Benefits of simulation using standardized patients for training dermatology residents in breaking bad news.

INTRODUCTION: Simulation in healthcare is a rapidly developing teaching method in the training of technical procedures. It is also used to enable caregivers to learn how to inform patients of serious illness and complex health status. However, its use is not widespread in the field of dermatology. This study investigated the utility of simulation as regards disclosing melanoma diagnosis, taking resident physician satisfaction as a primary endpoint. MATERIALS AND METHODS: Fifteen dermatology residents were recruited as trainees. Four scenarios were allocated based on length of residency. An introductory briefing was held prior to the training sessions. Debriefing took place on completion of the diagnosis disclosure consultation. The participants completed questionnaires after the simulation session, after debriefing, and 3 months after the simulation session. The primary endpoint was usefulness of the session felt by trainees several months after the simulation. RESULTS: The majority of participants (93.3%) thought the session helped with stress management, improved their attitude and control over their reaction (86.6%), and improved their communication skills (100%). They rated the usefulness of the simulation at 7.79/10 on average (range: 5-10). DISCUSSION: According to our findings the resident physicians involved, particularly those with the least experience, were satisfied with this type of learning technique. Any difficulties encountered by these residents were brought to light and addressed during debriefing. CONCLUSION: There would appear to be real benefits to be reaped from simulation, whatever the stage of medical training at which it takes place. Simulation should become an increasingly important part of contemporary pregraduate specialty programs.

[Use of simulation in healthcare for therapeutic training of the parents of children with hereditary angioedema]. / Utilisation de la simulation en santé pour l'éducation thérapeutique des parents d'enfants souffrant d'un angio-œdème héréditaire.

BACKGROUND: C1INH-deficiency hereditary angioedema (HAE) is characterized by recurrent episodes of potentially severe oedema. Icatibant for SC injection will soon be approved for use in children and it is necessary to train parents in recognising severe episodes of AOH and in the technique for injection of icatibant. Simulation in healthcare (SH) is a set of educational methods for improving skills in a safe environment. We wished to assess the feasibility of a therapeutic training session (TTS) involving scripted scenarios for the parents of children with HAE. PATIENTS AND METHODS: The TTS session included pre- and post-training testing on AOH, two scenarios (calling emergency services for lingual AO; gastrointestinal AO) involving actors and a volunteer parent, a workshop for learning the SC injection technique, and a satisfaction questionnaire. We analysed the answers on the questionnaire and noted down parents' verbatim observations during debriefing sessions. RESULTS: Eight parents from 5 families took part in this session. Parents rated their overall satisfaction as 9.3/10. The parents commented that during the simulations, they felt "in the thick of it" and that they "experienced stress while viewing the scenes", thus attesting to the realism and relevance of the simulated scenarios. DISCUSSION: This session met the parents' expectations in terms of being able to cope and having adequate know-how, based on both the simulations and the level of knowledge acquired. The main limitation lay in the parents' difficulty in confronting certain situations reminiscent of traumatic past experiences. TTS shares many common features with SH for the parents of sick children. The place of the latter in TTS must be evaluated.

Skills improvement after observation or direct practice of a simulated laparoscopic intervention.

BACKGROUND: Laparoscopic skills are more and more often being learned on simulators. PURPOSE: To assess the respective roles of observation and direct practice in the retention of laparoscopic procedural skills. BASIC PROCEDURES: Twelve surgical residents were included in a two-session laparoscopic training course. During the first session (S1), one participant completed a cholecystectomy on the Simbionix LAPMentor™ and then observed his colleague carrying out a total hysterectomy and vice versa. During the second session (S2), each participant completed both interventions. Skills evaluation was assessed using the Objective Structured Assessment of Technical Skills (OSATS) global rating scale and LAPMentor™ metrics. MAIN FINDINGS: Mean OSATS score during the first session was 19.3±5.1, and increased by 37% in the group of former observer students (S2O, P=0.003), and by 54% in the group of former practising students (S2A, P=0.001). Self- and peer-grading results were concordant with the supervisor's evaluation. Detailed analysis of LAPMentor™ metrics showed a trend toward more parameters being improved in group S2A as compared to group S2O on both interventions. The most significant improvements concerned the time of completion for the hysterectomy and the efficiency of cautery for the cholecystectomy. CONCLUSIONS: Observation of laparoscopic skills still allows for surgical improvement, but direct practice on a virtual reality trainer provides better results. Self- and peer-grading were concordant with the supervisor's evaluation. This work may advocate the integration of both personal training on simulators and surgical observation into residents' surgical curricula.

[Training of medical students for pelvic examination: Benefits of teaching on anatomic models]. / Formation des externes à l'examen gynécologique : intérêt de l'enseignement sur modèles anatomiques.

OBJECTIVES: To evaluate the benefits of training sessions for pelvic examination using anatomic models. MATERIAL AND METHODS: The medical students (MS) registered in their 5th year of medical studies at Angers University Hospital had to complete two anonymous questionnaires; one at the beginning of the workshop and one at the end. Every procedure which included pelvic exam (PE), vaginal sample (VS), smear test (ST), insertion of a speculum and insertion of intra-uterine device (IUD) was evaluated. RESULTS: Seventy-one MS answered both questionnaires. They were very satisfied or satisfied with the outcomes of the workshop in 91 % of the cases. At the beginning of the workshop, 28 %, 52 %, 30 %, 25 % and 3 % reported a low level of difficulty to carry out, respectively, a PE, VS, ST, insertion of a speculum, insertion of an IUD. At the end of the session, there were respectively 55 %, 83 %, 76 %, 66 % and 16 % of MS to report a low level of difficulty of these same procedures. For all of these procedures, there were a significant (P<0.05) number of MS who estimated the procedure's level of difficulty as being low at the end of the session. CONCLUSION: The level of technical difficulty of all procedures was significantly decreased at the end of the workshop.

[Simulation training: a pilot-study on reception of parents in a pediatric intensive care unit]. / Formation par la simulation : étude-pilote sur l'accueil des parents par une équipe de réanimation pédiatrique.

BACKGROUND: Simulation training is gradually being integrated into the curriculum for caregivers in intensive care units. There are few training programs on communication with families. GOAL: This pilot-study evaluated the impact of a training protocol on professional practices including a protocol for the reception of the parents of a child admitted to a pediatric intensive care unit. MATERIALS AND METHODS: The training program lasted 3 months and included three parts: a theoretical contribution, a simulation session with debriefing, and a focus group. During the simulation session, a multi-professional team of three healthcare providers (physician, nurse, assistant nurse) must apply a protocol for the reception of the parents of a child who had just been admitted. The protocol lasted 35 min and included three sequences: reception and dressing by the assistant nurse, medical meeting conducted by the physician and the nurse, support of the parents in the room by the nurse and the assistant nurse. The child was simulated by a manikin (SimBaby™, Laerdal) and the parents were prepared actors. The main objective of the pilot-study was to measure the rate of change in professional practices 1 year after the end of training. RESULTS: One year later, all healthcare providers (n=15) declared they had changed their professional practices and felt that half of these changes were due to the pilot-study. New practices such as receiving parents in pairs in a dedicated room or managing a short interview with the parents before supporting the child were applied "always" or "if possible". CONCLUSION: The pilot-study showed that the training program induced half of the changes of professional practices for welcoming the parents of a child admitted to pediatric intensive care unit 1 year later.

[Declarative survey about postpartum haemorrhage management by anaesthesiologists in Pays de la Loire area (France): what's the adherence to clinical practice guidelines?]. / Enquête déclarative sur la prise en charge anesthésique des hémorragies du post-partum dans la région Pays de la Loire: quelle adhésion aux recommandations pour la pratique clinique?

OBJECTIVE: To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area. METHODS: A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP". RESULTS: Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much. CONCLUSION: Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.

[Simulation in healthcare in North America: update and evolution after two decades]. / La simulation en santé en Amérique du Nord: état actuel et évolution après deux décennies.

OBJECTIVE: Update on simulation-based education and its evolution in North America. DATA SOURCES: Main articles including those published within the last five years and indexed in Medline, and unpublished data from the Royal College of Physicians and Surgeons of Canada have been analyzed. DATA SYNTHESIS: After a review of historical development of simulation in North America, this article draw the place of simulation in healthcare, for medical education, research and assessment. Funding and accreditation of simulation centres are also discussed. CONCLUSION: Simulation is fully integrated in healthcare in North America and represents one of the main elements for healthcare professional education. Simulation is also a symbol of excellence for health and teaching institutions. The evolution of simulation in North America is likely to inform the future of simulation in France.

Managing unforeseen events in anesthesia: collective trade-off between "understanding" and "doing".

This study aims to describe how anesthesia teams handle unforeseen events that may affect the patients' health. More precisely, it investigates the mechanisms of decisions made by anesthesia teams to manage unthought-of situations, i.e. situations that have not been foreseen as "possible" ones before their occurrence. An empirical study, based on the analysis of simulated situations, was conducted in a pediatric anesthesia service of a university hospital in France. The results highlighted three ways of managing unthought-of situations (determined management, cautious management and overwhelmed management). They support the hypothesis of a collective cognitive trade-off, whereby teams would behave as virtual operators, with their own collective trade-off between "understanding" and "doing". The discussion of the results questions the assessment criteria, the safety perspectives we adopt and the possible ways to improve the management of unforeseen situations.

[Use of the Airtraq by inexperienced physicians supervised during a series of tracheal intubation in adult patient with anticipated difficult airway]. / Utilisation de l'Airtraq par des praticiens inexpérimentés supervisés pour une série de patients adultes prévus difficiles à intuber.

INTRODUCTION: The Airtraq optical laryngoscope (Vygon, Écouen, France) is a new intubation device designed to provide a view of the glottis without alignment of the oral, pharyngeal and laryngeal axes. In recent literature, the efficiency of the Airtraq even in difficult intubation and its short learning curve were characterized. The goal of our study is to evaluate Airtraq efficiency when use by inexperienced physicians in anticipated difficult intubation adult patients. METHODS: The patients showing at least one of the four difficult intubation predictors (history of difficult intubation, thyromental distance less than 60mm, mouth opening less than 35 mm and Mallampati class 3 or 4 were included. Before induction of anaesthesia, the inexperienced physicians participating the study received a short oral formation on the use of the Airtraq. For each intubation manoeuvres, the participant were supervised by an expert in Airtraq handling. The Cormack and Lehane grade of direct laryngoscopy view, the duration times to best glottis view and to intubate the trachea, the success or failure of tracheal intubation, the drop in arterial oxygen saturation of below 95%, the need for external manipulation, and the difficulties met by the operators were noted. RESULTS: Twenty patients were included over a month period. Thirteen had a history of difficult intubation, eight a thyromental distance less than 60mm, nine a mouth opening less than 35 mm and 12 patients were classified as Mallampati IV. The success rate of tracheal intubation with the Airtraq laryngoscope was 80%. Times to best glottis view and to complete tracheal intubation were 28 and 47 s, respectively. Four tracheal intubation failures were encountered. The LMA Fastrach and the flexible fiberoscope were used respectively in one and three patients. DISCUSSION: In the majority of the cases, the insertion of the Airtraq, the visualization of the glottis and the subsequent intubation were easy and rapid, without arterial oxygen desaturation. However, the four tracheal intubation failures associated with prolonged tracheal intubation times in some patients highlight the fact that the Airtraq laryngoscope requires a clinical training process particularly in case of anticipated difficult airway management situations.

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study.

BACKGROUND: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia. METHODS: In this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded. RESULTS: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8+/-11.6, lidocaine 12.4+/-9.7; and saline 16.2+/-11.5, P=0.08). CONCLUSION: For the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.

[Medical paediatric simulation: a European survey]. / Enquête européenne sur la pratique de la simulation médicale pédiatrique.

OBJECTIVE: To present the effective applications of paediatric medical simulation in terms of education, evaluation, density, development, goals and constraints. STUDY DESIGN: Survey realized within 38 paediatric simulation centres (PSC) in Europe, identified by Web search and through the Society in Europe for Simulation Applied to Medicine (SESAM. RESULTS: Twenty centers answered the questionnaire (52%). Ninety-four percent of the PSC had beforehand acquired an experience of adult medical simulation, 94.6% of the PSC were created before 2006. Ninety percent of the PSC owned at least one high-fidelity pediatric simulator. The 80% of the PSC indicated multiple funding sources. Eighty percent of the PSC had at least one specific instructor for the paediatric simulation (average=2.7 paediatric instructors per centre). The PCS reported to get onto various topics: neonatology (25% of the PCS), prehospital medicine (36.8%), paediatric anaesthesiology (74%) and paediatric intensive care (89%). Simulation allowed 70% of the centers to lead some research project. Ninety-five percent of the centers agreed about an European collaboration on research projects or about the mutualization of the created scenarios. CONCLUSION: The material, financial and human means of the interviewed centres are consequential but heterogeneous in Europe. MSP offers numerous and various application fields and generates some research activity.

[Night cardiac rhythm and conduction disturbances revealing obstructive sleep apnoea syndrome]. / Trouble de conduction atrioventriculaire paroxystique nocturne révélant un syndrome d'apnée du sommeil.

There is a strong prevalence of sleep apnoea syndrome in general population. Cardiac arrhythmia and conduction disturbances during sleep may complicate this syndrome. We report the case of a 73-year-old patient to whom the sleep apnoea syndrome was diagnosed after varied heart blocks during the sleep. A treatment by continuous positive airway pressure (CPAP) permitted to correct these conduction disturbances and to avoid pacemaker implantation.

[Delayed evaluation of continuous medical education]. / Evaluation à distance d'une action de formation médicale continue.

OBJECTIVES: To analyse the results of delayed evaluation of European teaching sessions using a questionnaire provided by the French College of Anaesthesiologists. STUDY DESIGN: Open evaluation. MATERIAL: Questionnaires were completed 3-6 months after European courses provided in November-December 1999. METHOD: The types of professional exercise and the medical practice as well as the theme of the courses were pointed out. The evaluation included six items noted from 1 to 10: usefulness of the abstract book, discussion with colleagues, discussion with a manager, decision to modify medical practice, application of that decision, own objectives fulfilled. The global mean score for each item was calculated. Results were compared according to the professional mode of exercise and the theme of the course. RESULTS: 5/7 centres provided information. 91/239 questionnaires were returned to the organizers. The participants were working in different structures (private clinic: 25, university hospital: 31, general hospital: 27, PSPH: 8). The main exercise was anaesthesiology (75/77 answers). Means scores affected to the different items were around 7 for all but one of them. The mean score concerning discussion with a manager was significantly decreased to 3.5 +/- 3.2. Decision to modify their own practise was higher in private clinics compared to PSPH. The abstract book was more consulted after the first course (respiration and thorax). CONCLUSION: 3-6 months following the FEEA courses the participants thought to have fulfil their objectives and declared to have modify their medical practise. The lack of discussion with a manager should be analysed.

Nine cases of foodborne botulism type B in France and literature review.

Presented here is an outbreak of nine cases of type B botulism that occurred in France in 2000 followed by a review of the relevant literature. The outbreak resulted from the consumption of home-canned asparagus and required the intubation of six patients. Despite complications, all patients recovered completely. Specific antitoxin treatment was not administered because it is no longer manufactured in France. The literature review covers the epidemiologic data reported from Europe and the USA to date and an assessment of the treatment options for botulism. The usefulness of establishing a European network to provide access to botulism antitoxins is discussed. Although their efficacy is not unanimously accepted, they remain the only specific treatment now known.

[Intestinal gas explosion during operation: a case report]. / Explosion peropératoire de gaz intestinaux: à propos d'un cas.

A case of intestinal gas explosion during the course of carcinologic surgery in a 51-year-old patient is reported. This accident, often dramatic, has become exceptional since the use of mannitol for colonic preparation has disappeared. This incident occurred during the course of a total pelvic exenteration performed under general anaesthesia with inhalation of both a mixture oxygen-nitrous oxide and volatile agents. The colon incision with an electrocautery was contemporaneous with a violent deflagration accountable for organic lesions. This case report reminds us that the risk of a dangerous explosion persists in relation with surgical, anaesthetic and individual risk factors.