Exposure to a Virtual Reality Mass-Casualty Simulation Elicits a Differential Sympathetic Response in Medical Trainees and Attending Physicians.

BACKGROUND: Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario. METHODS: An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch's t-test, and multivariate logistic regression were performed with statistical significance established at P <.05. RESULTS: Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030). CONCLUSIONS: Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

Simulation Training for In-Flight Medical Emergencies Improves Provider Knowledge and Confidence.

INTRODUCTION: In-flight medical emergencies require healthcare providers to operate in confined spaces with limited resources and delayed access to definitive care. These emergencies are common, with an estimated frequency of 1 per 100 to 1000 flights. Despite this, training for medical response in these environments is limited. We hypothesize that integrating such education into a pre-existing medical student elective course would improve knowledge and ability to respond appropriately to in-flight medical emergencies.METHODS: The available literature surrounding in-flight medical emergencies was reviewed. Syncope, respiratory distress, allergic reaction, and cardiac arrest were identified as common and potentially life-threatening complaints. Simulation cases were designed for each of these complaints and a simulation room was modified to mimic an airplane cabin. These simulation cases and accompanying relevant didactic lectures were incorporated into an existing wilderness and extreme environmental medicine course, with multiple-choice tests completed by the students at the beginning and end of the 2-wk course.RESULTS: Participating in this study were 18 students. The pretest average was 76%, which improved to 87% on the posttest. Qualitative feedback regarding this type of training was overwhelmingly positive.DISCUSSION: Simulation-based training for in-flight medical emergencies can significantly improve medical students' knowledge. This training was very well received by the students. Opportunities for training to manage in-flight medical emergencies remain limited; incorporating such training into existing curricula could provide a means by which to improve provider knowledge. Such a curriculum could be adapted for use by flight crews and other populations.Padaki A, Redha W, Clark T, Nichols T, Jacoby L, Slivka R, Ranniger C, Lehnhardt K. Simulation training for in-flight medical emergencies improves provider knowledge and confidence. Aerosp Med Hum Perform. 2018; 89(12):1076-1079.

Effects of designated leadership and team-size on cardiopulmonary resuscitation: The Basel-Washington SIMulation (BaWaSim) trial.

OBJECTIVE: During cardiopulmonary resuscitation (CPR), it remains unclear whether designating an individual person as team leader compared with emergent leadership results in better team performance. Also, the effect of CPR team size on team performance remains understudied. METHODS: This randomized-controlled trial compared designated versus emergent leadership and size of rescue team (3 vs 6 rescuers) on resuscitation performance. RESULTS: We included 90 teams with a total of 408 students. No difference in mean (±SD) hands-on time (seconds) were observed between emergent leadership (106 ±â€¯30) compared to designated leadership (103 ±â€¯27) groups (adjusted difference - 2.97 (95%CI -15.75 to 9.80, p = 0.645), or between smaller (103 ±â€¯30) and larger teams (106 ±â€¯26, adjusted difference 3.53, 95%CI -8.47 to 15.53, p = 0.56). Emergent leadership groups had a shorter time to circulation check and first defibrillation, but the quality of CPR based on arm and shoulder position was lower. No differences in CPR quality measures were observed between smaller and larger teams. CONCLUSIONS: Within this international US/Swiss trial, leadership designation and larger team size did not improve hands-on time, but emergent leadership teams initiated defibrillation earlier. Improvements in performance may be more likely to be achieved by optimization of emergent leadership than increasing the size of cardiac arrest teams.

Developing a curriculum for emergency medicine residency orientation programs.

BACKGROUND: New residents enter emergency medicine (EM) residency programs with varying EM experiences, which makes residency orientation programs challenging to design. There is a paucity of literature to support best practices. OBJECTIVE: We report on a curriculum development project for EM residency orientation using the Kern Model. CURRICULUM: Components of the revised curriculum include administrative inculcation into the program; delivering skills and knowledge training to ensure an entering level of competence; setting expectations for learning in the overall residency curriculum; performing an introductory performance evaluation; and socialization into the program. RESULTS: Post-implementation resident surveys found the new curriculum to be helpful in preparing them for the first year of training. CONCLUSIONS: The Kern Model was a relevant and useful method for redesigning a new-resident orientation curriculum.

Are one or two dangerous? Calcium channel blocker exposure in toddlers.

Unintentional pediatric ingestions of calcium channel blockers are increasing in frequency due to increased use of this antihypertensive class. Potential toxic effects include severe refractory hypotension and death; however, the true toxicity of unintentional pediatric ingestions of 1-2 pills is poorly defined. A literature review was conducted to more closely determine toxic and lethal dosages of calcium channel blockers in the pediatric population under 6 years of age. Results indicate that, although most accidental pediatric ingestions are asymptomatic, a small number do result in cardiovascular instability or even death. The dihydropyridines, particularly nifedipine, and the phenylalkylamine verapamil are most often implicated in symptomatic ingestions. There are no adequate data to identify which children are predisposed to illness, or to determine cutoffs for toxic dosages. However, ingestions of only one pill have been documented to cause severe symptoms, including death. Thus, emergency evaluation to assess potential toxicity is necessary, and gastrointestinal decontamination and in-hospital observation of at least 6 h after toxic ingestion for regular release medications, and 12-24 h after toxic ingestion for sustained release medications is recommended for all cases of unintentional calcium channel blocker ingestion in children younger than 6 years of age.