Ibero-American consensus on learning outcomes for the acquisition of competencies by medical students through clinical simulation.

OBJECTIVE: Our aim was to reach expert consensus on specific learning outcomes (LOs) that can be achieved through clinical simulation aimed at developing the competencies that medical students need to be able to successfully manage patients and assume general clinical responsibilities. MATERIALS AND METHODS: The six-member scientific committee peer-reviewed Spanish reference documentation (in line with the Bologna Process) on required competencies in medical undergraduate students to select an initial set of 16 competencies that could feasibly be developed through simulation and a corresponding set of 75 LOs. Snowball sampling was used to identify candidates for an international panel of simulation experts. Applying a set of pre-defined criteria, 19 panelists from seven Spanish-speaking regions were recruited to participate in a modified two-round Delphi procedure based on electronic questionnaires and aimed at reaching formal consensus on appropriate LOs for simulated medical training. RESULTS: Final agreement between the panelists was high: no mean score fell below 7.26 of a maximum of 9, and all 75 LOs were agreed on, 74 in the first round and only one requiring the second round. The 16 LOs with mean scores in the top 25th percentile were selected as a set of core LOs to attain via simulation. CONCLUSIONS: This Ibero-American consensus on observable and measurable LOs, reflecting competencies that can feasibly be developed via clinical simulation, is a framework that aims at helping medical schools' plans and delivering specific kinds of undergraduate medical training through simulation. It is also proposed in a set of core LOs as a starting point for less experienced schools to design a simulated training program.

Niveles de capnometría como indicador de evolución de injerto renal de donantes en asistolia no controlada / Capnometry levels as an indicator of renal graft evolution in uncontrolled non-heart beating donors

OBJETIVO: Los valores de capnometría durante la resucitación son un factor predictor de la evolución de los riñones obtenidos a partir de donantes en asistolia no controlada. DISEÑO: Cohorte de comienzo retrospectivo de 37 donantes en asistolia y cohorte de validación de 55 trasplantados de riñón, entre 2013-2017. Ámbito: Población atendida por el servicio de urgencias y derivada al Hospital Universitario 12 de Octubre, Madrid, como potenciales donantes en asistolia no controlada. PACIENTES: Cincuenta y cinco trasplantados renales con hemodiálisis, procedentes de donantes en asistolia no controlada. INTERVENCIONES: Determinaciones de capnometría y capnografía en pacientes candidatos a donación en asistolia no controlada. Variables: Calores de capnometría inicial y en el momento de la transferencia en el hospital para su comparación con la viabilidad de los riñones extraídos; fallo renal y retraso en función renal. RESULTADOS: Treinta y siete potenciales donantes de los que se consiguen 30 utilizados, de los cuales se trasplantan 55 riñones. El resto de ellos fueron descartados por mala perfusión o signos de isquemia. Se encontró una asociación (p = 0,016) entre valores de capnometría durante la resucitación en los donantes utilizados (μ, = 22,8 mmHg) frente a los donantes no utilizados para el trasplante (μ, = 17,35 mmHg). CONCLUSIONES: Se ha demostrado que los valores de capnometría durante las maniobras de resucitación ofrecen un marcador a tener en cuenta en relación con la viabilidad de los órganos a trasplantar en la donación en asistolia no controlada

OBJECTIVE: The capnometry values during resuscitation are an evolutive predictor of kidneys obtained from uncontrolled non-heart beating donors. DESIGN: The study comprised a retrospective onset cohort of 37 non-heart beating donors and a validation cohort of 55 trasplanted kidneys in the period 2013-2017. Scope: The population served by the emergency service and referred to Hospital Universitario Doce de Octubre (Madrid, Spain) as potential uncontrolled non-heart beating donors. PATIENTS: A total of 55 renal transplant patients subjected to hemodialysis and with grafts from uncontrolled non-heart beating donors. INTERVENTIONS: Capnometry and capnography measurements in potential uncontrolled non-heart beating donors. Variables: Capnometry values recorded initially and at transfer in hospital for comparison with the viability of the extracted kidneys; renal failure and delayed renal function. RESULTS: A total of 55 out of 74 extracted kidneys were trasplanted (74.3%). The rest were ruled out due to poor perfusion or signs of ischemia. An association was observed (P = .016) between the capnometry values during resuscitation in the grafted kidneys (μ = 22.8 mmHg) and in the kidneys discarded for transplantation (μ = 17.35 mmHg). CONCLUSIONS: Capnometry during resuscitation serves as a marker to be taken into account in relation to the viability of the trasplanted organs in uncontrolled non-heart beating donors

Capnometry levels as an indicator of renal graft evolution in uncontrolled non-heart beating donors. / Niveles de capnometría como indicador de evolución de injerto renal de donantes en asistolia no controlada.

OBJECTIVE: The capnometry values during resuscitation are an evolutive predictor of kidneys obtained from uncontrolled non-heart beating donors. DESIGN: The study comprised a retrospective onset cohort of 37 non-heart beating donors and a validation cohort of 55 trasplanted kidneys in the period 2013-2017. SCOPE: The population served by the emergency service and referred to Hospital Universitario Doce de Octubre (Madrid, Spain) as potential uncontrolled non-heart beating donors. PATIENTS: A total of 55 renal transplant patients subjected to hemodialysis and with grafts from uncontrolled non-heart beating donors. INTERVENTIONS: Capnometry and capnography measurements in potential uncontrolled non-heart beating donors. VARIABLES: Capnometry values recorded initially and at transfer in hospital for comparison with the viability of the extracted kidneys; renal failure and delayed renal function. RESULTS: A total of 55 out of 74 extracted kidneys were trasplanted (74.3%). The rest were ruled out due to poor perfusion or signs of ischemia. An association was observed (P=.016) between the capnometry values during resuscitation in the grafted kidneys (µ=22.8 mmHg) and in the kidneys discarded for transplantation (µ=17.35 mmHg). CONCLUSIONS: Capnometry during resuscitation serves as a marker to be taken into account in relation to the viability of the trasplanted organs in uncontrolled non-heart beating donors.

Reflexiones sobre el plan de atención al ictus en la Comunidad de Madrid / Reflections on the stroke care plan for the Region of Madrid

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[Validity of airway predictors in outpatient medicine]. / Validez de los predictores de vía aérea difícil en medicina extrahospitalaria.

Isolation of the airway sometimes determines the survival or death of the patient. To anticipate the presence of a difficult airway (DA) there are a number of indicators that are validated for hospitals: Mallampati, sternum and thyromental distance, interdental distance and Cormack grade. The aim of this study is to evaluate the use of these indicators in the ambulatory setting and to know the incidence of DA. This data was collected from 324 intubations. Most patients were males (65.2%). The average age of the population was 63 years and no significant difference in age between DA and DA was found. A DA presence of 20.7% was objectified and an alternative device utilization of 21.4%. The thyromental distance was abnormal in 59% of patients and sternomentonal distance in 56.4% but neither showed an association with the presence of DA (p = 0.681 and p = 0.415 respectively). Interdental distance was less than 3 cm if presence is associated with DA (p = 0.005). The sensitivity and specificity of all measures are low. According to our series the sternum and thyromental distance are not useful in the ambulatory setting, but interdental distance is useful for predicting a DA.

Comentario original. Unidades de soporte vital básico y avanzado en España: análisis de la situación actual / Coment on the original article. Basic and advanced life support units in Spain: analysis and current situations

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Traslado en helicóptero de donantes tras muerte cardiaca / Helicopter transport of cardiac death donors

Objetivo: Describir el traslado en helicóptero de potenciales donantes tras muerte cardiaca y comparar sus resultados con el traslado terrestre. Método: Se revisan todos los traslados en helicóptero desde 2005 hasta 2009 (53 meses).Resultados: La edad fue de 36 años, y la mayoría hombres (89%). El tiempo medio de llegada al hospital fue de 114 minutos. Se extrajeron 24 riñones, 5 hígados, 5 tejidos corneales, 4 tejidos óseos y 1 pulmón (2,6 órganos o tejidos por donante). La evolución posterior de estos injertos fue similar que la de los procedentes de los donantes trasladados por vía terrestre, y en concreto se obtuvo una tasa de no función primaria del 11% y una supervivencia del receptor a los dos años del 94%. Conclusión: El rendimiento en los donantes trasladados en helicóptero es similar al delos donantes trasladados por vía terrestre (AU)

Since 2005 helicopters have been used to transport potential donors after cardiac death. This study aims to describe this means of transport and compare outcomes to those for donors transported over land. Helicopter transfers during a 53-month period were included. Fifteen were carried out. The mean donor age was 36 years; most were men (89%). The mean duration of flights was 113 minutes and 46 seconds. Twenty-four kidneys, 5 livers, 5 corneas, 4 bone grafts, and 1lung were recovered (mean of 2.6 organs or tissues per donor). The outcomes for these grafts were similar to those for tissues and organs from donors transported over land. The rate of primary graft failure of kidneys from helicopter transporteddonors was 11% and the rate of 2-year survival of recipients was 94%. These rates are also similar to those for land-transferred donors (AU)

Actitud de los profesionales de emergencia ante la donación de órganos tras una muerte cardiaca / Emergency staff attitudes toward organ donation after cardiac death

Objetivo: La donación tras una muerte cardiaca constituye una alternativa eficaz a la donación tras la muerte encefálica. Existen estudios que comprueban la importancia de los profesionales sanitarios en la actitud de la familia ante la donación y otros exploran la actitud de estos profesionales. El objetivo de nuestra investigación es conocer la actitud de los profesionales de emergencia ante la donación tras muerte cardiaca. Método: Se envió una encuesta que preguntaba sobre la opinión de los médicos, enfermeros y técnicos de los equipos de soporte vital avanzado del SUMMA112 acerca de aspectos de la donación de órganos y tejidos, y evalúan si existen diferencias entre colectivos. Resultados: Se recogieron 180 contestaciones, la mayoría varones (61,7%). El 54,4%de los encuestados activan el protocolo de donación tras 20 minutos de reanimación cardiopulmonar. Al 57,2% de los encuestados de donación le supone un gran estrés informar a la familia del fallecimiento y un 59,4% dice no sentirse preparado. El 99% de los encuestados está de acuerdo con la donación. Un 87,2% de los encuestados donaría sus órganos. El 97,8% cree que son necesarios cursos de comunicación de malas noticias. No existen grandes diferencias entre los distintos colectivos. Conclusión: Aunque la predisposición de los profesionales del SUMMA 112 es buena y uniforme entre sus profesionales, creen necesaria una formación específica (AU)

Objetives: Organ donation after cardiac death is an effective alternative to donation after brain death. Studies have shown that health care staff have considerable influence on family attitudes toward donation. Researchers have also explored the attitudes of staff members. We aimed to determine emergency staff attitudes to donation after cardiac death. Methods: A survey questionnaire concerning attitudes toward organ and tissue donation sought the opinions of physicians, nurses, and ambulance staff of the advanced life support teams of the SUMMA112 emergency service of Madrid, Spain. We analyzed the results to detect differences among groups of respondents. Results: A total of 180 responses (61.7% from men) were received; 54.4% of the respondents report that they apply the protocol after 20 minutes of cardiopulmonary resuscitation. Informing the family of the death is very important according to 57.2%, but 59.4% declared that they felt lack of preparation. Ninety-nine percent approved of organ donation, and87.2% would like to be organ donors. Courses on how to communicate unwelcome news are needed according to 97.8%. Nogross differences were found among profesional categories. Conclusions: The SUMMA 112 emergency care professionals are similarly and well disposed to give information in this seetting, but they feel a need for specific training (AU)

Programa de formación de residentes en un sistema de emergencias extrahospitalarias / Emergency medicine residency training for out-of-hospital emergencies

En el nuevo programa de la especialidad de Medicina Familiar y Comunitaria (MFyC) se incluye un periodo de rotación en formato de guardias en servicios de urgencias de atención primaria y de emergencias. Este periodo varía entre el 25% de las guardias de los residentes de primer año y el 75% de los de cuarto año. En este sentido en la Comunidad de Madrid toda la asistencia de urgencias y emergencias es competencia del Servicio de Urgencia Médica de Madrid SUMMA112, por lo que este Servicio ha puesto en marcha un programa específico para dar cabida a estos residentes, lo cual resulta novedoso para los Servicios de Emergencias Médicas en general al carecer en España, a día de hoy, de una especialidad específica de Medicina de Urgencias y Emergencias. Se ha creado una unidad docente de MFyC con coordinador, tutores y comisión asesora. Se ha redactado un programa formativo del SUMMA112 que se extrae del programa formativo de la comisión nacional de la especialidad de MFyC. Pero, además, se ha ampliado con algunas competencias muy específicas de los servicios de emergencias que no venían recogidas en el documento anterior. Asimismo, se ha elaborado un plan sobre la metodología docente a aplicar y un plan evaluativo global para que todos los tutores lleven una línea educativa similar. El objetivo de este artículo es explicar estas mejoras, puesto que puede constituir un buen punto de partida para cuando se apruebe la especialidad de Medicina de Urgencias y Emergencias en España (AU)

The new residency training program in family and community medicine requires a rotation responding to calls received by primary care and emergency services. The intensity of these rotations ranges from 25% of calls for first-year residents to 75% for fourth-year trainees. All emergencies in the Spanish autonomous community of Madrid are handled by the SUMMA112 emergency medical service, which has developed and launched a program specifically for these residents. The program is new to Spain, where until now no specialty training in emergency medicine has been offered. The developers created an educational unit with a coordinator, instructors in family and community medicine, and an organizing committee. The SUMMA112 syllabus is compatible with the training program of the Spanish national board for the specialty of family and community medicine, although additional competencies that are highly specific to emergency health services have been incorporated. Teaching and assessment methods have also been planned so that instructors will take a similar educational approach. This article explains these improvements to the syllabus so that the description can serve as a starting point once the specialty in emergency medicine is approved in Spain (AU)

Instrucciones previas: actitud de los profesionales de emergencias / “Aforegoing instructions”: attitude of the emergency care professionals

Objetivo: Mediante las instrucciones previas (IP) una persona puede plasmar en un documento las preferencias que tiene con relación a los cuidados de salud y destino de su cuerpo u órganos una vez él no está capacitado para expresarlo. El objetivo de este estudio es conocer el grado de conocimiento y aceptación de las IP entre médicos y enfermeros de un servicio de emergencias extrahospitalario. Material y Método: Se enviaron encuestas autoadministradas a todos los profesionales sanitarios del servicio con una serie de preguntas. Resultados: De las 200 encuestas enviadas sólo fueron contestadas 49. El 58,3% de los respondedores eran enfermeros y el 41,7% médicos. A la pregunta ¿sabe lo qué es un documento de voluntades anticipadas? contestaron afirmativamente el 73,5% de los respondedores. A la pregunta ¿sabe lo qué es una orden de no iniciar reanimación cardiopulmonar (RCP)? contestaron sí el 81,6%. El 51% afirmaron haber preguntado alguna vez sobre si alguien conocía las preferencias del paciente antes de iniciar maniobras de RCP. El 83,3% de los que respondieron la encuesta estaban dispuestos a hacerse una IP. Ninguno de los respondedores tenían una IP a su nombre. Sólo un 18,4% afirmaba conocer la legislación vigente al respecto. Conclusión: Con estos datos se concluye que las IP tienen una buena aceptación entre los profesionales sanitarios pero todavía tienen poca información sobre la misma (AU)

Aims and purpose: Through a document of “aforegoing instructions” (Vital Testament, Previous Dispositions), any person may lay down documentarily his or her preferences regarding health care and the final destination of his/her body and/or organs whenever the time should come that he/she is not able to personally exptress them. The aim of the present work is to assess thre degree of knowledge and acceptance of such “Aforegoing Instructions” documnts among health care professionals (medical and nursing staff) of an extrahospitalary emergency service. Material and methods: Self-administered survey questionnaires with a number of items / questions were sent to all health care professionals in the Service. Results: Only 49 questionnaires out of 200 mailed were completed and returned. Among the total number of responders, 58.3% were nurses (male and female) and 41.7% physicians. The question asking whether the surveyee knew what an “aforegoing instructions” (anticipated will, vital testament, etc.) document is was answered in the positive by 73.5% of the responders; 81.6% answered affirmatively to the question whether they knew what an order not to begin advanced cardiopulmonary resuscitation or DNAR. Fifty-one per cent stated they had sometime asked whether anyone knew or was aware of the patient’s preferences before starting CPR manoeuvres. Some 83.3% of the responders stated they would be willing to prepare an “Aforegoing Instructions” document for themselves, yet none had done so. Only 18.4% stated they knew the current legislation involved. Conclusions: Considering the above data, we conclude that “Aforegoing Instructions” documents enjoy good acceptance among health care professionals, yet that the latter have as yet but scanty information on this subject (AU)

Características epidemiológicas del intento autolítico por fármacos / Epidemiological characteristics of autolytic attempts using drugs

I ntroducción: El intento autolítico (IA) supone uno de los motivos de llamada de emergencia más frecuente en nuestro medio. Uno de los métodos más habituales para realizar un IA es la utilización de fármacos. En el año 2005 casi un 1% de las llamadas de emergencia en la Comunidad de Madrid alertaban por un posible IA por fármacos. Nuestro objetivo es conocer las características de esta población. Material y método: Se revisan de forma retrospectiva las historias de 4 meses (septiembre-diciembre 2005) que hayan tenido como diagnóstico final “intento autolítico por fármacos”. Se recogieron las siguientes variables: edad, sexo, IA previos, patología psiquiátrica, fármaco y cantidad ingerida y tratamiento administrado. Resultados: Se recogieron 145 historias. De estos pacientes el 65,8% eran mujeres. La mediana de la edad se situó en 37 años. Un 19,2% habían realizado un IA previo. La patología psiquiátrica más frecuente fue el trastorno del estado de ánimo (43,4%) seguido de las dependencias (9%), los trastornos psicóticos (2,8%) y los trastornos de la alimentación (1,4%). El grupo de fármacos más utilizado fue las benzodiacepinas (57,6%), seguido de los inhibidores selectivos de la recaptación de la serotonina (7,9%). El fármaco más usado con fines autolíticos resulto ser el loracepam (15,1%), pero existe una gran variabilidad. El tratamiento extrahospitalario efectuado más veces fue la administración de flumazenilo (52,1%). Conclusiones: De nuestra serie se concluye que el paciente que más frecuentemente realiza un IA en nuestro medio es una mujer entre 20 y 40 años con trastorno del estado de ánimo que no ha tenido IA previos. Los fármacos más usados para el IA son las benzodiacepinas y, evidentemente, el tratamiento más veces aplicado fue el flumazenilo (AU)

Background: Suicidal or autolytic attempts (SA, AA) represent one of the most frequent causes for emergency calls in our environment. Drugs are among the most frequent instruments selected in and for SA / AA: in the year 2005, almost 1% of the emergency calls within the Autonomous Community of Madrid (Spain) alerted about possible drug-implemented SA / AA. The aim of the present study was to assess the characteristics of this particular population. Material and methods: Retrospective review of all clinical records over four months (September to December 2005) with a final diagnosis of “Drug-Implemented Autolytic Attempt”. The following variables were recorded and analysed: age, gender, previous SA / AA, psychiatric conditions, involved drug and ingested quantity, and implemented therapy. Results: A total of 145 clinical records were reviewed and analysed. Among this patient population, 65.8% were females. The age median was 37 years. A previous SA / AA was recorded in 19.2% of the cases. The most frequent associated psychiatric condition was depression / anxiety disorder (43.4%), followed by drug dependency states (9%), psychotic disorders (2.8%) and food intake disorders (1.4%). The most frequently involved drug group were the benzodiazepines (57.6%), followed by selective serotonin uptake inhibitors (7.9%). More precisely, the most frequently involved single drug was lorazepam (15.1%), though the variability was considerable. Flumazenil administration was the most frequently used (52.1%) extrahospitalary therapeutic measure. Conclusions: From our series it can be concluded that the patient most frequently undertaking a SA / AA in our environment is a female, 20 to 40 years old, with a depressive / anxious disorders and with no foregoing SA / AA. The drugs most frequently involved in such attempts are the benzodiazepines and, evidently, the most frequently applied therapeutic measure was flumazenil administration (AU)