Medical Simulation Training

From the New York Times:

Medical simulation training, which is similar to that used in aviation and in the military, uses mannequins, computers, virtual reality or actors posing as patients to teach doctors, nurses and other clinicians. While simulation training has been used in medicine for nearly 40 years, it has until recently been limited primarily to teaching standard techniques like chest compressions in cardiopulmonary resuscitation or pelvic exams.

But over the last few years, as the technology and training techniques have advanced, experts in the field have begun to broaden the scope of training. No longer confined to isolated procedures, simulation can now recreate entire clinical situations, giving clinicians the opportunity to develop skills in what is often identified as one of the major causes of errors and quality issues in health care: poor teamwork and communication.

Cardiac Arrest: Drug, then Shock or Shock, then Drug?

From Resuscitation:

Increase in pre-shock pause caused by drug administration before defibrillation: An observational, full-scale simulation study

Background: The importance of circulation during cardiopulmonary resuscitation has led to efforts to decrease time without chest compressions (“no-flow time”). The no-flow time from the interruption of chest compressions until defibrillation is referred to as the “pre-shock pause”. A shorter pre-shock pause increases the chance of successful defibrillation. It is unclear whether drug administration affects the length of the pre-shock pause. Our study compares pre-shock pause with and without drug administration in a full-scale simulation.

Methods: This was an observational study in an ambulance including 72 junior physicians and a cardiac arrest scenario. Data were extracted by reviewing video recordings of the resuscitation. Sequences including defibrillation and/or drug administration were identified and assigned to one out of four categories: Defibrillation only (DC-only) and drug administration just prior to defibrillation (Drug+DC) for which the pre-shock pause was calculated, and drug administration alone (Drug-only) for which pre-drug time was calculated.

Results: DC-only sequences were identified in 68/72 simulations, Drug+DC in 24/72, and Drug-only in 33/72. Median pre-shock pauses were 18s (DC-only) and 32 (Drug+DC), and median pre-drug pause 6. The variation between pauses was statistically significant (p≪0.001). DC-only and Drug+DC sequences was found in 22/72 simulations. A statistically significant difference of 8s was found between the median pre-shock pauses: 17s (DC-only) and 25 (Drug+DC) (p≪0.001). For un-paired observations, the pre-shock pause increased with 78% and for paired observations 47%.

Conclusions: Drug administration prior to defibrillation was associated with significant increases in pre-shock pauses in this full-scale simulation study.

Prehospital Portable Ultrasound

From the Journal of Emergency Medicine:

Portable Ultrasound for Remote Environments, Part II: Current Indications

Background: With recent advances in ultrasound technology, it is now possible to deploy lightweight portable imaging devices in the field. Techniques and studies initially developed for hospital use have been extrapolated out of the hospital setting in a wide variety of environments in an effort to increase diagnostic accuracy in austere or prehospital environments. Objectives: This review summarizes current ultrasound applications used in out-of-hospital arenas and highlights existing evidence for such use. The diversity of applications and environments is organized by indication to better inform equipment selection as well as future directions for research and development. Discussion: Trauma evaluation, casualty triage, and assessment for pneumothorax, acute mountain sickness, and other applications have been studied by field medical teams. A wide range of outcomes have been reported, from alterations in patient care to determinations of accuracy compared to clinical judgment or other diagnostic modalities. Conclusions: The use of lightweight portable ultrasound shows great promise in augmenting clinical assessment for field medical operations. Although some studies of diagnostic accuracy exist in this setting, further research focused on clinically relevant outcomes data is needed.

EMCrit Podcast 18 – The Infamous Awake Intubation Video

From EMCrit, via The Central Line:

Awake intubation can save your butt!

It requires forethought and humility–you must be able to say to yourself, “I am not sure I will be able to successfully intubate this patient.” However, the payoff for this thought process is enormous. You can attempt an intubation on a difficult airway with very few downsides. If you get it, you look like a star, if you don’t you have not made the situation worse.

Two of my critical care resident specialists, Raghu Seethala and Xun Zhong, volunteered to intubate each other awake. The purpose of this was to let them gain experience, understand what their patients would feel during the procedure, and to prove that awake intubation can be done without complicated nerve block injections or fragile equipment, such as a bronchoscope.

Demographics will alter healthcare staffing

From Modern Healthcare:

Despite all the ongoing efforts to expand the healthcare workforce, industry experts say it’s time for employers to realize that demographic trends are not going to allow them to maintain their existing staffing patterns in coming decades,according to a new American Hospital Association study.

If current trends persist, researchers project workforce shortfalls of 109,600 physicians by 2020, and of 260,000 full-time-equivalent nurse positions by 2025—during a time when many other major U.S. industries will also be experiencing labor shortfalls. A new report from the AHA, Workforce 2015: Strategy Trumps Shortage, says hospitals need to find ways to retain their existing workforces while attracting newly educated workers.

Do Additional Views Improve the Diagnostic Performance of Cervical Spine Radiography in Pediatric Trauma?

From the Journal of Roentgenology:

OBJECTIVE. The aims of this study were to measure the diagnostic performances of lateral views alone and multiple radiographic views of the cervical spine in comparison with MDCT scans in pediatric trauma and to determine whether evaluation of additional views, in relation to lateral views alone, improves the performance of radiography.

MATERIALS AND METHODS. Retrospective analysis of cervical spine radiographs of 234 pediatric patients (age range, 3 months–17 years 11 months) who had been seen in our pediatric emergency department during the period of 2000–2005 for evaluation after acute trauma was performed. All patients underwent cervical spine MDCT examination at the same presentation. Radiographs were evaluated for the presence of fractures, subluxations, and dislocations. Radiographic abnormalities were correlated to findings on MDCT, which was used as the reference standard.

RESULTS. Twenty-two patients had positive findings on CT: Atlantooccipital subluxation/dislocation was seen in one patient; C1 ring fracture, in three patients; C1–C2 rotatory subluxation, in one; C1–C2 subluxation/dislocation, in one; odontoid fracture, in two; vertebral body wedge fracture, in six; posterior arch fracture dislocation, in 10; and spinous process fracture, in none. The lateral view radiograph alone had 73% sensitivity (95% CI, 50–89%) and 92% specificity (95% CI, 87–95%) for cervical spine abnormalities compared with MDCT. The addition of other views did not change the sensitivity of radiography but rather marginally decreased its specificity to 91% (95% CI, 86–94%).

CONCLUSION. Lateral view radiographs had a borderline acceptable sensitivity to cervical spine abnormalities in pediatric patients compared with MDCT. The addition of other radiographic views did not seem to improve the diagnostic performance of radiography.