Cricothyrotomy in Acute Upper Gastrointestinal Bleed: A Difficult Airway Simulation Case for Anesthesiology Residents.

Introduction: Patients with acute upper gastrointestinal bleeding may have challenging airways. This simulation teaches anesthesiology residents the skill of cricothyrotomy as a surgical last resort while managing acute bleeding in the airway. Methods: The simulation involved a 55-year-old patient with history of alcohol abuse admitted to the ICU with hematemesis and acute blood loss for esophagogastroduodenoscopy in the ICU setting. The mannequin had tubing in the posterior oropharynx connected to a pressurized bag of simulated blood hidden from view. While conversing, the patient began to cough and gag, and the bag of fluid was opened, filling the posterior oropharynx with blood, which prompted immediate intubation attempts, designed to fail no matter what the learners attempted. When residents requested a surgical airway, they were provided with a cricothyrotomy kit and a task trainer to perform the procedure. Residents were evaluated using a behavior checklist, debriefed, then asked to complete a postsimulation survey. Results: Fifty-eight anesthesiology residents completed the simulation and provided feedback via a 5-point Likert scale of agreement. Most residents quickly recognized the need for emergency intubation. Eighty-eight percent of participants strongly agreed that the simulation was a valuable learning experience, with 99% stating it increased their confidence and clinical decision-making in handling similar scenarios in the future. Discussion: This simulation provides a chance to practice valuable airway management skills that increase resident confidence in cricothyrotomy. Future work may examine if these skills and confidence levels are sustainable over time and if they are applied in future patient encounters.

Situation, Background, Assessment, Recommendation (SBAR) Education for Health Care Students: Assessment of a Training Program.

Introduction: Interprofessional communication failures are estimated to be a factor in two-thirds of serious health care-related accidents. Using a standardized communication protocol during transfer of patient information between providers improves patient safety. An interprofessional education (IPE) event for first-year health professions students was designed using the Situation, Background, Assessment, Recommendation (SBAR) tool as a structured communication framework. IPE literature, including a valid measurement tool specifically tailored for SBAR, was utilized to design the Interprofessional Team Training Day (ITTD) and evaluate learner gains in SBAR skills. Methods: Learners from six educational programs participated in ITTD, which consisted of didactics, small-group discussion, and role-play using the SBAR protocol. Individual learners were assessed using the SBAR Brief Assessment Rubric for Learner Assessment (SBAR-LA) on SBAR communication skills before and after the ITTD event. Learners received a written clinical vignette and submitted video recordings of themselves simulating the use of SBAR to communicate to another health care professional. Pre- and postrecordings were scored using the SBAR-LA rubric. Normalized gain scores were calculated to estimate the improvement attributable to ITTD. Results: SBAR-LA scores increased for 60% of participants. For skills not demonstrated before the event, the average learner acquired 44% of those skills from ITTD. Learners demonstrated statistically significant increases for five of 10 SBAR-LA skills. Discussion: The value to patient safety of utilizing structured communication between health care providers is proven; however, evaluating IPE teaching of communication skills effectiveness is challenging. Using SBAR-LA, communication skills were shown to improve following ITTD.

Intraoperative Accidental Extubation during Thyroidectomy in a Known Difficult-Airway Patient: An Adult Simulation Case for Anesthesiology Residents.

Intraoperative accidental extubation on a known difficult-airway patient requires prompt attention. A good understanding of the steps to re-establish the airway is critical, especially when the patient is known to have a difficult airway documented or discovered on induction or acquires a difficult airway secondary to intraoperative events. The situation becomes even more complicated if the case has been handed off to another anesthesiologist, where specific and detailed information may not have been conveyed. This simulation was designed to train first-year clinical anesthesia residents. It was a 50 min encounter that focused on the management of complete loss of an airway during a thyroidectomy on a known difficult-airway patient. The endotracheal tube dislodgement was simulated by deliberate tube manipulation through the cervical access window of the mannequin. Learners received a formative assessment of their performance during the debrief, and most of the residents met the educational objectives. Learners were asked to complete a survey of their experience, and the feedback was positive and constructive. The response rate was 68% (17/25). Our simulation program helped anesthesiology residents develop intraoperative emergency airway management skills in a safe environment, as well as foster communication skills among anesthesiologists and the surgery team.

Intraoperative Tension Pneumothorax in a Trauma Patient: An Adult Simulation Case for Anesthesia Residents.

Anesthesiologists may encounter multiple obstacles in communication when attempting to collect information for emergency surgeries. Occult tension pneumothorax that was asymptomatic in the emergency department (ED) could become apparent upon positive pressure ventilation and pose a critical threat to the patient intraoperatively. Here, we describe a simulation exercise that was developed as a curriculum module for the Indiana University (IU) Anesthesiology residency program. It is primarily designed for first-year clinical anesthesia residents (CA-1/PGY-2). It is a 50 min encounter with two scenarios. The first scenario focuses on information collection and communication with a non-cooperative patient with multiple distractors. The second scenario focuses on the early diagnosis of tension pneumothorax and subsequent treatment. The residents were given formative feedback and met the educational objectives. Commonly missed critical actions included misdiagnosing the tension pneumothorax as mainstem intubation, bronchospasm, pulmonary thromboembolism, and anaphylaxis. Residents rated the feedback and debriefing as "extremely useful" or "very useful." Time constraints limit the number of residents who can sit in the "hot seat." The structure of the mannequin limits the ability to diagnose pneumothorax by auscultation and ultrasound. In the future, the scenarios may also be utilized to educate student anesthesiologist assistants and other non-physician anesthesia learners.

Development of a simulation technical competence curriculum for medical simulation fellows.

BACKGROUND AND NEEDS: Medical educators with simulation fellowship training have a unique skill set. Simulation fellowship graduates have the ability to handle basic and common troubleshooting issues with simulation software, hardware, and equipment setup. Outside of formal training programs such as this, simulation skills are inconsistently taught and organically learned. This is important to address because there are high expectations of medical educators who complete simulation fellowships. To fill the gap, we offer one way of teaching and assessing simulation technical skills within a fellowship curriculum and reflect on lessons learned throughout the process. This report describes the instructional designs, implementation, and program evaluation of an educational intervention: a simulation technology curriculum for simulation fellows. CURRICULUM DESIGN: The current iteration of the simulation technical skill curriculum was introduced in 2018 and took approximately 8 months to develop under the guidance of expert simulation technology specialists, simulation fellowship-trained faculty, and simulation center administrators. Kern's six steps to curriculum development was used as the guiding conceptual framework. The curriculum was categorized into four domains, which emerged from the outcome of a qualitative needs assessment. Instructional sessions occurred on 5 days spanning a 2-week block. The final session concluded with summative testing. PROGRAM EVALUATION: Fellows were administered summative objective structured exams at three stations. The performance was rated by instructors using station-specific checklists. Scores approached 100% accuracy/completion for all stations. CONCLUSIONS: The development of an evidence-based educational intervention, a simulation technical skill curriculum, was highly regarded by participants and demonstrated effective training of the simulation fellows. This curriculum serves as a template for other simulationists to implement formal training in simulation technical skills.

Resilience matters: Student perceptions of the impact of COVID-19 on medical education.

INTRODUCTION: We assessed students' perception of the impact of the pandemic on their well-being, education, academic achievement, and whether grit and resilience alter students' ability to mitigate the stress associated with disruptions in education. We hypothesized that students would report a negative impact, and those with higher grit and resilience scores would be less impacted. METHODS: A multidisciplinary team of educators created and distributed a survey to medical students. Survey results were analyzed using descriptive statistics, ANOVA, and multivariate linear regressions. A p-value <.05 was considered statistically significant. RESULTS: A total of 195 students were included in the study. Approximately 92% reported that clinical education was negatively affected, including participants with higher grit scores. Students with higher resilience scores were more optimistic about clinical education. Those with higher resilience scores were less likely to report anxiety, insomnia, and tiredness. CONCLUSION: More resilient students were able to manage the stress associated with the disruption in their education. Resiliency training should be year-specific, and integrated into the UME curriculum due to the different demands each year presents.

SBAR-LA: SBAR Brief Assessment Rubric for Learner Assessment.

Introduction: Structured communication tools are associated with improvement in information transfer and lead to improved patient safety. Situation, Background, Assessment, Recommendation (SBAR) is one such tool. Because there is a paucity of instruments to measure SBAR effectiveness, we developed and validated an assessment tool for use with prepractice health professions students. Methods: We developed the SBAR Brief Assessment Rubric for Learner Assessment (SBAR-LA) by starting with a preliminary list of items based on the SBAR framework. During an interprofessional team training event, students were trained in the use of SBAR. Subsequently, they were assigned to perform a simulated communication scenario demonstrating use of SBAR principles. We used 10 videos from these scenarios to refine the items and scales over two rounds. Finally, we applied the instrument on another subset of 10 students to conduct rater calibration and measure interrater reliability. Results: We used a total of 20 out of 225 videos of student performance to create the 10-item instrument. Interrater reliability was .672, and for eight items, the Fleiss' kappa was considered good or fair. Discussion: We developed a scoring rubric for teaching SBAR communication that met criteria for validity and demonstrated adequate interrater reliability. Our development process provided evidence of validity for the content, construct, and response process used. Additional evidence from the use of SBAR-LA in settings where communication skills can be directly observed, such as simulation and clinical environments, may further enhance the instrument's accuracy. The SBAR-LA is a valid and reliable instrument to assess student performance.

Modernizing Education of the Pediatric Anesthesiologist.

This article discusses modernizing the education of pediatric anesthesiologists in the United States. First, the current education requirements to become an American Board of Anesthesiology certified pediatric anesthesiologist are detailed and then, through a historical lens, the development of the subspecialty is examined. Gaps and challenges in the current training system are identified and interventions for improvement discussed. Additionally, suggestions are made and questions posed on how to move from a time-based model towards a competency-based curriculum.

Innovative Use of High-Fidelity Lung Simulators to Test a Ventilator Splitter Device.

The coronavirus disease 2019 (COVID-19) pandemic has rapidly exposed health care system inadequacies. Hospital ventilator shortages in Italy compelled US physicians to consider creative solutions, such as using Y-pieces or T-pieces, to preclude the need to make decisions of life or death based on medical equipment availability. We add to current knowledge and testing capacity for ventilator splitters by reporting the ability to examine the functionality of ventilator splitters by using 2 high-fidelity lung simulators. Data obtained by the high-fidelity lung simulators included: tidal volume, respiratory rate, minute ventilation, peak inspiratory pressure, peak plateau pressure, and positive end-expiratory pressure.

Intraoperative Sepsis: A Simulation Case for Anesthesiology Residents.

Introduction: Sepsis is a major cause of morbidity and mortality in medicine and is managed in ICUs daily. Critical care training is a vital part of anesthesiology residency, and understanding the presentation, management, and treatment of septic shock is fundamental to intraoperative patient care. Methods: This simulation involved a 58-year-old man undergoing surgical debridement of a peripancreatic cyst with hemodynamic instability and septic shock. We conducted the simulation yearly for clinical anesthesia year 2 residents (n = 26) in 1-hour sessions with three to five learners at a time. The simulation covered the six Anesthesiology Milestones related to sepsis and septic shock as outlined in the Anesthesiology Milestones Project. Results: To date, 155 anesthesiology residents have completed the simulation. Commonly missed critical actions included failure to recognize the need for invasive lines, provide appropriate volumes of fluid resuscitation, inquire about blood cultures and antibiotics, and recognize the need for the patient to remain intubated. Most participants could appropriately diagnose and treat intraoperative septic shock, but all had moments of action or inaction to discuss and improve upon, and all learned from this scenario. Discussion: Simulation is an optimal way to practice the more rare and life-threatening clinical events in medicine. Even though septic shock is commonly managed in the ICU, it is relatively uncommon for it to develop acutely in the OR. This simulation is an effective and educational way to discuss the most recent sepsis/septic shock definition and review evidence-based guidelines for treatment.

Identification of a motif that mediates polypyrimidine tract-binding protein-dependent internal ribosome entry.

We have identified a novel motif which consists of the sequence (CCU)(n) as part of a polypyrimidine-rich tract and permits internal ribosome entry. A number of constructs containing variations of this motif were generated and these were found to function as artificial internal ribosome entry segments (AIRESs) in vivo and in vitro in the presence of polypyrimidine tract-binding protein (PTB). The data show that for these sequences to function as IRESs the RNA must be present as a double-stranded stem and, in agreement with this, rather surprisingly, we show that PTB binds strongly to double-stranded RNA. All the cellular 5' untranslated regions (UTRs) tested that harbor this sequence were shown to contain internal ribosome entry segments that are dependent upon PTB for function in vivo and in vitro. This therefore raises the possibility that PTB or its interacting protein partners could provide a bridge between the IRES-RNA and the ribosome. Given the number of putative cellular IRESs that could be dependent on PTB for function, these data strongly suggest that PTB-1 is a universal IRES-trans-acting factor.

Bag-1 internal ribosome entry segment activity is promoted by structural changes mediated by poly(rC) binding protein 1 and recruitment of polypyrimidine tract binding protein 1.

We have shown previously that an internal ribosome entry segment (IRES) directs the synthesis of the p36 isoform of Bag-1 and that polypyrimidine tract binding protein 1 (PTB-1) and poly(rC) binding protein 1 (PCBP1) stimulate IRES-mediated translation initiation in vitro and in vivo. Here, a secondary structural model of the Bag-1 IRES has been derived by using chemical and enzymatic probing data as constraints on the RNA folding algorithm Mfold. The ribosome entry window has been identified within this structural model and is located in a region in which many residues are involved in base-pairing interactions. The interactions of PTB-1 and PCBP1 with their cognate binding sites on the IRES disrupt many of the RNA-RNA interactions, and this creates a largely unstructured region of approximately 40 nucleotides that could permit ribosome binding. Mutational analysis of the PTB-1 and PCBP1 binding sites suggests that PCBP1 acts as an RNA chaperone to open the RNA in the vicinity of the ribosome entry window while PTB-1 is probably an essential part of the preinitiation complex.

L-Myc protein synthesis is initiated by internal ribosome entry.

An internal ribosome entry segment (IRES) has been identified in the 5' untranslated region (5' UTR) of two members of the myc family of proto-oncogenes, c-myc and N-myc. Hence, the synthesis of c-Myc and N-Myc polypeptides can involve the alternative mechanism of internal initiation. Here, we show that the 5' UTR of L-myc, another myc family member, also contains an IRES. Previous studies have shown that the translation of mRNAs containing the c-myc and N-myc IRESs can involve both cap-dependent initiation and internal initiation. In contrast, the data presented here suggest that internal initiation can account for all of the translation initiation that occurs on an mRNA with the L-myc IRES in its 5' UTR. Like many other cellular IRESs, the L-myc IRES appears to be modular in nature and the entire 5' UTR is required for maximum IRES efficiency. The ribosome entry window within the L-myc IRES is located some distance upstream of the initiation codon, and thus, this IRES uses a "land and scan" mechanism to initiate translation. Finally, we have derived a secondary structural model for the IRES. The model confirms that the L-myc IRES is highly structured and predicts that a pseudoknot may form near the 5' end of the mRNA.

Members of the poly (rC) binding protein family stimulate the activity of the c-myc internal ribosome entry segment in vitro and in vivo.

The 5' untranslated region of the proto-oncogene c-myc contains an internal ribosome entry segment and c-Myc translation can be initiated by cap-independent as well as cap-dependent mechanisms. In contrast to the process of cap-dependent initiation, the trans-acting factor requirements for cellular internal ribosome entry are poorly understood. Here, we show that members of the poly (rC) binding protein family, poly (rC) binding protein 1 (PCBP1), poly (rC) binding protein 2 (PCBP2) and hnRNPK were able to activate the IRES in vitro up to threefold when added in combination with upstream of N-ras and unr-interacting protein. The interactions of PCBP1, PCBP2 and hnRNPK with c-myc-IRES-RNA were shown to be specific by ultraviolet crosslinking analysis and electrophoretic mobility shift assays, while immunoprecipitation of the three proteins using specific antibodies followed by reverse transcriptase-polymerase chain reaction showed that they were able to bind c-myc mRNA. c-myc-IRES-mediated translation from the reporter vector was stimulated by cotransfection of plasmids encoding PCBP1, PCBP2 and hnRNPK. Interestingly, the mutated version of the c-myc IRES that is prevalent in patients with multiple myeloma bound hnRNPK more efficiently in vitro and was stimulated by hnRNPK to a greater extent in vivo.

The Apaf-1 internal ribosome entry segment attains the correct structural conformation for function via interactions with PTB and unr.

We have shown previously that polypyrimidine tract binding protein 1 (PTB) binds and activates the Apaf-1 internal ribosome entry segment (IRES) when the protein upstream of N-ras (unr) is prebound. Here we show that the Apaf-1 IRES is highly active in neuronal-derived cell lines due to the presence of the neuronal-enhanced version of PTB, nPTB. The unr and PTB/nPTB binding sites have been located on the Apaf-1 IRES RNA, and a structural model for the IRES bound to these proteins has been derived. The ribosome landing site has been located to a single-stranded region, and this is generated by the binding of the nPTB and unr to the RNA. These data suggest that unr and nPTB act as RNA chaperones by changing the structure of the IRES into one that permits translation initiation.

Polypyrimidine tract binding protein and poly r(C) binding protein 1 interact with the BAG-1 IRES and stimulate its activity in vitro and in vivo.

The 5'-untranslated region of Bag-1 mRNA contains an internal ribosome entry segment (IRES) and the translation of Bag-1 protein can be initiated by both cap-dependent and cap-independent mechanisms. In general, cellular IRESs require non-canonical trans-acting factors for their activity, however, very few of the proteins that act on cellular IRESs have been identified. Proteins that interact with viral IRESs have also been shown to stimulate the activity of cellular IRESs and therefore the ability of a range of known viral trans-acting factors to stimulate the Bag-1 IRES was tested. Two proteins, poly r(C) binding protein 1 (PCBP1) and polypyrimidine tract binding protein (PTB), were found to increase the activity of the Bag-1 IRES in vitro and in vivo. The regions of the Bag-1 IRES RNA to which they bind have been determined, and it was shown that PCBP1 binds to a short 66 nt section of RNA, whilst PTB interacts with a number of sites over a larger area. The minimum section of the RNA that still retained activity was determined and both PCBP1 and PTB interacted with this region suggesting that these proteins are essential for Bag-1 IRES function.

Low proliferative and high migratory activity in the area of Brachyury expressing mesoderm progenitor cells in the gastrulating rabbit embryo.

General mechanisms initiating the gastrulation process in early animal development are still elusive, not least because embryonic morphology differs widely among species. The rabbit embryo is revived here as a model to study vertebrate gastrulation, because its relatively simple morphology at the appropriate stages makes interspecific differences and similarities particularly obvious between mammals and birds. Three approaches that centre on mesoderm specification as a key event at the start of gastrulation were chosen. (1) A cDNA fragment encoding 212 amino acids of the rabbit Brachyury gene was cloned by RT-PCR and used as a molecular marker for mesoderm progenitors. Whole-mount in situ hybridisation revealed single Brachyury-expressing cells in the epiblast at 6.2 days post conception, i.e. several hours before the first ingressing mesoderm cells can be detected histologically. With the anterior marginal crescent as a landmark, these mesoderm progenitors are shown to lie in a posterior quadrant of the embryonic disc, which we call the posterior gastrula extension (PGE), for reasons established during the following functional analysis. (2) Vital dye (DiI) labelling in vitro suggests that epiblast cells arrive in the PGE from anterior parts of the embryonic disc and then move within this area in a complex pattern of posterior, centripetal and anterior directions to form the primitive streak. (3) BrdU labelling shows that proliferation is reduced in the PGE, while the remaining anterior part of the embryonic disc contains several areas of increased proliferation. These results reveal similarities with the chick with respect to Brachyury expression and cellular migration. They differ, however, in that local differences in proliferation are not seen in the pre-streak avian embryo. Rather, rabbit epiblast cells start mesoderm differentiation in a way similar to Drosophila, where a transient downregulation of proliferation initiates mesoderm differentiation and, hence, gastrulation.