The effects of bystander interventions for foreign body airway obstruction on survival and neurological outcomes: Findings of the MOCHI registry.

INTRODUCTION: Foreign body airway obstruction (FBAO) is a life-threatening condition. We aimed to quantify the impact of bystander FBAO interventions on survival and neurological outcomes. METHODS: We conducted a Japan-wide prospective, multi-center, observational study including all FBAO patients who presented to the Emergency Department from April 2020 to March 2023. Information on bystander FBAO interventions was collected through interviews with emergency medical services personnel. Primary outcomes included 1-month survival and favorable neurologic outcome defined as Cerebral Performance Category 1 or 2. We performed a multivariable logistic regression and a Cox proportional hazards modeling to adjust for confounders. RESULTS: We analyzed a total of 407 patients in the registry who had the median age of 82 years old (IQR 73-88). The FBAO incidents were often witnessed (86.5%, n = 352/407) and the witnesses intervened in just over half of the cases (54.5%, n = 192/352). The incidents frequently occurred at home (54.3%, n = 221/407) and nursing home (21.6%, n = 88/407). Common first interventions included suction (24.8%, n = 101/407) and back blow (20.9%, n = 85/407). The overall success rate of bystander interventions was 48.4% (n = 93/192). About half (48.2%, n = 196/407) survived to 1-month and 23.8% patients (n = 97/407) had a favorable neurological outcome. Adjusting for pre-specified confounders, bystander interventions were independently associated with survival (hazard ratio, 0.55; 95% CI, 0.39-0.77) and a favorable neurological outcome (adjusted OR, 2.18; 95% CI, 1.23-3.95). CONCLUSION: Bystander interventions were independently associated with survival and favorable neurological outcome, however, they were performed only in the half of patients.

Ambulance Traffic Crashes in Japan: Characteristics of Casualties and Efforts to Improve Ambulance Safety.

BACKGROUND: An ambulance traffic crash not only leads to injuries among emergency medical service (EMS) professionals but also injures patients or their companions during transportation. We aimed to describe the incidence of ambulance crashes, seating location, seatbelt use for casualties (ie, both fatal and nonfatal injuries), ambulance safety efforts, and to identify factors affecting the number of ambulance crashes in Japan. METHODS: We conducted a nationwide survey of all fire departments in Japan. The survey queried each fire department about the number of ambulance crashes between January 1, 2017, and December 31, 2019, the number of casualties, their locations, and seatbelt usage. Additionally, the survey collected information on fire department characteristics, including the number of ambulance dispatches, and their safety efforts including emergency vehicle operation training and seatbelt policies. We used regression methods including a zero-inflated negative binomial model to identify factors associated with the number of crashes. RESULTS: Among the 726 fire departments in Japan, 553 (76.2%) responded to the survey, reporting a total of 11,901,210 ambulance dispatches with 1,659 ambulance crashes (13.9 for every 100,000 ambulance dispatches) that resulted in a total of 130 casualties during the 3-year study period (1.1 in every 100,000 dispatches). Among the rear cabin occupants, seatbelt use was limited for both EMS professionals (n = 3/29, 10.3%) and patients/companions (n = 3/26, 11.5%). Only 46.7% of the fire departments had an internal policy regarding seatbelt use. About three-fourths of fire departments (76.3%) conducted emergency vehicle operation training internally. The output of the regression model revealed that fire departments that conduct internal emergency vehicle operation training had fewer ambulance crashes compared to those that do not (odds of being an excessive zero -2.20, 95% CI: -3.6 to -0.8). CONCLUSION: Two-thirds of fire departments experienced at least one crash during the study period. The majority of rear cabin occupants who were injured in ambulance crashes were not wearing a seatbelt. Although efforts to ascertain seatbelt compliance were limited, Japanese fire departments have attempted a variety of methods to reduce ambulance crashes including internal emergency vehicle operation training, which was associated with fewer ambulance crashes.

Five Domains of a Conceptual Framework of Continuing Professional Development.

ABSTRACT: Continuing professional development (CPD) for health professionals involves efforts at improving health of individuals and the population through educational activities of health professionals who previously attained a recognized level of acceptable proficiency (licensure). However, those educational activities have inconsistently improved health care outcomes of patients. We suggest a conceptual change of emphasis in designing CPD to better align it with the goals of improving health care value for patients through the dynamic incorporation of five distinct domains to be included in learning activities. We identify these domains as: (1) identifying, appraising, and learning new information [New Knowledge]; (2) ongoing practicing of newly or previously acquired skills to maintain expertise [New Skills and Maintenance]; (3) sharing and transfer of new learning for the health care team which changes their practice [Teams]; (4) analyzing data to identify problems and drive change resulting in improvements in the health care system and patient outcomes [Quality Improvement]; and (5) promoting population health and prevention of disease [Prevention]. We describe how these five domains can be integrated into a comprehensive conceptual framework of CPD, supported by appropriate learning theories that align with the goals of the health care delivery system. Drawing on these distinct but interrelated areas of CPD will help organizers and directors of learning events to develop their activities to meet the goals of learners and the health care system.

Food choking incidents in the hospital: Incidents, characteristics, effectiveness of interventions, and mortality and morbidity outcomes.

AIM: Foreign body airway obstruction (FBAO) due to food can occur wherever people eat, including in hospitals. We characterized in-hospital FBAO incidents and their outcomes. METHODS: We searched the Japan Council for Quality Health Care nationwide in-hospital adverse events database for relevant events from 1,549 institutions. We included all patients with FBAO incidents due to food in the hospital from January 2010 to June 2021 and collected data on the characteristics, interventions, and outcomes. FBAO from non-food materials were excluded. Our primary outcomes were mortality and morbidity from FBAO incidents. RESULTS: We identified 300 patients who had a FBAO incident from food. The most common age group was 80-89 years old (32.3%, n = 97/300). One-half (50.0%, n = 150/300) were witnessed events. Suction was the most common first intervention (31.3%, n = 94/300) and resulted in successful removal of foreign body in 17.0% of cases (n = 16/94). Back blows (16.0%, n = 48/300) and abdominal thrusts (8.1%, n = 24/300) were less frequently performed as the first intervention and the success rates were 10.4% (n = 5/48) and 20.8% (n = 5/24), respectively. About one-third of the patients (31%, n = 93/300) died and 26.7% (n = 80/300) had a high potential of residual disability from these incidents. CONCLUSION: FBAO from food in the hospital is an uncommon but life-threatening event. The majority of patients who suffered from in-hospital FBAO incidents did not receive effective interventions initially and many of them died or suffered residual disability.

Driving Ambulances Safely: Findings of Ten Years of Japanese Ambulance Crash Data.

OBJECTIVE: Rules and regulations for ambulance operations differ across countries and regions, however, little is known about ambulance crashes outside of the United States. Japan is unique in several aspects, for example, routine use of lights and sirens during response and transport regardless of the urgency of the case and low speed limits for ambulances. The aim of this study was to describe the incidence and characteristics of ambulance crashes in Japan. METHODS: We retrospectively analyzed data from the Institute for Traffic Accident Research and Data Analysis (ITARDA) that include all traffic crashes resulting in injury or death in Japan. The study included all ambulance crashes from 2009 to 2018. We compared crashes that occurred during emergency operations with lights and sirens (i.e., when responding to a call or transporting a patient) to those that occurred during non-emergency operations without lights or sirens. We also used data on total number of ambulance dispatches from the Japanese Fire and Disaster Management Agency to calculate ambulance crash risk. RESULTS: During the 10-year period, we identified a total of 486 ambulance crashes out of 59,208,761 ambulance dispatches (0.82 in every 100,000 dispatches or one crash for every 121,829 dispatches) that included two fatal crashes. Among all ambulance crashes, 142 (29.2%) occurred during emergency operations. The incidence of ambulance crashes decreased significantly over the 10-year period. Ambulance crashes at an intersection occurred more frequently during emergency operations than during non-emergency operations (72.5% vs. 58.1%; 14.4% difference, 95% CI 5.0-22.9). CONCLUSIONS: Ambulance crashes occurred infrequently in Japan with crash rates much lower than previously reported crash rates in the United States. Ambulance crashes during emergency operations occurred more frequently at intersections compared to non-emergency operations. Further investigation of the low Japanese ambulance crash rates could provide opportunities to improve ambulance safety in other countries.

How Academic Medicine Can Amplify Truth Amid the Noise of Misinformation, Inaccuracies, and Lies.

Inaccurate statements and lies from public figures and political and government leaders have the power to exacerbate dangerous upheavals in our political, health care, and social environments. The widespread misinformation, inaccuracies, and lies about the COVID-19 pandemic (about the origin of the virus, the severity of illness, vaccination, and "cures," to name a few) illustrate the potentially disastrous consequences of false information. Academic medicine must recognize the dangers of such lies and inaccuracies, particularly those related to health, and must understand their sources in traditional and social media and how and why many in the public accept them. Academic health professionals have a unique responsibility to promote and defend the truth in medicine and science, help the public to understand the sources of inaccurate scientific information, and find ways to debunk falsehoods spread by politicians and media outlets. Inaccurate information and lies have threatened the health of the population, the function of health systems, and the training of the future health workforce. They must be combatted by truth telling through scholarly work, clinical activities, and educating health professions trainees at all levels. Academic medicine's institutions should also consider joining the communities they serve and their medical specialty organizations to engage in political advocacy whenever possible. Health professions journals have an important role in highlighting and clarifying important topics and sustaining conversations on them within the academic medicine community. Across all its missions and activities, academic medicine must do its best to combat today's poisonous misinformation, inaccuracies, and lies, and to enter the larger social and political struggles that will determine the health of society and the future.

CT imaging of extraglottic airway device-pictorial review.

Compared to intubation with a cuffed endotracheal tube, extraglottic airway devices (EGDs), such as laryngeal mask airways, are considered less definitive ventilation conduit devices and are therefore often exchanged via endotracheal intubation (ETI) prior to obtaining CT images. With more widespread use and growing comfort among providers, reports have now described use of EGDs for up to 24 h including cases for which clinicians obtained CT scans with an EGD in situ. The term EGD encompasses a wide variety of devices with more complex structure and CT appearance compared to ETI. All EGDs are typically placed without direct visualization and require less training and time for insertion compared to ETI. While blind insertion generally results in functional positioning, numerous studies have reported misplacements of EGDs identified by CT in the emergency department or post-mortem. A CT-based classification system has recently been suggested to categorize these misplacements in six dimensions: depth, size, rotation, device kinking, mechanical blockage of the ventilation opening(s), and injury from EGD placement. Identifying the type of EGD and its correct placement is critically important both to provide prompt feedback to clinicians and prevent inappropriate medicolegal problems. In this review, we introduce the main types of EGDs, demonstrate their appearance on CT images, and describe examples of misplacements.

Extraglottic Airway Device Misplacement: A Novel Classification System and Findings in Postmortem Computed Tomography.

STUDY OBJECTIVE: Extraglottic airway devices are frequently used during cardiac arrest resuscitations and for failed intubation attempts. Recent literature suggests that many extraglottic airway devices are misplaced. The aim of this study is to create a classification system for extraglottic airway device misplacement and describe its frequency in a cohort of decedents who died with an extraglottic airway device in situ. METHODS: We assembled a cohort of all decedents who died with an extraglottic airway device in situ and underwent postmortem computed tomographic (CT) imaging at the state medical examiner's office during a 6-year period, using retrospective data. An expert panel developed a novel extraglottic airway device misplacement classification system. We then applied the schema in reviewing postmortem CT for extraglottic airway device position and potential complications. RESULTS: We identified 341 eligible decedents. The median age was 47.0 years (interquartile range 32 to 59 years). Out-of-hospital personnel placed extraglottic airway devices in 265 patients (77.7%) who subsequently died out of hospital; the remainder died inhospital. The classification system consisted of 6 components: depth, size, rotation, device kinking, mechanical blockage of ventilation opening, and injury. Under the system, extraglottic airway devices were found to be misplaced in 49 cases (14.4%), including 5 (1.5%) that resulted in severe injuries. CONCLUSION: We created a novel extraglottic airway device misplacement classification system. Misplacement occurred in greater than 14% of cases. Severe traumatic complications occurred rarely. Quality improvement activities should include review of extraglottic airway device placement when CT images are available and use the classification system to describe misplacements.

COVID-19: Lessons From the Disaster That Can Improve Health Professions Education.

COVID-19 has disrupted every aspect of the U.S. health care and health professions education systems, creating anxiety, suffering, and chaos and exposing many of the flaws in the nation's public health, medical education, and political systems. The pandemic has starkly revealed the need for a better public health infrastructure and a health system with incentives for population health and prevention of disease as well as outstanding personalized curative health. It has also provided opportunities for innovations in health care and has inspired courageous actions of residents, who have responded to the needs of their patients despite risk to themselves. In this Invited Commentary, the author shares lessons he learned from 3 earlier disasters and discusses needed changes in medical education, health care, and health policy that the COVID-19 pandemic has revealed. He encourages health professions educators to use the experiences of this pandemic to reexamine the current curricular emphasis on the bioscientific model of health and to broaden the educational approach to incorporate the behavioral, social, and environmental factors that influence health. Surveillance for disease, investment in disease and injury prevention, and disaster planning should be basic elements of health professions education. Incorporating innovations such as telemedicine, used under duress during the pandemic, could alter educational and clinical approaches to create something better for students, residents, and patients. He explains that journals such as Academic Medicine can provide rapid, curated, expert advice that can be an important counterweight to the misinformation that circulates during disasters. Such journals can also inform their readers about new training in skills needed to mitigate the ongoing effects of the disaster and prepare the workforce for future disasters.