Deception in simulation-based education: a randomised controlled trial of the effect of deliberate deception on the performance of anaesthesia trainees.

The use of deliberate deception in simulation allows for a level of realism that is not normally feasible. However, the use of deception is controversial, and carries the risk of psychological harm to learners. There are currently no quantitative data on the effect of deception on learner performance, making it difficult to judge its usefulness. The objective of this study was to examine the impact of deception on learners' performance during a life-threatening scenario. In this simulation study, second-year anaesthesia residents were randomly allocated into two groups: the non-deception group was told that the participating consultant was acting a part, while the deception group was told that the consultant was a subject in the study. Learners then participated in a simulated crisis that presented them with situational opportunities to challenge the consultant regarding clearly wrong decisions. Two independent raters scored the performances using the modified advocacy-inquiry scale. Forty-four participants were analysed. The median (IQR [range]) highest scoring modified advocacy-inquiry scale was 5.0 (4.5-5.1 [4.0-5.5]) for the non-deception group and 4.0 (3.0-4.0 [2.5-5.0]) for the deception group, (p < 0.001), and the median total number of challenges per participant was 26.8 (21.0-31.1 [16.5-35.5]) and 18.0 (14.3-23.3 [7.0-33.0]), respectively (p = 0.001). Trainees exposed to deliberate deception, who thought that the consultant anaesthetist was a subject, had a less-effective best challenge, likely mimicking real-life behaviour. Deliberate deception appears to modify behaviour, particularly relating to communication involving hierarchical relationships. This technique may improve authenticity, especially with a steep power gradient, and so has demonstrable value which must be balanced against the ethical considerations.

Challenging authority and speaking up in the operating room environment: a narrative synthesis.

Multidisciplinary care teams exist throughout healthcare systems. In the operating room (OR), effective communication between teams is essential, especially during crisis situations where patient safety can be in acute danger. An often-neglected skillset in educational curriculums is challenging authority. This narrative synthesis aims to explore the literature on challenging authority in the OR environment. A systematic search of Medline, EBM reviews and PsycINFO was conducted using terms related to challenging authority, speaking up, communication, patient safety, gradients and hierarchy. The initial search identified 4822 publications, out of which 31 studies were included. The data synthesis of the included studies was grouped into three distinct categories following a meta-aggregative approach: discussion and review articles, observational or qualitative studies, and studies identifying the role of specific barriers or investigating the effect of educational interventions. Themes emerging from expert beliefs, what reality tells us and what we test are consistent. Hierarchy, organisational culture and education are the most frequently observed and tested themes. Simulation research has been successful in eliciting and confirming the role of specific barriers to speaking up. Barriers and enablers are largely modifiable within institutions however, education regarding the importance of speaking up will need to accompany these modifications for any significant changes to occur.

Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.

BACKGROUND: Effective communication within teams is crucial, especially in crisis situations. Hierarchy gradients between team members can contribute to communication failures and are influenced by many factors. The effect of gender on team performance has not been well studied. The objective of this study was to examine the effect of the physician's gender on respiratory therapists' ability to effectively challenge clearly incorrect clinical decisions during a life-threatening crisis. METHODS: Respiratory therapists were recruited to take part in a high-fidelity simulation of can't-intubate can't-oxygenate scenarios. They were randomized into two groups, either assisting a male or a female anaesthetist in managing an airway crisis during which the anaesthetist made incorrect clinical decisions. Two independent raters scored the performances using the modified Advocacy-Inquiry Score (min 1, max 6). RESULTS: Twenty-nine subjects completed the study. The median best challenge score when the staff anaesthetist was female was 4 (3-5 IQR [2-6 range]) compared with 3 (3-3[0-3]) for challenges to a male anaesthetist (P=0.017). The median of the total challenges against a female staff member 11 (7.3-14.8 [2-18]) was significantly higher compared with 4 (3.5-7 [2-11.5]) for a male staff (P=0.006). CONCLUSIONS: The study showed a significant effect of superiors' gender on a respiratory therapist's ability to challenge leadership. A female staff anaesthetist was challenged more often and with greater assertiveness and effectiveness. This has implications for an educational intervention targeting the ability to challenge a wrong decision by a supervisor and emphasizing the effect of gender on the willingness to speak up.

Power and conflict: the effect of a superior's interpersonal behaviour on trainees' ability to challenge authority during a simulated airway emergency.

A key factor that may contribute to communication failures is status asymmetry between team members. We examined the effect of a consultant anaesthetist's interpersonal behaviour on trainees' ability to effectively challenge clearly incorrect clinical decisions. Thirty-four trainees were recruited to participate in a video-recorded scenario of an airway crisis. They were randomised to a group in which a confederate consultant anaesthetist's interpersonal behaviour was scripted to recreate either a strict/exclusive or an open/inclusive communication dynamic. The scenario allowed trainees four opportunities to challenge clearly wrong decisions. Performances were scored using the modified Advocacy-Inquiry Score. The highest median (IQR [range]) score was 3.0 (2.2-4.0 [1.0-5.0]) in the exclusive communication group, and 3.5 (3.0-4.5 [2.5-6.0]) in the inclusive communication group (p = 0.06). The study did not show a significant effect of consultant behaviour on trainees' ability to challenge their superior. It did demonstrate trainees' inability to challenge their seniors effectively, resulting in critical communication gaps.

Video-assisted structured teaching to improve aseptic technique during neuraxial block.

BACKGROUND: Teaching epidural catheter insertion tends to focus on developing manual dexterity rather than improving aseptic technique which usually remains poor despite increasing experience. The aim of this study was to compare epidural aseptic technique performance, by novice operators after a targeted teaching intervention, with operators taught aseptic technique before the intervention was initiated. METHODS: Starting July 2008, two groups of second-year anaesthesia residents (pre- and post-teaching intervention) performing their 4-month obstetric anaesthesia rotation in a university affiliated centre were videotaped three to four times while performing epidural procedures. Trained blinded independent examiners reviewed the procedures. The primary outcome was a comparison of aseptic technique performance scores (0-30 points) graded on a scale task-specific checklist. RESULTS: A total of 86 sessions by 29 residents were included in the study analysis. The intraclass correlation coefficient for inter-rater reliability for the aseptic technique was 0.90. The median aseptic technique scores for the rotation period were significantly higher in the post-intervention group [27.58, inter-quartile range (IQR) 22.33-29.50 vs 16.56, IQR 13.33-22.00]. Similar results were demonstrated when scores were analysed for low, moderate, and high levels of experience throughout the rotation. CONCLUSIONS: Procedure-specific aseptic technique teaching, aided by video assessment and video demonstration, helped significantly improve aseptic practice by novice trainees. Future studies should consider looking at retention over longer periods of time in more senior residents.

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.

BACKGROUND: Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. METHODS: We prospectively randomized 49 postgraduate year (PGY) 2-5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy-inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. RESULTS: The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. CONCLUSIONS: This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

Increased lung clearance of isoflurane shortens emergence in obesity: a prospective randomized-controlled trial.

BACKGROUND: There is a concern that obesity may play a role in prolonging emergence from fat-soluble inhalational anaesthetics. We hypothesized that increased pulmonary clearance of isoflurane will shorten immediate recovery from anaesthesia and post-anaesthesia care unit (PACU) stay in obese patients. METHODS: After Ethics Review Board approval, 44 ASA I-III patients with BMI>30 kg/m(2) undergoing elective gynaecological or urological surgery were randomized after completion of surgery to either an isocapnic hyperpnoea (IH) or a conventional recovery (C) group. The anaesthesia protocol included propofol, fentanyl, morphine, rocuronium and isoflurane in air/O(2) . Groups were compared using unpaired t-test and ANOVA. RESULTS: Minute ventilation in the IH group before extubation was 22.6 ± 2.7 vs. 6.3 ± 1.8 l/min in the C group. Compared with C, the IH group had a shorter time to extubation (5.4 ± 2.7 vs. 15.8 ± 2.7 min, P<0.01), initiation of spontaneous ventilation (2.7 ± 2.3 vs. 6.5 ± 4.5 min, P<0.01), BIS recovery >75 (3.2 ± 2.3 vs. 8.9 ± 5.8 min, P<0.01), eye opening (4.6 ± 2.9 vs. 13.6 ± 7.1 min, P<0.01) and eligibility for leaving the operating room (7.1 ± 2.9 vs. 19.9 ± 11.9 min, P<0.01). There was no difference in time for eligibility for PACU discharge. CONCLUSION: Increasing alveolar ventilation enhances anaesthetic elimination and accelerates short-term recovery in obese patients.

Simultaneous compression and speckle reduction of clinical breast and fetal ultrasound images using rate-fidelity optimized coding.

Medical ultrasound images are inherently noised with speckle noise, which may interfere with Computer Aided Diagnostics (CAD) tasks, such as automatic segmentation. A compression and speckle de-noising method is proposed and tested on real clinical breast and fetal ultrasound images. The proposed algorithm is based on the optimization of quantization coefficients when applying Wavelet representation on the image, where the optimization is held such that a pre-defined mathematical fidelity criterion with respect to a desired de-speckled image is obtained. The proposed algorithm yields effective speckle reduction whilst preserving the edges in the images, with a reduced computational burden compared to other existing state-of-the-art methods, such as Optimal Bayesian Non-Local Means (OBNLM). In addition, the images are simultaneously compressed to a target bit-rate. The proposed algorithm is evaluated using both objective mathematical fidelity criteria (such as Structural Similarity and Edge Preserve) as well as subjective radiologists tests. The experimental results demonstrate the ability of the proposed method to achieve de-speckled images with compression ratios of approximately 30:1, whilst obtaining competitive subjective as well as objective fidelity measures with respect to the desired de-speckled images.

Effect of sleep deprivation on labour epidural catheter placement.

BACKGROUND: Epidural catheter insertion for labour analgesia is an invasive procedure with potential serious complications, often performed by a sleep-deprived clinician. The aim of this study was to examine the effects of sleep deprivation on physicians of variable levels of experience performing this procedural skill in the clinical setting. METHODS: After institutional review board approval, anaesthetists of three levels of experience were recruited: novice residents (<30 epidurals, n=9), experienced residents (>100 epidurals, n=8), and attending anaesthetists (>500 epidurals, n=12). All participants were measured twice, rested and sleep deprived in a random order while performing a labour epidural for analgesia. Our primary outcome measures were scores achieved on the Imperial College Surgical Assessment Device (ICSAD) (measuring path length, number of movements, and time), task-specific checklist (CL), and global rating scale (GRS). Sleep deprivation was documented by the ActiGraph and Epworth sleepiness scale. RESULTS: Subjects were adequately sleep deprived for their sleep deprivation observation. Data were analysed with a two-way mixed design analysis of variance. No significant difference in the effect of sleep deprivation on performance was detected between the groups on the ICSAD measures of movement (P=0.86), path length (P=0.79), and time (P=0.80), or for the CL (P=0.65), and GRS (P=0.86). CONCLUSIONS: The performance of this procedural skill in a clinical setting does not seem to be affected by sleep deprivation irrespective of the level of experience.

Optimal hand washing technique to minimize bacterial contamination before neuraxial anesthesia: a randomized control trial.

INTRODUCTION: Infectious complications related to neuraxial anesthesia may result in adverse outcomes. There are no best practice guidelines regarding hand-sanitizing measures specifically for these procedures. The objective of this study was to compare the growth of microbial organisms on the operator's forearm between five common techniques of hand washing for labor epidurals. METHODS: In this single blind randomized controlled trial, all anesthesiologists performing labor epidurals in a tertiary care hospital were randomized into five study groups: hand washing with alcohol gel only up to elbows (Group A); hand washing with soap up to elbows, sterile towel to dry, followed by alcohol gel (Group B); hand washing with soap up to elbows, non-sterile towel to dry, followed by alcohol gel (Group C); hand washing with soap up to elbows, non-sterile towel to dry (Group D) or hand washing with soap up to elbows, sterile towel to dry (Group E). The number of colonies for each specimen/rate per 100 specimens on one or both arms per group was measured. RESULTS: The incidence of colonization was 2.5, 23.0, 18.5, 114.5, and 53.0 in Groups A, B, C, D and E, respectively. Compared to Group A, the odds ratio of bacterial growth for Group B was 1.52 (P=0.519), Group C 5.44 (P=0.003), Group D 13.82 (P<0.001), and Group E 8.65 (P<0.001). CONCLUSION: Alcohol-based antiseptic solutions are superior in terms of reducing the incidence of colonization. The results will enable us to develop guidelines to standardize and improve hand-sanitizing practices among epidural practitioners.

Essential fatty acid consideration at birth in the premature neonate and the specific requirement for preformed prostaglandin precursors in the infant.

The essentiality of certain PUFA is probably related to their capability to be incorporated into lipids and to act as precursor in the formation of ecosanoids. Esterified to phospholipids, the EFA influence the physico-chemical characteristics of biomembranes. Normal growth of infants is dependent upon an adequate supply of EFA. The human fetus, like the adult, is unable to synthesize the EFA, which must therefore be derived from the maternal circulation and pass through the placenta. Increased concentration of the polyenoic fatty acids with advanced gestational age may result from increased synthetic activity of these fatty acids by the fetus or the placenta or by preferential transfer of these fatty acids across the placenta. Several clinical manifestations have been ascribed in the human infant to prolonged EFA deficiency; however, none of these findings were noted in a group of sick newborn infants with very rapid onset of deficiency. Platelet dysfunction, decreased prostaglandin biosynthesis and turnover and altered pulmonary surfactant are among the effects of EFA deficiency on infants. Supplementation of the diet with EFA, parenterally or by the inunction of oil rich in linoleic acid, were reported to alleviate the symptoms of EPA deficiency. The minimal estimated requirement of linoleic acid is 1% of calories and 4% is an optimal intake. Most diets, including human breast milk, infant formulas and parenteral fat emulsions, far exceed the optimal intake of linoleic acid. Relatively little is known about the possible effects of high levels of linoleate in the diet.

beta-Adrenergic receptors stimulated peroxidase secretion from rat lacrimal gland.

Incubation of rat extraorbital lacrimal gland slices with the beta-agonist isoproterenol caused peroxidase secretion but no K+ release. The peroxidase secretion was inhibited by propranolol. Addition of dibutyryl cyclic AMP or adenosine 3'5'-cyclic phosphorothioate to lacrimal slices produced peroxidase secretion at a higher rate than that obtained with optimal concentration of isoproterenol. Methyl isobutylxanthine is also a strong stimulator of peroxidase secretion. Peroxidase activity was determined by a modified sensitive guaiacol method. Membrane fraction of lacrimal cells was shown to contain an isoproterenol-stimulated adenylate cyclase activity. It is therefore suggested that there is a beta-adrenergic receptor in the rat lacrimal gland and that its stimulation causes activation of an adenylate cyclase which leads to peroxidase secretion.

Substance P degrading systems of rat parotid and hypothalamus.

Inactivation of substance P and its C-terminal hexapeptide analog [p-Glu6]substance P6-11 was studied in rat parotid and hypothalamic slices. It was found that in the parotid slice system the decay of substance P induced K+ release occurs concurrently with a decrease in the biologically active concentration of the peptide in the medium. The inactivation was further studied using [p-Glu6]substance P6-11 as substrate in the parotid and in the hypothalamic slice systems. In both tissue preparations the hexapeptide is degraded to small peptide fragments by metalloendopeptidase. Separation of the peptide fragments by high performance liquid chromatography and determination of their amino acid composition showed that in the hypothalamic slice system the major cleavage of the hexapeptide analog occurs between Phe8-Gly9 with minor cleavage sites between Phe7-Phe8 and Gly9-Leu10. In the rat parotid slice system the major cleavage occurs between Gly9-Leu10 with a minor cleavage site between Phe7-Phe8. The degradation of the hexapeptide analog in the hypothalamic system was inhibited 77% and 67% by treatment with 1 mM p-chloromercuriphenylsulfonate and p-chloromercuribenzoate, respectively, whereas in the parotid system these reagents inhibited the degradation of the hexapeptide only by 15% and 8%. These results may indicate that different proteases in the parotid and hypothalamus are involved in degradation of substance P. Kinetic studies, including the use of various inhibitors as well as competition by the peptide hormones somatostatin, LHRH, TRH and Leu-enkephalin-NH2, revealed that in both tissues the hexapeptide analog is a preferred substrate for degradation by protease of considerable specificity towards the C-terminal sequence of substance P. It is suggested that this metalloendopeptidase may be important in the termination of the substance P response.

Myofibrillar protein degradation in premature infants with respiratory distress as assessed by 3-methylhistidine and creatinine excretions.

The skeletal muscle content of 3-methylhistidine has been measured in two fetuses and four infants of 15 to 38 wk of gestation. The average concentration of skeletal muscle 3-methylhistidine is 1.11, 2.64, and 3.28 (mumol/mixed protein) for fetuses of 15 to 18 of gestation and infants of 26 to 32 and 37 to 38 wk of gestation, respectively. Myofibrillar protein degradation has been measured by the rate of 3-methylhistidine excretion in premature infants suffering from respiratory distress and weighing between 1310 and 2420 g. In 26 balance studies in six infants, total muscle protein breakdown varied from 0.92 to 1.58 g day-1 kg-1 body weight. Calculated fractional catabolism of myofibrillar protein varied from 0.38 to 1.07% per day. A trend toward a higher rate of myofibrillar protein degradation is noted during the infants' acute illness and during their rapid growing phase.

Abnormal lung surfactant related to essential fatty acid deficiency in a neonate.

A low-birth-weight infant, suffering from chronic bronchopulmonary dysplasia following hyaline membrane disease and recurrent episodes of necrotizing enterocolitis, developed biochemical evidence of essential fatty acid (EFA) deficiency in the plasma. Fatty acid composition of phosphatidylcholine and phosphatidylglycerol in the lung lavage fluid was abnormal. Plasma changes included a decrease in the level of linoleic acid and an increased level of palmitic, palmitoleic, oleic, and 5,8,11-eicosatrienoic acid to arachidonic acid being greater than 0.4:1. A lower than normal level of palmitic acid and an increased level of palmitoleic and oleic acids were seen in pulmonary sufactant phospholipid components. Upon treatment and recovery from EFA deficiency, the fatty acid pattern both in plasma and surfactant phospholipids returned to normal along with clinical improvement. An association between EFA deficiency and altered fatty acid composition of pulmonary surfactant phospholipids is suggested.

Essential fatty acids, prostaglandins, and respiratory distress syndrome of the newborn.

The lungs are a major metabolic site for the synthesis, release, and degradation of prostaglandins. Prostaglandins of the E and F series exert a potent physiological effect on the smooth muscle of blood vessels and the tracheobronchial tree; prostaglandin E dilates while prostaglandin F constricts. Thus, altered prostaglandin metabolism may contribute to the pathophysiology of respiratory distress syndrome (RDS). Twenty-one infants with RDS and ten age- and weight-matched controls were studied by analyzing their plasma for prostaglandins and their precursor essential fatty acids. The two groups showed no differences in the essential fatty acid prostaglandin precursors, dihomo-gamma-linolenic and arachidonic acids. During the acute phase of RDS, plasma levels of the primary prostaglandins E and F are significantly elevated compared with control values and the ratio of prostaglandin E to prostaglandin F significantly reduced. Prostaglandins E and F returned to control values on recovery from the acute stage of the disease. Two infants with persistent patent ductus arteriosus had significantly elevated prostglandin E values in their plasma compared with controls. The elevated levels of circulating plasma prostaglandins E and F and the reversal of their ratio during the acute phase of RDS may have adverse pulmonary and multisystem effects.

Prostaglandins in human milk.

Levels of prostaglandin E2 and prostaglandin F2 alpha were measured by radioimmunoassay in aliquots of foremilk and hindmilk obtained at different stages of lactation (colostrum, transitional, and mature milk) from six healthy nursing mothers who delivered at term. Immunoreactive prostaglandin E2 and prostaglandin F2 alpha were detected in all fresh human milk samples, but not in cows' milk-based formulas. Further studies are necessary to investigate the role of these hormones in the physiologic function, the extrauterine adaptation, and the cytoprotective effect on the gastrointestinal tract in the breast-fed human infant.

A simple device for reducing insensible water loss in low-birth-weight infants.

Insensible water loss (IWL) was measured in five premature infants, 1 to 4 days old, by multiple weighings on an electronic balance inside an incubator. The babies were studied naked before and after being covered with a transparent thermal blanket. The use of the thermal blanket produced a mean reduction of 70% in IWL and a net caloric saving of 27 kcal/kg/day. There was minimal interference with nursing care. The important caloric saving achieved from reduced vaporization of water and evaporative heat loss may be an important determinant of intact survival in the high-risk infant.

Intravenous alimentation and insensible water loss in low-birth-weight infants.

Insensible water loss (IWL) was measured in six premature infants, between 4 and 21 days of age, by continuous weight monitoring on an electronic balance inside an incubator. Multiple measurements of IWL were made during the sequential infusion of 10% dextrose in 0.225% NaCl, 10% dextrose-amino acid solution, or 10% dextrose-amino acid and a commercial intravenous fat emulsion. Each solution was administered for three hours by constant infusion through a scalp vein needle. The order of the infusion was random and a 30- to 60-minute infusion with 5% dextrose water was given between each solution. During the infusion of 10% dextrose in 0.225% NaCl and 10% dextrose + amino acid solution, IWL was 1.0 +/- 0.8 gm/kg/hr and 1.1 +/- 0.8 gm/kg/hr, respectively. In contrast, IWL increased significantly to 1.6 +/- 0.7 gm/kg/hr when additional calories were given using the 10% dextrose-amino acid with the intravenous fat emulsion (P less than .005). There was a positive correlation between calorie intake and IWL. These data suggest that parenteral nutrition solutions with intravenous fat emulsion are rapidly metabolized and the increase in IWL is probably secondary to an increase in thermogenesis.

Effect of parenteral fat emulsion on the pulmonary and reticuloendothelial systems in the newborn infant.

Analysis of phospholipids (PL), cholesterol esters, triglycerides (TG), and free fatty acids (FFA) was performed on plasma and RBCs in two sick low-birth-weight infants who received total parenteral nutrition including Intralipid for the first 9 and 12 weeks of life, respectively. There was an increase in the total concentration of the plasma IG and FFA in the infants receiving Intralipid as compared with controls. These elevated lipid levels were not detected by visual inspection of the plasma. When compared with control infants, higher levels of linoleic acid were found in the plasma and RBCs of infants receiving Intralipid while plasma PL contained less arachidonate. Histological examination of the lung in both infants who received Intralipid revealed numerous globules of sudanophilic material in alveolar macrophages and capillaries. There is a possibility that prolonged administration of Intralipid may be associated with altered pulmonary and reticuloendothelial system function.