The Code Silver Exercise: a low-cost simulation alternative to prepare hospitals for an active shooter event.

Mass-shooting incidents have been increasing in recent years and Code Silver-the hospital response to a person with a weapon such as an active shooter in many Provinces or States in North America-is quickly shifting from a theoretical safety measure to a realistic scenario for which hospitals must prepare their staff. A Code Silver Exercise (CSE) involving an independent mental practice exercise with written responses to scenarios and questions, followed by a facilitated debrief with all participants, was conceptualized and trialled for feasibility and efficacy. The CSE was piloted as a quality improvement and emergency preparedness initiative in three different settings including in situ within a hospital Emergency Department or Intensive Care Unit, offsite in a large conference room workshop, and online via virtual platform. These sessions took place in 4 different cities in Canada and included 3 academic teaching hospitals. Participants of the in situ and virtual CSE completed pre- and post-simulation surveys which showed improved understanding of Code Silver protocols following participation.The CSE is a reproducible simulation alternative, designed to operationalize a Code Silver policy at a large healthcare institution in a sustainable way. This training model can be administered in multiple settings in-person (in situ or offsite), and virtually, making it versatile and easily accessible for participants. This exercise enables participants to mentally rehearse practical responses to an active shooter in their unique work environments and to discuss ethical and medical-legal implications of their responses during a facilitated debrief with fellow healthcare providers. Implementation of a CSE for training in hospitals may help staff to create a mental schema prior to an active shooter event, and thus indirectly improve the chances of survivability in the event of a real active shooter situation.

Interactive virtual cases for emergency medicine physicians during the COVID-19 pandemic.

Continuing professional development activities often involve interactive learning modalities, such as simulation. The COVID-19 pandemic limited many in-hospital activities, at a time when practicing high stress procedural scenarios and testing rapidly evolving processes was coveted. Thus, an interactive virtual case curriculum was conceptualized, piloted, and implemented to provide ongoing professional development for emergency medicine (EM) physicians. Each interactive virtual case consisted of: (1) an online scenario delivered in survey format with multiple pathways dependent on participant responses; (2) a facilitated 1-h online debrief 1 week later; and (3) a summary document detailing key learning points distributed to all EM physicians, regardless of participation. This reproducible interactive virtual learning model influenced EM physician practice and confidence, improved participation in continuing professional development activities, and identified departmental areas for improvement. Participants have expressed a desire for these interactive virtual cases to continue for beyond the COVID-19 pandemic.

RÉSUMÉ: Les activités de développement professionnel continu font souvent appel à des modalités d'apprentissage interactives telles que la simulation. La pandémie de COVID-19 a limité de nombreuses activités en milieu hospitalier, à une époque où la pratique de scénarios de procédures à haut niveau de stress et l'essai de processus en évolution rapide étaient convoités. Ainsi, un programme interactif de cas virtuels a été conceptualisé, piloté et mis en œuvre pour assurer le développement professionnel continu aux médecins de médecine d'urgence (MU). Chaque cas virtuel interactif consistait en: 1) un scénario en ligne présenté sous la forme d'une enquête avec plusieurs parcours en fonction des réponses des participants; 2) un débriefing en ligne d'une heure, une semaine plus tard; et 3) un document de synthèse détaillant les principaux points d'apprentissage distribué à tous les médecins de médecine d'urgence, quelle que soit leur participation. Ce modèle d'apprentissage virtuel interactif reproductible a influencé la pratique et la confiance de médecin urgentiste, a amélioré la participation aux activités de développement professionnel continu et a identifié les domaines d'amélioration du service. Les participants ont exprimé le souhait que ces cas virtuels interactifs se poursuivent au-delà de la pandémie COVID-19.

Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial.

OBJECTIVES: Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners' rates of omission of tasks during simulated airway management scenarios. METHODS: Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey. RESULTS: The average percentage of omitted tasks over three scenarios was 45.7% in the control group (n = 25) and 13.5% in the checklist group (n = 29)-an absolute difference of 32.2% (95% CI 27.8, 36.6%). Time to definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI -18.0 to 98.0 respectively). CONCLUSIONS: In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management.

RéSUMé: OBJECTIFS: Des listes de contrôle ont été utilisées pour réduire les événements indésirables associés aux procédures médicales. La simulation offre un cadre sûr pour évaluer une nouvelle liste de contrôle. L'objectif de cette étude était de déterminer si l'utilisation d'une nouvelle liste de contrôle de péri-intubation permettrait de réduire les taux d'omission de tâches des praticiens lors de scénarios de gestion des voies aériennes simulés. MéTHODES: Cinquante-quatre praticiens de médecine d'urgence de deux centres universitaires ont été randomisés selon leur approche habituelle ou l'utilisation de notre liste de contrôle, puis ont réalisé trois scénarios de gestion des voies aériennes simulés. Un minimum de deux évaluateurs ont documenté le nombre de tâches omises et le délai avant la gestion définitive des voies respiratoires. Les divergences entre les évaluateurs ont été résolues par la revue vidéo d'un seul évaluateur. Les participants ont également rempli une enquête post-simulation. RéSULTATS: Le pourcentage moyen de tâches omises sur trois scénarios était de 45,7 % dans le groupe témoin (n = 25) et de 13,5 % dans le groupe liste de contrôle (n = 29) - une différence absolue de 32,2 % (IC à 95 %: 27,8 %, 36,6 %). Le délai de prise en charge définitive des voies respiratoires était plus long dans le groupe liste de contrôle dans les deux premiers des trois scénarios (différence de 110,0 s, IC à 95% : 55,0 à 167,0 ; 83,0 s, IC à 95 % : 35,0 à 128,0 ; et 36,0 s, IC à 95 % : -18,0 à 98,0 respectivement). CONCLUSIONS: Dans cet essai contrôlé randomisé à double centre, l'utilisation d'une liste de contrôle des voies respiratoires dans un environnement simulé a considérablement réduit le nombre de tâches importantes des voies respiratoires omises par les praticiens de médecine d'urgence, mais a prolongé le délai de prise en charge définitive des voies aérienne.

Calcium binds and rigidifies the dysferlin C2A domain in a tightly coupled manner.

The membrane protein dysferlin (DYSF) is important for calcium-activated plasma membrane repair, especially in muscle fibre cells. Nearly 600 mutations in the DYSF gene have been identified that are causative for rare genetic forms of muscular dystrophy. The dysferlin protein consists of seven C2 domains (C2A-C2G, 13%-33% identity) used to recruit calcium ions and traffic accessory proteins and vesicles to injured membrane sites needed to reseal a wound. Amongst these, the C2A is the most prominent facilitating the calcium-sensitive interaction with membrane surfaces. In this work, we determined the calcium-free and calcium-bound structures of the dysferlin C2A domain using NMR spectroscopy and X-ray crystallography. We show that binding two calcium ions to this domain reduces the flexibility of the Ca2+-binding loops in the structure. Furthermore, calcium titration and mutagenesis experiments reveal the tight coupling of these calcium-binding sites whereby the elimination of one site abolishes calcium binding to its partner site. We propose that the electrostatic potential distributed by the flexible, negatively charged calcium-binding loops in the dysferlin C2A domain control first contact with calcium that promotes subsequent binding. Based on these results, we hypothesize that dysferlin uses a 'calcium-catching' mechanism to respond to calcium influx during membrane repair.

Simulation in the Continuing Professional Development of Academic Emergency Physicians: A Canadian National Survey.

INTRODUCTION: Simulation is becoming a popular educational modality for physician continuing professional development (CPD). This study sought to characterize how simulation-based CPD (SBCPD) is being used in Canada and what academic emergency physicians (AEPs) desire in an SBCPD program. METHODS: Two national surveys were conducted from March to June 2018. First, the SBCPD Needs Assessment Survey was administered online to all full-time AEPs across 9 Canadian academic emergency medicine (EM) sites. Second, the SBCPD Status Survey was administered by telephone to the department representatives (DRs)-simulation directors or equivalent-at 20 Canadian academic EM sites. RESULTS: Response rates for the SBCPD Needs Assessment and the SBCPD Status Survey were 40% (252/635) and 100% (20/20) respectively. Sixty percent of Canadian academic EM sites reported using SBCPD, although only 30% reported dedicated funding support. Academic emergency physician responses demonstrated a median annual SBCPD of 3 hours. Reported incentivization for SBCPD participation varied with AEPs reporting less incentivization than DRs. Academic emergency physicians identified time commitments outside of shift, lack of opportunities, and lack of departmental funding as their top barriers to participation, whereas DRs thought AEPs fear of peer judgment and inexperience with simulation were substantial barriers. Content areas of interest for SBCPD were as follows: rare procedures, pediatric resuscitation, and neonatal resuscitation. Lastly, interprofessional involvement in SBCPD was valued by both DRs and AEPs. CONCLUSIONS: Simulation-based CPD programs are becoming common in Canadian academic EM sites. Our findings will guide program coordinators in addressing barriers to participation, selecting content, and determining the frequency of SBCPD events.

Simulation-based research in emergency medicine in Canada: Priorities and perspectives.

OBJECTIVE: Simulation plays an integral role in the Canadian healthcare system with applications in quality improvement, systems development, and medical education. High-quality, simulation-based research will ensure its effective use. This study sought to summarize simulation-based research activity and its facilitators and barriers, as well as establish priorities for simulation-based research in Canadian emergency medicine (EM). METHODS: Simulation-leads from Canadian departments or divisions of EM associated with a general FRCP-EM training program surveyed and documented active EM simulation-based research at their institutions and identified the perceived facilitators and barriers. Priorities for simulation-based research were generated by simulation-leads via a second survey; these were grouped into themes and finally endorsed by consensus during an in-person meeting of simulation leads. Priority themes were also reviewed by senior simulation educators. RESULTS: Twenty simulation-leads representing all 14 invited institutions participated in the study between February and May, 2018. Sixty-two active, simulation-based research projects were identified (median per institution = 4.5, IQR 4), as well as six common facilitators and five barriers. Forty-nine priorities for simulation-based research were reported and summarized into eight themes: simulation in competency-based medical education, simulation for inter-professional learning, simulation for summative assessment, simulation for continuing professional development, national curricular development, best practices in simulation-based education, simulation-based education outcomes, and simulation as an investigative methodology. CONCLUSION: This study summarized simulation-based research activity in EM in Canada, identified its perceived facilitators and barriers, and built national consensus on priority research themes. This represents the first step in the development of a simulation-based research agenda specific to Canadian EM.

Predictors of Hypothermia upon Trauma Center Arrival in Severe Trauma Patients Transported to Hospital via EMS.

Introduction: Hypothermia in severe trauma patients can increase mortality by 25%. Active warming practices decrease mortality and are recommended in the Advanced Trauma Life Support (ATLS) guidelines. Despite this, many emergency medical services (EMS) vehicles do not carry equipment necessary to perform active warming. The intent of this study was to determine the rate of hypothermia in severe trauma patients upon major trauma center (MTC) arrival, as well as to characterize factors associated with hypothermia in trauma in order to devote potential resources to those at highest risk. Methods: This single-center retrospective chart review included adults (age ≥ 18) in the local trauma registry (trauma team activation or injury severity score ≥12) from January 2009 to June 2016. Logistic regression was used to identify predictors of hypothermia on MTC arrival. Results: A total of 3,070 patient charts were reviewed, of which 159 (5.2%) were hypothermic. Multivariate logistic regression identified 7 factors that were significantly associated with hypothermia on MTC arrival in severe trauma. Risk factors for hypothermia on MTC arrival after severe trauma included: intubation pre-MTC, increased number of co-morbidities, and increased injury severity. Conversely, protective factors against hypothermia were: higher initial systolic blood pressure (SBP), penetrating injury, referral to MTC, and higher ambient outdoor temperatures. Median length of stay in hospital was 7 days for hypothermic patients compared to 4 days for normothermic patients (Δ 3 days; p < 0.001). Only 69.2% of hypothermic patients survived to discharge compared to 93.9% of normothermic patients (Δ 24.7%; χ2 = 133.4, p < 0.001). Conclusions: This retrospective study of hypothermia in major trauma patients found a rate of hypothermia of 5%. Factors associated with higher risk of hypothermia include pre-MTC intubation, high ISS, multiple comorbidities, low SBP, non-penetrating mechanism of injury, and being transferred directly to MTC, and colder outdoor temperature. Avoidance of hypothermia is imperative to the management of major trauma patients. Prospective studies are required to determine if prehospital warming in these high-risk patients decreases the rate of hypothermia in major trauma and improves patient outcomes.

Loss of the mammalian DREAM complex deregulates chondrocyte proliferation.

Mammalian DREAM is a conserved protein complex that functions in cellular quiescence. DREAM contains an E2F, a retinoblastoma (RB)-family protein, and the MuvB core (LIN9, LIN37, LIN52, LIN54, and RBBP4). In mammals, MuvB can alternatively bind to BMYB to form a complex that promotes mitotic gene expression. Because BMYB-MuvB is essential for proliferation, loss-of-function approaches to study MuvB have generated limited insight into DREAM function. Here, we report a gene-targeted mouse model that is uniquely deficient for DREAM complex assembly. We have targeted p107 (Rbl1) to prevent MuvB binding and combined it with deficiency for p130 (Rbl2). Our data demonstrate that cells from these mice preferentially assemble BMYB-MuvB complexes and fail to repress transcription. DREAM-deficient mice show defects in endochondral bone formation and die shortly after birth. Micro-computed tomography and histology demonstrate that in the absence of DREAM, chondrocytes fail to arrest proliferation. Since DREAM requires DYRK1A (dual-specificity tyrosine phosphorylation-regulated protein kinase 1A) phosphorylation of LIN52 for assembly, we utilized an embryonic bone culture system and pharmacologic inhibition of (DYRK) kinase to demonstrate a similar defect in endochondral bone growth. This reveals that assembly of mammalian DREAM is required to induce cell cycle exit in chondrocytes.