3’

‘Location, location, location’: another example of a puzzle in the escape room. The participants need to identify whether a chest radiograph is normal or abnormal. If abnormal, then the location of the consolidation should be determined and matched to the number code given in the box in the bottom left corner of the poster. For example, in this game, the three number combination is 2, 6 and 1

‘Diagnose Doctor Perry Osteum’: another example of a puzzle in the escape room. a A poster of various body parts some with and some without fractures are shown. The participants need to identify which bones have an abnormality and match it to the (b) large paper skeleton in the other corner of the room. This skeleton has numbers written on every bone, and only by correlating the correct bone and laterality can the students resolve the three-number combination. In this example, the bones to be interrogated on the skeleton would be the distal right radius, posterior right ribs and proximal left tibia

‘Radiation dosages’ puzzle: In this puzzle (a) the patient scenarios are placed on the wall, with a list of (b) radiation dosages on another wall, based on the WHO 2016 publication, ‘Communicating radiation risks in paediatric imaging’ [27 ]. Students are required to calculate the radiation dosages from the different radiology modalities and examinations to solve the three-number combination. In this example, the combination code was 0, 3 and 2

Equipment in the escape room. a The equipment on the central desk included a copy of the escape room rules, the kitchen timer to time the participants (yellow arrow), the four tin containers (white arrow) which were each locked with a three-number combination lock and contained a note for the final crossword puzzle, and clues on how to unlock the briefcase containing the puzzle (dashed white arrow). Photo frames containing images of Roentgen and an early example of a hand radiograph were not part of the escape room puzzles, and only placed on the table for decoration. b All the equipment was easily transportable between teaching sites within a single carry bag

Crossword puzzle. a This image demonstrates the four different notes that were contained within the four containers shown in Fig. 5. They provide clues to the crossword puzzle (b). The answers to the crossword are 1—RED DOT; 2—FRONT; 3—THYMIC; 4—CANCER. The escape room word was ‘ROENTGEN’

The layout of the escape room. The puzzles listed in Figs. 1, 2, 3 and 4 are colour coded in this image. Those with more than one component are intentionally placed on opposite sides of the room to force students to interact with each other and communicate findings. The escape room rules read to students prior to the activity had already informed them that removing posters from the wall or use of mobile phones was not allowed

Prior to running the undergraduate teaching session, a ‘practice run’ was piloted on two paediatric radiology fellows active in undergraduate teaching (J.B., L.R.—each with 6 years of radiology experience and 1 year paediatric radiology) to identify errors in the design, feedback on level of difficulty and to inform estimated time required to complete the puzzles. Both radiology fellows were blinded to the escape room design prior to the practice run.
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