Fracture of an Intravenous Cannula in the Hand: A Case Report.

BACKGROUND: Intravenous cannula insertion is important, given that it is the most common invasive procedure in the emergency department for blood sampling, fluid resuscitation, and intravenous drug administration. Complications of intravenous catheterization include pain, phlebitis, extravasation, inflammation, and embolization. Fracture of an intravenous cannula is rare, but delayed removal may result in secondary damage, such as vasculitis or embolization, with critical consequences. Here, we report a case of intravenous cannula fracture that occurred in our emergency department. CASE PRESENTATION: A 63-year-old woman with a history of left ovarian cancer visited our emergency department owing to poor oral intake and general weakness. Intravenous catheterization using an 18 gauge cannula was attempted for intravenous fluid administration by a skilled operator, but it failed owing to collapsed veins and poor skin condition. After several attempts, a vein in the patient's hand was ruptured, and the patient complained of severe pain. The cannula was removed, but one-third of the cannula tip could not be seen. X-ray imaging was performed to locate the fragment of the cannula, and venotomy was performed for removal of the foreign body in the emergency department. CONCLUSION: Emergency physicians and nurses should be vigilant about potential risk factors that can cause fracture of an intravenous cannula, and after the fracture is discovered, rapid removal of the cannula tip should be performed in the emergency department.

Prehospital advanced cardiac life support by EMT with a smartphone-based direct medical control for nursing home cardiac arrest.

OBJECTIVE: To compare the survival to discharge between nursing home (NH) cardiac arrest patients receiving smartphone-based advanced cardiac life support (SALS) and basic life support (BLS). METHODS: The SALS registry includes data on cardiac arrest from 7 urban and suburban areas in Korea between July 2015 and December 2016. We include adult patients (>18) with out-of-hospital cardiac arrest (OHCA) of medical causes and EMS attended and dispatched in. SALS is an advanced field resuscitation including drug administration by paramedics with video communication-based direct medical direction. Prehospital resuscitation method was key exposure (SALS, BLS). The primary outcome was survival to discharge. RESULTS: A total of 616 consecutive out-of-hospital cardiopulmonary resuscitation cases in NHs were recorded, and 199 (32.3%) underwent SALS. Among the NH arrest patients, the survival discharge rate was a little higher in the SALS group than the BLS group (4.0% vs 1.7%), but the difference was not significant (P = 0.078). Survival discharge with good neurologic outcome rates was 0.5% in the SALS group and 1.0% in the BLS group (P = 0.119). On the other hand, in the non-NH group, all outcome measures significantly improved when SALS was performed compared to BLS alone (survival discharge rate: 10.0% vs 7.3%, P = 0.001; good neurologic outcome: 6.8% vs 3.3%, P < 0.001). CONCLUSIONS: As a result of providing prehospital ACLS with direct medical intervention through remote video calls to paramedics, the survival to discharge rate and that with good neurologic outcome (CPC 1, 2) of non-NH patients significantly improved, however those of NH patients were not significantly increased.

The pattern of Tpeak-Tend and QT interval, and J wave during therapeutic hypothermia.

BACKGROUND AND PURPOSE: The electrocardiogram manifestations of hypothermia include J waves and prolongation of QT intervals. This study described changes in repolarization patterns during therapeutic hypothermia (TH). METHODS: We measured the QTc and the interval from the peak to the end of the T wave (TpTe) from the V4 and V6 leads in 20 patients with TH. The TpTe was also expressed as a ratio to the duration of QT ([TpTe/QT]×100%), and to the corrected value for heart rate (TpTe/√RR). RESULTS: The QTc became prolonged in all patients during TH. While the TpTe/√RR did not change, the ([TpTe/QTe]×100%] decreased significantly during TH. The J wave developed during TH in seven patients. With one patient, ventricular fibrillation occurred preceded by an abnormal J wave and prolonged TpTe during TH. CONCLUSIONS: QTc prolongation without TpTe increase or abnormal J wave may not be arrhythmogenic during TH.

Injuries associated with the 580 km university student grand voluntary road march: focus on foot injuries.

College student volunteers (n = 142) completed a 580 km road march for 21 consecutive days. Each volunteer carried a backpack that weighed 14.1 ± 1.4 kg on the average. We investigated the incidence and location of blisters associated with the road march using a foot map along with other injuries. Overall, 95.1% of the subjects (135 of 142) sustained one or more injuries. All injured subjects had foot blisters, and 18% had other foot injuries. The most common locations of blister development were the right 5th toe (61%) and the left 5th toe (57%). The little toes seem to have been subjected to the greatest friction and shearing forces. March-related injuries, excluding foot injuries, were ankle pain (12.7%), knee pain (12.7%) and Achilles tendon pain (7.7%). Six subjects (4.2%) needed extra medical treatment for more than 2 weeks prior to returning to their daily lives after completion of the march due to associated injuries. The present study observed a very high incidence rate of injuries (95.1%) associated with the 580 km university students grand road march. These injuries posed an obstacle against completion of the road march and against returning to daily life. Active preventive interventions such as physical therapy and customized reinforced shoes and education program are recommended for reducing incidence rate and severity of injuries.

Faculty perceptions and use of e-learning resources for medical education and future predictions.

PURPOSE: This study aims to investigate medical faculties' perceptions and current practice of using e-learning resources, needs and suggestions for more effective use of such resources, and future directions of e-learning in medical education. METHODS: This descriptive study was conducted on full-time faculty members who were registered users of the e-learning portal of the consortium of Korean medical schools. Participants were invited to an online survey containing 45 items that addressed their perceptions and use of e-learning resources, and their predictions of future use. Descriptive analysis and reliability analysis were conducted as well as a thematic analysis of qualitative data. RESULTS: Ninety faculty members from 31 medical schools returned the questionnaires. Participants positively perceived e-learning resources and that they predicted their use would become increasingly popular. Still, only half of the respondents were using e-learning resources for teaching and agreed that they were willing to share their e-learning resources. Our study illustrates several barriers inhibit faculty use and sharing of e-learning resources, and a need for a more comprehensive, better-organized resource repository. Participants also pointed out the needs for more resources on multimedia assessment items, clinical videos, and virtual patients. CONCLUSION: Our study sheds light on medical faculty needs for institutional support and faculty development programs on e-learning, and institutional policies that address faculty concerns regarding ownership, intellectual property rights, and so forth on creating and sharing such resources. Collaborations among medical schools are suggested for creating a better organized around learning outcomes and more comprehensive repository of resources.

Emergent use of a King laryngeal tube for traumatic intraoral bleeding: two case reports.

Maxillofacial trauma occasionally presents a serious challenge for physicians, and an orofacial injury can be considered life-threatening. It is difficult to control the bleeding and prevent airway obstruction simultaneously with conventional treatment. Herein, we share two cases in which we managed massive orofacial bleeding using a King laryngeal tube, a supraglottic airway device equipped with an inflatable balloon. Both patients had uncontrolled orofacial bleeding. In one of the patients, endotracheal intubation was possible; however, bleeding continued, and vital signs became unstable. The second patient had failed endotracheal intubation due to uncontrolled bleeding. We deployed the King laryngeal tube in both patients and achieved bleeding control and airway maintenance. Both patients were discharged without complications after 3 to 4 weeks. The King laryngeal tube method can be considered a useful management option for addressing massive orofacial bleeding that is uncontrollable with conventional treatment.

Evaluating the Effectiveness of the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM): A Pilot Simulation Study With a Before and After Design.

Background With the occurrence of a number of major disasters around the world, there is growing interest in chemical disaster medicine. In South Korea, there is a training program for mass casualty incidents (MCI) and backup by legal regulations by the Framework Act on the Management of Disasters and Safety. However, there is no program focusing on chemical disasters. Thus, the authors newly created a program, the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM) in September 2019. This was a pilot study to verify the educational effect of the program. Method A pre/post study was conducted of a chemical MCI training program based on simulation. A total of 25 representative and qualified participants were recruited from fire departments, administrative staff of public health centers, and healthcare workers of hospitals in the Gyeonggi-do province of South Korea. They participated in a one-day training program. A knowledge test and confidence survey were provided to participants just before training, and again immediately following the training online. The authors compared improvements of pre/post-test results. In the tabletop drill exercise, quantified qualitative analyses were used to measure the educational effect on the participants. Results In the knowledge test, the mean (standard deviation) scores for all 25 participants at baseline and after training were 41.72 (15.186) and 77.96 (11.227), respectively (p < 0.001). In the confidence survey for chemical MCI response for all 25 participants, all the sub-items concerning personal protective equipment selection, antidote selection, antidote stockpiling and passing on knowledge to colleagues, zone setup and decontamination, and chemical triage were improved compared to the baseline score (p < 0.001). The tabletop exercise represented a prehospital setting and had 11 participants. The self-efficacy qualitative survey showed pre- and post-exercise scores of 64/100 and 84/100 respectively. For a hospital setting exercise, it had 14 participants. The survey showed pre/post-exercise scores of 26/100 and 73/100 respectively. Twenty-two (88%) participants responded to the final satisfaction survey, and their overall mean scores regarding willingness to recommend this training program to others, overall satisfaction with theoretical education, overall satisfaction with tabletop drill simulation, and opinion about whether policymakers need this training were all over 8 out of 10 respectively. Conclusion C-MCIREM, the newly created chemical MCI program, provided effective education to the selected 25 participants among Korean chemical MCI responders in terms of both knowledge and practice at a single pilot trial. Participants were highly satisfied with the educational material and their confidence in disaster preparedness was clearly improved. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.

The efficacy of peer assessment in objective structured clinical examinations for formative feedback: a preliminary study.

PURPOSE: We sought to determine the impact of medical students' prior experience of assessing peers in the objective structured clinical examination (OSCE) on their clinical performance. METHODS: Forty-two year 4 medical students participated in an OSCE comprised of three 10-minute stations (syncope, hemoptysis, and back pain). Each student took part in two iterations of the three-station OSCE as either the examiner or examinee, and student performance was assessed using a checklist by a medical faculty member and a student simultaneously. Students were randomly assigned to two groups and their OSCE scores were compared. Students in the control group were tested at a station first and then participated at the same station as a peer examiner, and those in the intervention group participated as a peer examiner first and then as an examinee. Moreover, student OSCE scores rated by peer examiners were compared with those awarded by faculty to evaluate the accuracy of peer assessment. Following the test, students completed surveys on their perceptions of the usefulness of this formative OSCE. RESULTS: Student overall OSCE scores did not differ between groups. Students in the study group performed better at the hemoptysis station (p<0.001), but poorer at the syncope station (p<0.01). Student performances at the back-pain station were similar in these two groups (p=0.48). OSCE scores rated by faculty and peer examiners were moderately negatively associated at the hemoptysis station (p<0.05), but no such association was observed at the other two stations. This trend was similar in peer examiners who were high-achievers and low-achievers in OSCEs. Students showed positive perceptions of their experience with this OSCE. CONCLUSION: Student experience as peer assessor offers a feasible means of providing them greater access to OSCEs without consuming more resources, although its impact on enhancing performance in the OSCE is likely to differ across stations.

Effect of Prehospital Epinephrine on Outcomes of Out-of-Hospital Cardiac Arrest: A Bayesian Network Approach.

BACKGROUND: The benefit of prehospital epinephrine in out-of-hospital cardiac arrest (OHCA) was shown in a recent large placebo-controlled trial. However, placebo-controlled studies cannot identify the nonpharmacologic influences on concurrent or downstream events that might modify the main effect positively or negatively. We sought to identify the real-world effect of epinephrine from a clinical registry using Bayesian network with time-sequence constraints. METHODS: We analyzed a prospective regional registry of OHCA where a prehospital advanced life support (ALS) protocol named "Smart ALS (SALS)" was gradually implemented from July 2015 to December 2016. Using Bayesian network, a causal structure was estimated. The effect of epinephrine and SALS program was modelled based on the structure using extended Cox-regression and logistic regression, respectively. RESULTS: Among 4324 patients, SALS was applied to 2351 (54.4%) and epinephrine was administered in 1644 (38.0%). Epinephrine was associated with faster ROSC rate in nonshockable rhythm (HR: 2.02, 6.94, and 7.43; 95% CI: 1.08-3.78, 4.15-11.61, and 2.92-18.91, respectively, for 1-10, 11-20, and >20 minutes) while it was associated with slower rate up to 20 minutes in shockable rhythm (HR: 0.40, 0.50, and 2.20; 95% CI: 0.21-0.76, 0.32-0.77, and 0.76-6.33). SALS was associated with increased prehospital ROSC and neurologic recovery in noncardiac etiology (HR: 5.36 and 2.05; 95% CI: 3.48-8.24 and 1.40-3.01, respectively, for nonshockable and shockable rhythm). CONCLUSIONS: Epinephrine was associated with faster ROSC rate in nonshockable rhythm but slower rate in shockable rhythm up to 20 minutes. SALS was associated with improved prehospital ROSC and neurologic recovery in noncardiac etiology.

Can We Predict Good Survival Outcomes by Classifying Initial and Re-Arrest Rhythm Change Patterns in Out-of-Hospital Cardiac Arrest Settings?

Objective The purpose of this study was to investigate whether a change in prehospital arrest rhythms could allow medical personnel to predict survival outcomes in patients who achieved a return of spontaneous circulation (ROSC) in the setting of out-of-hospital cardiac arrest (OHCA). Methods The design of this study was retrospective, multi-regional, observational, and cross-sectional with a determining period between August 2015 and July 2016. Cardiac arrest rhythms were defined as a shockable rhythm (S), which refers to ventricular fibrillation (VF) or pulseless ventricular tachycardia (pVT), and non-shockable rhythm (NS), which refers to pulseless electrical activity or asystole. Survival to admission, survival to discharge, and good cerebral performance category (CPC) (CPC 1 or 2) were defined as good survival outcomes. Results A total of 163 subjects were classified into four groups according to the rhythm change pattern: NS→NS (98), S→S (27), S→NS (23), and NS→S (15). NS→NS pattern was used as the reference in logistic regression analysis. In the case of survival to hospital admission, the odds ratio (OR) (95% CI) of the S→S pattern was the highest [12.63 (3.56-44.85), p: <0.001 by no correction] and [7.29 (1.96-27.10), p = 0.003 with adjusting]. In the case of survival to hospital discharge, the OR (95% CI) of the S→S pattern was the highest [37.14 (11.71-117.78), p: <0.001 by no correction] and [13.85 (3.69-51.97), p: <0.001 with adjusting]. In the case of good CPC (CPC 1 or 2) at discharge, the OR (95% CI) of the S→S pattern was the highest [96 (19.14-481.60), p: <0.001 by no correction] and [149.69 (19.51-1148.48), p: <0.001 with adjusting]. Conclusions The S→S group showed the highest correlation with survival to hospital admission, survival to hospital discharge, and good CPC (CPC 1 or 2) at discharge compared to the NS→NS group. Verifying changes in initial cardiac arrest rhythm and prehospital re-arrest (RA) rhythm patterns after prehospital ROSC can help us predict good survival outcomes in the OHCA setting.

Correction to: Impact of early intravenous amiodarone administration on neurological outcome in refractory ventricular fibrillation: retrospective analysis of prospectively collected prehospital data.

Following the publication of the original article [1], the authors unfortunately became aware of some typesetting and resolution problems in Figs. 1 and 2.

Development of e-learning in medical education: 10 years' experience of Korean medical schools.

PURPOSE: We aimed to explore medical students' online learning patterns and needs by analyzing data obtained from an e-learning portal of Korean medical schools. METHODS: Data were obtained from learning resources and registered users of the e-learning portal by the consortium of 36 Korean medical schools, e-MedEdu (www.mededu.or.kr) over a period of 10 years. Data analytics were performed of its contents and usage patterns using descriptive statistics. RESULTS: The website currently has over 1,600 resources, which have almost tripled over the past decade, and 28,000 registered users. Two hundred and twenty medical faculty have contributed the resources; a majority of them were clinical cases and video clips, which accounted for 30% and 27% of all resources, respectively. The website has received increasing hits over the past decade; annual website hits increased from 80,000 in 2009 to over 300,000 in 2018. The number of hits on resources varied across resource types and subjects; 90% of all website hits were on online videos, and 28% of them originated from mobile devices. Among the online videos, those on procedural skills received more hits than those on patient encounters and video lectures. CONCLUSION: Our findings demonstrate the increasing use of e-learning in medical education in Korea over the past decade. Our study also shows a wide disparity in the frequency of use in learning resources across resource types and subjects, which have implications for improvements in the design and development of learning resources to better meet medical students' curricular needs and their learning styles.

Impact of early intravenous amiodarone administration on neurological outcome in refractory ventricular fibrillation: retrospective analysis of prospectively collected prehospital data.

BACKGROUND: The 2015 AHA guidelines recommend that amiodarone should be used for patients with refractory ventricular fibrillation (RVF). However, the optimal time interval between the incoming call and amiodarone administration (call-to-amiodarone administration interval) in RVF patients has not been investigated. We hypothesized that the time elapsed until amiodarone administration could affect the neurological outcome at hospital discharge in patients with RVF. METHODS AND RESULTS: This study is a retrospective analysis of prospectively collected data. One hundred thirty-four patients were enrolled. In univariate logistic regression, the probability of a good neurological outcome at hospital discharge decreased as the time elapsed until amiodarone administration increased (OR 0.89 [95% CI = 0.80-0.99]). In multivariate logistic regression, the patients who were administered amiodarone in less than 20 min showed higher rates of prehospital ROSC, survival at hospital arrival, any ROSC, survival at admission, survival to discharge, and good CPC at hospital discharge. The call-to-amiodarone administration interval of ≤20 min (OR 6.92, 95% CI 1.72-27.80) was the independent factor affecting the neurological outcome at hospital discharge. CONCLUSION: Early amiodarone administration (≤ 20 min) showed better neurological outcome at hospital discharge for OHCA patients who showed initial ventricular fibrillation and subsequent RVF.

Effect of typhoons on the Korean national emergency medical service system.

OBJECTIVE: While the effect of typhoons on emergency medicine has been evaluated, data are scarce on their effects on the emergency medical service (EMS). This study evaluated the effect of typhoons on EMS patients and performance. METHODS: The study period was January 2010 to December 2012. Meteorological data regarding typhoons were provided by the Korean Meteorological Administration. EMS data were retrieved from the EMS database of the national emergency management agency. The database includes ambulance run sheets, which contain clinical and operational data. In this case-crossover study, the cases and controls were EMS calls on the day of typhoon warnings and calls one week prior to the typhoon warnings, respectively. RESULTS: During the study period, 11 typhoons affected Korea. A total of 14,521 cases were selected for analysis. Overall, there were no obvious differences between the case and control groups. However, there were statistically significant differences in age, place, and time requests. There were fewer patients between 0 and 15 years of age (P=0.01) and more unconscious patients (P=0.01) in the case group. The EMS operational performance, as measured by the times elapsed between call to start, call to field, and call to hospital did not differ significantly. There was also no significant difference in the time from hospital arrival between the cases (28.67, standard deviation 16.37) and controls (28.97, standard deviation 28.91) (P=0.39). CONCLUSION: Typhoons did not significantly affect the EMS system in this study. Further study is necessary to understand the reasons for this finding.

The gap between medical faculty's perceptions and use of e-learning resources.

BACKGROUND: e-Learning resources have become increasingly popular in medical education; however, there has been scant research on faculty perceptions and use of these resources. OBJECTIVE: To investigate medical faculty's use of e-learning resources and to draw on practical implications for fostering their use of such resources. DESIGN: Approximately 500 full-time faculty members in 35 medical schools across the nation in South Korea were invited to participate in a 30-item questionnaire on their perceptions and use of e-learning resources in medical education. The questionnaires were distributed in both online and paper formats. Descriptive analysis and reliability analysis were conducted of the data. RESULTS: Eighty faculty members from 28 medical schools returned the questionnaires. Twenty-two percent of respondents were female and 78% were male, and their rank, disciplines, and years of teaching experience all varied. Participants had positive perceptions of e-learning resources in terms of usefulness for student learning and usability; still, only 39% of them incorporated those resources in their teaching. The most frequently selected reasons for not using e-learning resources in their teaching were 'lack of resources relevant to my lectures,' 'lack of time to use them during lectures,' and 'was not aware of their availability.' CONCLUSIONS: Our study indicates a gap between medical faculty's positive perceptions of e-learning resources and their low use of such resources. Our findings highlight the needs for further study of individual and institutional barriers to faculty adoption of e-learning resources to bridge this gap.

Comparison of internal jugular vein dilation between Valsalva maneuver and proximal internal jugular vein compression.

OBJECTIVE: The Valsalva maneuver is recognized as an effective method to dilate the internal jugular vein (IJV). However, this maneuver cannot be performed in many cases, such as children and unconscious patients. The aim of this study was to evaluate the effectiveness of proximal IJV compression, which can easily be performed, regardless of patient cooperation. METHODS: Healthy adult volunteers were recruited from tertiary hospital employees. Basic anatomic and physiologic data were collected. The subjects lay down as if they were undergoing IJV catheter insertion, in the supine position with their necks turned 30 degrees to the left. The main outcome was the cross-sectional area (CSA) of the distal IJV as measured by ultrasound in four stages. The first stage was sham without any maneuver. The second was Valsalva maneuver, the third was digital IJV compression, and the fourth was digital compression accompanied by simultaneous Valsalva maneuver. RESULTS: A total of 41 volunteers were enrolled. Twenty-six (63.41%) were male with an average age of 28.15±2.85 years. Mean height was 170.74±8.66 cm and mean neck circumference was 35.28±3.87 cm. The mean CSA-IJV was 1.06±0.36 cm2 without any maneuver. It increased to 1.34±0.45 cm2 with Valsalva maneuver (P<0.001), to 1.26±0.41 cm2 with digital compression (P<0.001), and to 1.41±0.47 cm2 with the two maneuvers combined (P=0.01). CONCLUSION: Digital proximal IJV compression effectively dilates the distal IJV. When performed simultaneously with the Valsalva maneuver, the effect was enhanced.

Effectiveness of a compressive device in controlling hemorrhage following radial artery catheterization.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a compressive device in controlling hemorrhage following radial artery catheterization. METHODS: A prospective randomized trial was conducted on subjects receiving the standard taping method (group S) compared to a compressive device method (group C) after removal of the cannula in radial artery catheterization. Primary outcomes were the success rate of hemostasis and complication rate after cannula removal. Secondary outcomes were the cost of compression and the level of convenience. RESULTS: A total of 250 subjects were enrolled in this study. Hemostasis after removal was successful in 122 of 125 (97.6%) subjects in group S and 116 of 125 (92.8%) subjects in group C (P=0.18). Complication rates in group S and group C were 55.2% (69/125) and 48% (60/125), respectively (P=0.35). The cost of compression for group C (approximately 6,740 Korean won) was approximately two times cheaper than for group S (approximately 14,140 Korean won). The level of convenience was significantly higher in group C than in group S (7.4±2.1 vs. 3.7±1.9, p < 0.001). CONCLUSION: These findings suggest that hemostasis using a compressive device may be a suitable alternative method to the standard taping method in controlling hemorrhage following radial artery cannulation.