Comparing the stress response using heart rate variability during real and simulated crises: a pilot study.

Medical personnel often experience stress when responding to a medical emergency. A known stress-response is a measurable reduction in heart rate variability. It is currently unknown if crisis simulation can elicit the same stress response as real clinical emergencies. We aim to compare heart rate variability changes amongst medical trainees during simulated and real medical emergencies. We performed a single center prospective observational study, enrolling 19 resident physicians. Heart rate variability was measured in real time, using a 2-lead heart rate monitor (Bodyguard 2, Firstbeat Technologies Ltd) worn during 24 h critical care call shifts. Data was collected at baseline, during crisis simulation and when responding to medical emergencies. 57 observations were made to compare participant's heart rate variability. Each heart rate variability metric changed as expected in response to stress. Statistically significant differences were observed between baseline and simulated medical emergencies in Standard Deviation of the N-N interval (SDNN), Root mean square standard deviation of the N-N interval (RMSSD), Percentage of successive R-R intervals that differ by more than 50 ms (PNN50), Low Frequency (LF) and Low Frequency: High Frequency ratios (LF:HF). No statistically significant differences between simulated and real medical emergencies were identified in any heart rate variability metrics. We have shown using objective results, that simulation can elicit the same psychophysiological response as actual medical emergencies. Therefore, simulation may represent a reasonable way to practice not only essential skills in a safe environment but has the additional benefit of creating a realistic, physiological response in medical trainees.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

INTRODUCTION: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. METHODS: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. RESULTS: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. CONCLUSIONS: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

Multidisciplinary, multisite trauma team training during COVID-19: lessons from the first virtual E-S.T.A.R.T.T. course.

Trauma care delivery is a complex team-based task that requires deliberate practice. The COVID-19 pandemic has not diminished the importance of excellent trauma team dynamics. However, the pandemic hampers our ability to gather safely and train together. A mitigating solution is the provision of high-fidelity simulation training in a virtual setting. The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course has provided multidisciplinary trauma team members with skills in crisis resource management (CRM) for nearly 10 years. It has promoted collaborative learning from coast to coast, as the course typically runs at our national surgical and trauma meetings. In response to COVID-19 challenges, the course content has been modified to virtually connect 2 centres in different provinces simultaneously. High participant satisfaction suggests that the new virtual E-S.T.A.R.T.T course is able to continue to help providers develop important CRM skills in a multidisciplinary setting while remaining compliant with COVID-19 safety precautions.

A New Inexpensive Simulation Model for Ultrasound Assessment of Optic Nerve Sheath Diameter.

BACKGROUND: Sonographic measurement of optic nerve sheath diameter (ONSD) is becoming increasingly accepted as a diagnostic modality to detect elevations in intracranial pressure. As this technique becomes more widespread, methods to address the inherent operator-dependent nature of this modality will need to be developed. We propose a novel low-cost model to accurately simulate sonographic ONSD measurement for purposes of training and assessment. METHODS: We designed models composed of medical tubing of various diameters readily available from typical hospital supplies and suspended them in gelatin. The models were evaluated by ultrasound by three expert point-of-care sonographers using a standard linear array probe and technique proposed in the literature. RESULTS: This model generates faithful simulation of the ONS that closely approximates in vivo images and can be used to produce accurate, reproducible measurements. Materials are low cost and easy to acquire and assemble. CONCLUSIONS: Our model provides realistic simulated images of the ONS. Through comparison of sonographic measurements to the known tube diameters, this model serves as a promising inexpensive tool to teach the method of ultrasound assessment of ONSD or as a way to determine accuracy of this novel ultrasound technology.

Fidelity in surgical simulation: further lessons from the S.T.A.R.T.T. course

Summary: Simulation has become a popular and ubiquitous medical education tool. In response to learner demands, and because of technological advancement, there is a trend toward increasing the realism of simulation. However, there is a paucity of evidence regarding what degree of fidelity is needed to deliver optimal simulation-based medical education. Feedback from the Simulated Trauma And Resuscitation Team Training (S.T.A.R.T.T.) course suggests that higherfidelity simulation is viewed as highly valuable to learners. Research is needed in order to guide the growing demand for higher-fidelity simulation in our medical training curricula and in order to justify or mitigate the associated costs and logistical challenges.

Ultrasound in the surgical ICU: uses, abuses, and pitfalls.

PURPOSE OF REVIEW: Point-of-care ultrasound (POCUS) has become an integral component of daily care in the surgical ICU. There have been many novel advancements in the past two decades, too numerous to count. Many are of critical importance to the intensive care physician, whereas others are still accumulating evidence. Without appropriate training, diligence, and incorporation of the ultrasound findings into the whole clinical picture, this technique can be gravely misused. This review examines POCUS use in the surgical ICU, as well as highlights potential hazards and common pitfalls. RECENT FINDINGS: POCUS is essential for guidance of vascular access procedures, as well as in the characterization and treatment of respiratory failure, shock, and unstable blunt abdominal trauma. Ultrasound has growing evidence for rapidly evaluating many other diseases throughout the entire body, as well as guidance for procedures. Using advanced ultrasound techniques should only be done with corresponding levels of training and experience. SUMMARY: Ultrasound in the critical care setting has become an essential component of the assessment of most ICU patients. As more evidence accumulates, along with ever-increasing availability of ultrasound technology, its use will continue to expand. It, thus, behoves clinicians to not only ensure they are adept at obtaining and interpreting POCUS images but also efficiently incorporate these skills into holistic bedside care without delaying lifesaving therapies.

Effect of rater training on the reliability of technical skill assessments: a randomized controlled trial.

BACKGROUND: Rater training improves the reliability of observational assessment tools but has not been well studied for technical skills. This study assessed whether rater training could improve the reliability of technical skill assessment. METHODS: Academic and community surgeons in Royal College of Physicians and Surgeons of Canada surgical subspecialties were randomly allocated to either rater training (7-minute video incorporating frame-of-reference training elements) or no training. Participants then assessed trainees performing a suturing and knot-tying task using 3 assessment tools: a visual analogue scale, a task-specific checklist and a modified version of the Objective Structured Assessment of Technical Skill global rating scale (GRS). We measured interrater reliability (IRR) using intraclass correlation type 2. RESULTS: There were 24 surgeons in the training group and 23 in the no-training group. Mean assessment tool scores were not significantly different between the 2 groups. The training group had higher IRR than the no-training group on the visual analogue scale (0.71 v. 0.46), task-specific checklist (0.46 v. 0.33) and GRS (0.71 v. 0.61). However, confidence intervals were wide and overlapping for all 3 tools. CONCLUSION: For education purposes, the reliability of the visual analogue scale and GRS would be considered "good" for the training group but "moderate" for the no-training group. However, a significant difference in IRR was not shown, and reliability remained below the desired level of 0.8 for high-stakes testing. Training did not significantly improve assessment tool reliability. Although rater training may represent a way to improve reliability, further study is needed to determine effective training methods.

CONTEXTE: La formation des évaluateurs améliore la fiabilité des outils d'évaluation observationnels, mais n'a pas été rigoureusement étudiée au plan des habiletés techniques. Cette étude a tenté de vérifier si la formation des évaluateurs permettait d'améliorer la fiabilité de l'évaluation des habiletés techniques. MÉTHODES: On a assigné des chirurgiens universitaires et communautaires appartenant aux surspécialités chirurgicales du Collège royal des médecins et chirurgiens du Canada, soit à une formation des évaluateurs (vidéo de 7 minutes comprenant des éléments de formation afférents au cadre de référence), soit à l'absence de formation. les participants ont ensuite évalué des stagiaires qui effectuaient tâches, telles sutures et nœuds, à l'aide de trois outils d'évaluation : échelle analogique visuelle, liste de vérification spécifique à la tâche et version modifiée de l'échelle d'appréciation globale (ÉAG) de l'Objective Structured Assessment of Technical Skill. Nous avons mesuré la fiabilité interévaluateurs (FIÉ) à l'aide de la corrélation intraclasse de type 2. RÉSULTATS: Il y avait 24 chirurgiens dans le groupe soumis à la formation et 23 dans le groupe non soumis à la formation. Les scores moyens des outils d'évaluation n'ont pas été significativement différents entre les deux groupes. Le groupe soumis à la formation a présenté une FIÉ plus élevée que l'autre groupe à l'échelle analogique visuelle (0,71 c. 0,46), à la liste de vérification spécifique à la tâche (0,46 c. 0,33) et à l'ÉAG (0,71 c. 0,61). Par contre, les intervalles de confiance étaient larges et se recoupaient pour les trois outils. CONCLUSION: Aux fins de la formation, la fiabilité de l'échelle analogique visuelle et de l'ÉAG serait considérée «.bonne.¼ pour le groupe soumis à la formation, mais «.modérée.¼ pour le groupe non soumis à la formation. On n'a toutefois pas démontré de différence significative quant à la FIÉ et la fiabilité est demeurée inférieure au niveau souhaité de 0,8 pour les tests importants. La formation n'a pas significativement amélioré la fiabilité de l'outil d'évaluation. Même si la formation des évaluateurs représente potentiellement une façon d'améliorer la fiabilité, il faudra approfondir la recherche pour déterminer quelles méthodes de formation sont efficaces.

A day in the life of emergency general surgery in Canada: a multicentre observational study.

BACKGROUND: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. METHODS: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. RESULTS: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). CONCLUSION: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

CONTEXTE: Les services de chirurgie générale d'urgence (CGU) gagnent en popularité au Canada en tant qu'approches systémiques aux urgences chirurgicales. Malgré le volume élevé, le caractère urgent et la complexité des populations de patients desservies en CGU, peu de rapports ont porté sur la structure, les processus, les clientèles ou les résultats de ces services. La présente étude instaure une démarche de surveillance nationale qui servira à définir et à améliorer la qualité des chirurgies destinées à cette population importante et hétérogène. MÉTHODES: Une étude transversale nationale sur les services de CGU a été réalisée sur une période de 24 heures en janvier 2017 dans 14 hôpitaux de 7 provinces canadiennes recrutés par l'entremise du comité pour les soins aigus de l'Association canadienne des chirurgiens généraux. On y a inclus les patients admis dans les services de CGU, les nouvelles consultations et les patients de l'extérieur suivis par les services de CGU pendant la période de l'étude. On a recueilli les caractéristiques démographiques des patients et les données sur les interventions, les procédures et les complications. RÉSULTATS: Douze sites ont fait état de la couverture assurée par les résidents. La plupart des services ont exclu la traumatologie. Dix sites disposaient de temps protégé au bloc opératoire. En tout, 393 rencontres avec des patients ont eu lieu pendant la période de l'étude (195/386 [50,4 %] chirurgicales, 191/386 [49,5 %] non chirurgicales), avec une moyenne de 3,8 chirurgies par service. La population regroupait des cas complexes : 136 patients (34,6 %) présentaient plus de 3 comorbidités. La clientèle était diversifiée et comprenait des cas de maladie de la vésicule biliaire (69 cas [17,8 %]) et de l'appendice (31 [8,0 %]), de même que des situations d'urgence délicates, telle qu'obstruction (56 [14,5 %]) et perforation (23 [5,9 %]). CONCLUSION: Leurs caractéristiques et leurs clientèles sont hétérogènes, mais les services de CGU sont tous achalandés et ils offrent tous des soins chirurgicaux et non chirurgicaux complets à des patients gravement malades porteurs d'importantes comorbidités.

Burst Suppression for ICP Control.

BACKGROUND: The goal of our study was to perform a systematic review of the literature to determine the effect that burst suppression has on intracranial pressure (ICP) control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and the Grading of Recommendation Assessment Development and Education (GRADE) methodology. RESULTS: Seven articles were considered for review. A total of 108 patients were studied, all receiving burst suppression therapy. Two studies failed to document a decrease in ICP with burst suppression therapy. There were reports of severe hypotension and increased infection rates with barbiturate-based therapy. Etomidate-based suppressive therapy was linked to severe renal dysfunction. CONCLUSIONS: There currently exists both Oxford level 2b and GRADE C evidence to support that achieving burst suppression reduces ICP, and also has no effect on ICP, in severe traumatic brain injury. The literature suggests burst suppression therapy may be useful for ICP reduction in certain cases, although these situations are currently unclear. In addition, the impact on patient functional outcome is unclear. Further prospective study is warranted.

Point of care ultrasonography use and training among trauma providers across Canada.

SUMMARY: Point of care ultrasonography (POCUS) is revolutionizing care of critically ill patients. However, training in POCUS is extremely variable, with no accepted curriculum or certification process. We aimed to delineate the training experience and use of POCUS among trauma providers across Canada via a secure e-questionnaire sent to members of the Trauma Association of Canada. This commentary discusses our survey results and argues for the standardization of POCUS training and certification in Canada.

S.T.A.R.T.T. plus: addition of prehospital personnel to a national multidisciplinary crisis resource management trauma team training course.

SUMMARY: The Simulated Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course is a unique multidisciplinary trauma team training course deliberately designed to address the common crisis resource management (CRM) skills of trauma team members. Moreover, the curriculum has been updated to also target the specific learning needs of individual participating professionals: physicians, nurses and respiratory therapists. This commentary outlines further modifications to the course curriculum in order to address the needs of a relatively undertargeted group: prehospital personnel (i.e., emergency medical services). Maintenance of high participant satisfaction, regardless of profession, suggests that the S.T.A.R.T.T. course can be readily modified to incorporate prehospital personnel without losing its utility or popularity.

Trauma simulation in bilingual Canada: Insurmountable barrier or unexpected strength? Insights from the first bilingual S.T.A.R.T.T. course.

SUMMARY: The Standardized Trauma and Resuscitation Team Training (S.T.A.R.T.T.) course focuses on training multidisciplinary trauma teams: surgeons/physicians, registered nurses (RNs), respiratory therapists (RTs) and, most recently, prehospital personnel. The S.T.A.R.T.T. curriculum highlights crisis management (CRM) skills: communication, teamwork, leadership, situational awareness and resource utilization. This commentary outlines the modifications made to the course curriculum in order to satisfy the learning needs of a bilingual audience. The results suggest that bilingual multidisciplinary CRM courses are feasible, are associated with high participant satisfaction and have no clear detriments.

Therapeutic Hypothermia for Refractory Status Epilepticus.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of therapeutic hypothermia for refractory status epilepticus (RSE) and its impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to May 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated by two independent reviewers, using both the Oxford and GRADE methodology. RESULTS: Overall, 13 studies were identified, with 10 manuscripts and 3 meeting abstracts. A total of 40 patients were treated. The common target temperature was 33 degrees Celsius, sustained for a median 48 hours. Patients displayed a 62.5%, 15% and 22.5% rate of seizure cessation, seizure reduction, and failure of treatment respectively. External cooling was utilized in the majority of cases. Deep venous thrombosis, coagulopathy and infections were the commonly reported complications. Two ongoing clinical trials were identified. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to support the use of therapeutic hypothermia to control seizures in RSE. Further prospective study is warranted.

Modern inhalational anesthetics for refractory status epilepticus.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of modern inhalational anesthetic agents for refractory status epilepticus and their impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2014), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendation Assessment Development and Education methodology by two independent reviewers. RESULTS: Overall, 19 studies were identified, with 16 manuscripts and 3 meeting abstracts. A total of 46 patients were treated. Adult (n=28) and pediatric patients (n=18) displayed 92.9% and 94.4% seizure control with treatment, respectively. Isoflurane was used in the majority of cases. Hypotension was the only complication described. CONCLUSIONS: Oxford level 4, Grading of Recommendation Assessment Development and Education D evidence exists to support the use of isoflurane in refractory status epilepticus to obtain burst suppression. Insufficient data exist to comment on the efficacy of desflurane and xenon at this time.

Lidocaine for Status Epilepticus in Pediatrics.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in pediatrics for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and Grading of Recommendations Assessment, Development, and Evaluation methodologies by two independent reviewers. RESULTS: Overall, 20 original studies were identified, with 19 manuscripts and one meeting abstract. Two hundred and thirty-five pediatric patients were treated for 252 episodes of SE/RSE. Patients had varying numbers of antiepileptic drugs (two to eight) on board before lidocaine therapy. During 20 of the 252 (7.9%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied, with some using bolus dosing alone; others used a combination of bolus and infusion therapy. Overall, 60.0% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 57.6% and 12.3%, respectively. Patient outcomes were sparingly reported. CONCLUSIONS: There currently exists Oxford level 2b, Grading of Recommendations Assessment Development, and Evaluation C evidence to support the consideration of lidocaine for SE and RSE in the pediatric population. Further prospective studies of lidocaine administration in this setting are warranted.

Indomethacin for control of ICP.

UNLABELLED: Our goal was to perform a systematic review of the literature on the use of indomethacin and its effects on intracranial pressure (ICP) in patients with neurological illness. All articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to July 2014), reference lists of relevant articles, and gray literature were searched. Two reviewers independently identified all manuscripts utilizing the following inclusion and exclusion criteria. INCLUSION CRITERIA: Humans, prospective studies (five or more patients), documented ICP response to indomethacin, and English. EXCLUSION CRITERIA: non-English, retrospective studies, no documentation of ICP response to indomethacin, and animal studies. A two-tier filter of references was conducted. First, we screened manuscripts by title and abstract. Second, those references passing the first filter were pulled, and the full manuscript was checked to see if it matched the criteria for inclusion. Two reviewers independently extracted data including population characteristics and treatment characteristics. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Our search strategy produced a total of 208 citations. Twelve original articles, 10 manuscripts, and 2 meeting proceeding, were considered for the review with all utilizing indomethacin, while documenting ICP in neurological patients. All studies were prospective. Across all studies, there were a total of 177 patients studied, with 152 receiving indomethacin and 25 serving as controls in a variety of heterogeneous studies. All but one study documented a decrease in ICP with indomethacin administration, with both bolus and continuous infusions. No significant complications were described. There currently exists Oxford level 2b, GRADE C evidence to support that indomethacin reduces ICP in the severe TBI population. Similar conclusions in other populations cannot be made at this time. Comments on its impact, on patient outcome, and side effects cannot be made given the available data. At this time, indomethacin for ICP control remains experimental and further prospective study is warranted.

Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator.

BACKGROUND: Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. METHODS: Medical students with no prior laparoscopic experience (novices, N = 12), junior surgical residents with some laparoscopic experience (intermediates, N = 12), and experienced surgeons (experts, N = 11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). RESULTS: We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. CONCLUSION: Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

A unique model for ultrasound assessment of optic nerve sheath diameter.

BACKGROUND: Ultrasonic assessment of optic nerve sheath diameter (ONSD) as a non-invasive measure of intracranial pressure (ICP) has been evaluated in the literature as a potential valid technique for rapid ICP estimation in the absence of invasive intracranial monitoring. The technique can be challenging to perform and little literature exists surrounding intra-operator variability. OBJECTIVES: In this study we describe the creation of a novel model of ONSD to be utilized in ultrasound training of this technique. We demonstrate the realistic ultrasonographic images created utilizing this novel model. METHODS: We designed ocular models composed of gelatin spheres and variable three dimensional printed cylinders, which simulate the globe of the eye and variable ONSD's respectively. These models were suspended in a gelatin background and ultrasound of the ONSD was conducted using standard techniques described in the literature. RESULTS: This model produces clear and accurate representation of ONSD that closely mimics in vivo images. It is affordable and easy to produce in large quantities, portending its use in an educational environment. CONCLUSIONS: Utilizing the standard linear array ultrasound probe for ONSD measurements in our model provided realistic images comparable to in vivo. This provides an affordable and exciting means to test intra- and inter- operator variability in a standardized environment. Knowing this, we can further apply this novel model of ONSD to ultrasound teaching and training courses with confidence in its ability and the technique's ability to produce consistent results.

A cross-sectional study evaluating the relationship between followership type and burnout amongst critical care followers.

INTRODUCTION: Healthcare teams include both leaders and followers, with followers making up the majority of the healthcare team. There are five followership styles which have been described by Kelly (1992) based on critical thinking and active engagement. We aim to explore if a relationship exists between followership style and burnout, and also with job satisfaction of followers within the critical care setting. Additionally, we aim to quantify the distribution of followership types amongst followers within the critical care setting. METHODS: Participants were recruited in person at random to participate in a single centered, cross sectional, four-part survey to determine their followership type (Kelly followership type), burnout (Maslach Burnout Inventory) and job satisfaction (Brayfiled-Rothe Survey and Work and Meaning Inventory). Correlations between followership type and burnout as well as followership type and job satisfaction were then determined. RESULTS: A total of 64 participants (27 residents and 37 critical care nurses) took part in the study. There was a weak-moderate correlation between independent critical thinking and personal accomplishment (R = 0.297), and moderate correlation to meaningful work (R = 0.390), and job satisfaction (R = -0.300). Active engagement was moderately correlated with personal accomplishment (R = 0.302), meaningful work (R = 0.448) and job satisfaction (R = -0.418). Neither independent critical thinking nor active engagement showed significant correlation with depersonalization and emotional exhaustion subscales. Most participants were characterized into effective/exemplary followership type with no statistically significant differences between nurses and residents. CONCLUSION: This research shows that by creating an environment which promotes critical thinking and active engagement, nurses and residents may display less burnout, and enhanced job satisfaction.

Accuracy of Optic Nerve Sheath Diameter Measurements in Pocket-Sized Ultrasound Devices in a Simulation Model.

Introduction: Transorbital sonographic measurement of optic nerve sheath diameter (ONSD) is an emerging non-invasive technique for the identification and monitoring of intracranial hypertension. In recent years, new pocket ultrasound devices have become available, and it is uncertain if they have the resolution to measure such small structures appropriately as compared to their predecessors. In this study, we measure the performance of three ultrasound units on a simulation model to establish their precision and accuracy. Methods: ONSD was measured by three expert point-of-care sonographers using ultrasound machines three times on each of seven discrete ONS model sizes ranging from 3.5 to 7.9 mm. Two pocket ultrasounds (IVIZ, Sonosite, and Lumify, Philips) and one standard-sized portable ultrasound (M-Turbo, Sonosite) were used. Measurements were analyzed for mean error and variance and tested for significance using blocked covariance matrix regression analyses. Results: The devices differed in their variances (Lumify: 0.19 mm2, M-Turbo: 0.26 mm2, IVIZ: 0.34 mm2) and their mean error (Lumify: -0.05 mm, M-Turbo: 0.10 mm, IVIZ: -0.10 mm). The difference in mean error between users is not significant (p = 0.45), but there is a significant difference in mean error between devices (p = 0.02). Conclusions: Accurate ONSD measurement is possible utilizing pocket-sized ultrasound, and in some cases, may be more accurate than larger portable ultrasound units. While the differences in these devices were statistically significant, all three were highly accurate, with one pocket device (Lumify) outperforming the rest. Further study in human subjects should be conducted prior to using pocket ultrasound devices for in vivo diagnosis of intracranial hypertension.