Multidisciplinary Simulation Improves Resident Confidence for Pregnant Patients Requiring Surgical Intervention.

INTRODUCTION: Hepatocellular adenomas are a rare but serious cause of bleeding, which is further complicated by pregnancy. Interprofessional cooperation is a key component of residency education, thus simulations designed to integrate multiple programs are mutually beneficial. This simulation details surgical and obstetric management of a pregnant patient in hemorrhagic shock from a bleeding hepatocellular adenoma. Objectives for the study were to evaluate learners' confidence to 1) prioritize the care of a pregnant patient with hemoperitoneum and hemorrhagic shock, 2) demonstrate interdisciplinary collaboration with other specialties, 3) apply massive transfusion protocol (MTP) in the appropriate clinical setting, and 4) analyze critical decisions for evaluating pregnant females with severe abdominal pain. METHODS: Obstetric, general surgery, and anesthesia residents, along with labor and delivery nurses participated in a simulated clinical scenario that focused on the management of a pregnant patient in hemorrhagic shock. The learners evaluated the educational session using a standard Return on Investment in Learning survey immediately following the session. RESULTS: A total of 23 residents and medical students gave feedback on the experience. The main learning objectives were met with increased confidence in the four learning objectives by 77.3-95.4% of responders. Overall, greater than 90% of participants felt the simulation was relevant to their training and realistic, with 100% responding that the course provided new, or clarified existing information for them. CONCLUSION: A multidisciplinary simulation-based educational intervention was successful in improving learner confidence in managing a complicated surgical emergency in a pregnant patient with inter-residency cooperation.

Multidisciplinary Simulation of Trauma in Pregnancy with Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Utilization.

Background Studies have demonstrated the use of resuscitative endovascular balloon occlusion catheters of the aorta (REBOA) in the setting of postpartum hemorrhage and traumatic hemorrhagic shock. However, REBOA is infrequently utilized leading to a lack of clinician comfort. This study's aim was to demonstrate the utility of REBOA in a hemorrhaging pregnant trauma patient and improve clinician comfort with the placement of REBOA while emphasizing collaboration between medical specialties. Methods A multidisciplinary in-situ simulation was developed for the management of a pregnant patient with an abdominal gunshot wound evaluated by obstetrics and surgery teams. A trauma survey, emergency c-section, massive transfusion protocol (MTP), and evaluation for and placement of REBOA were indicated during the simulation. A standardized Return on Learning questionnaire was utilized to determine participants' reactions and confidence gained during the simulation. Results A total of 32 of 41 participants completed the survey (78%). A statistically significant increase in confidence was reported in the ability to prioritize the care of a pregnant patient with hemorrhagic shock (p = 0.016), apply MTP to the appropriate clinical setting (p = 0.03), and analyze critical decisions made for abdominal trauma in pregnant patients (p = 0.006). Specifically for physicians, a significant increase in confidence in the ability to identify indications/contraindications for REBOA placement in hemorrhaging patients was observed (p = 0.021). Conclusions A multidisciplinary simulation for the management of a pregnant patient in hemorrhagic shock secondary to penetrating abdominal trauma improved learner confidence in MTP, care of pregnant patients in hemorrhagic shock, and abdominal trauma in pregnancy. Physician learners gained confidence in indications for REBOA placement in abdominal trauma. This simulation was highly relevant to all participants.

So Much Moulage, So Little Time: A Guide to Performing Moulage for Mass Casualty Scenarios.

Simulation has become a central component of healthcare education. Allowing learners to experience low-frequency high-risk situations, such as a mass casualty event, in a safe learning environment is a basic tenet of simulation-based education in healthcare. Creating realistic simulations often involves advanced moulage to accurately represent illness and injury. However, providing advanced moulage for mass casualty exercises can be time-consuming, resource-intensive, and costly. Here we discuss a novel means to execute moulage for multiple victims while maintaining a high level of realism. We executed two simultaneous mass casualty exercises as part of medical student education and employed our novel 3-step moulage process. Step 1-Preparation included case development, generation of a victim list, and victim designation into "zones" within the simulation. Step 2-Creation entailed making wounds, in-house 3D printing materials, and assembling each victim's moulage bag. Step 3-Application was an assembly line method of executing all victims' moulage on the day of the simulation. This method of moulage supported the highly realistic simulation activity that learners have come to expect while decreasing time, resources, and cost.

Airway Obstacle Course for Teaching Prehospital Providers Airway Techniques.

BACKGROUND:  Early airway intervention is a vital step in the management of critically ill patients. Emergency medical service (EMS) providers are often first in the chain of survival with equipment to manage airway problems that arise. Therefore, it is paramount that they receive thorough training in aspects of airway management. Often, the training providers currently undergo does not reflect the environmental challenges inherent in EMS. Our obstacle course not only offers trainees a situational environment that simulates common challenges associated with the prehospital environment, but also provides a break from traditional tabletop and lecture-based training methods. METHODS:  An airway obstacle course was created that comprised four different "obstacles". Each obstacle was a patient in a precarious position requiring airway management, and the trainees could manage the obstacles in the order of their choosing. Trainees could choose from four different airway devices based on the local protocol. Once the device was used successfully, it could no longer be implemented in the course, and thus each device was used once. A validated return on the learning model was used for evaluating learning. RESULTS:  Immediately following training, 95.1% (78) trainees felt they were more confident with airway management. Nearly all, 96.4% (79), agreed that the scenarios in the obstacle course were realistic. Participants retained confidence gains in resource management for intubation at the six-month follow-up (p=0.010). In the six months following training, there was a doubling in the number of intubation attempts (24 to 48) and an overall drop in the success rate (75% to 63%). At the six-month follow-up, participants were able to describe specific events where the training helped them with patient management. CONCLUSIONS:  The model of an intubation obstacle course as a means of training EMS providers is both realistic to the participants and provides lasting effects to their confidence in resource management skills. Further studies are needed to determine its effects on intubation success rates and patient outcomes.

Simulation Improves Internal Medicine Resident Confidence With Defibrillation, Cardioversion, and Transcutaneous Pacemaker Use.

Introduction While many graduate medical education programs require residents to be certified in advanced cardiac life support, this does not cover all aspects of cardiac stabilization in patients with a pulse. Residents are often on the front lines of providing care to patients with life-threatening dysrhythmias. Our residents expressed a lack of confidence in their ability to provide this care. Methods A convenience sample of internal medicine, preliminary medicine, and transitional year residents from our large community-based tertiary care hospital participated in our survey and training. We utilized a pre-post survey method of our residents' confidence in domains that are critical to caring for patients requiring cardiac resuscitation and stabilization. Our pre-post survey was a modified Likert scale. Our training consisted of a 1-hour faculty-led hands-on training session focused on these critical domains in our hospital's simulation suites. Follow-up survey data were collected immediately after the training and at six and 11 months after the training using mean confidence across all five domains as the study variable. Results Resident mean confidence in the five domains (placing leads and pads, manipulating defibrillator controls, performing defibrillation, performing synchronized cardioversion, and performing transcutaneous pacemaker use) increased immediately after our training compared to before the training (p<0.001). This increase in confidence from before the training was sustained at six and 11 months after the training (p=0.001 and p=0.002, respectively). Confidence was lower at six and 11 months than immediately after training (p=0.01 and p=0.004, respectively). Conclusion Our project showed that simulation-based training was effective in improving our trainee's confidence in providing care to patients with life-threatening dysrhythmias. As with previous studies in simulation, confidence degradation was seen over time and likely mirrors skill degradation in these low-frequency encounters. As such, future aims include identification of ideal time intervals between training.

Disaster Day: A Simulation-Based Disaster Medicine Curriculum for Novice Learners.

BACKGROUND: Mass casualty and multi-victim incidents have increased in recent years due to a number of factors including natural disasters and terrorism. The Association of American Medical Colleges (AAMC) recommends that medical students be trained in disaster preparedness and response. However, a majority of United States medical students are not provided such education. OBJECTIVE: The goal of this study was to evaluate the effectiveness of a 1 day, immersive, simulation-based Disaster Day curriculum. SETTINGS AND DESIGN: Learners were first and second year medical students from a single institution. MATERIALS AND METHODS: Our education provided learners with information on disaster management, allowed for application of this knowledge with hands-on skill stations, and culminated in near full-scale simulation where learners could evaluate the knowledge and skills they had acquired. STATISTICAL ANALYSIS USED: To study the effectiveness of our Disaster Day curriculum, we conducted a single-group pretest-posttest and paired analysis of self-reported confidence data. RESULTS: A total of 40 first and second year medical students participated in Disaster Day as learners. Learners strongly agreed that this course provided new information or provided clarity on previous training, and they intended to use what they learned, 97.6% and 88.4%, respectively. CONCLUSIONS: Medical students' self-reported confidence of key disaster management concepts including victim triage, tourniquet application, and incident command improved after a simulation-based disaster curriculum. This Disaster Day curriculum provides students the ability to apply concepts learned in the classroom and better understand the real-life difficulties experienced in a resource limited environment.

In Situ Simulation to Promote Residents as Resuscitation Leaders.

Objectives  Our study sought to assess whether perceptions of residents as resuscitation team leaders could be improved by using emergency department (ED) in situ simulations involving ED staff. Secondarily, we monitored changes indicated in overall resuscitation team dynamics. Methods We conducted a prospective experimental study over the 2018-2019 academic year. Data were collected at a community-based ED with an emergency medicine residency program. Prior to starting the education, all ED staff including residents, attending physicians nurses and techs completed a survey of their perceptions of team performance and leadership during medical resuscitations. Throughout the year, residents and ED staff members were exposed to various in situ simulation scenarios. A follow-up survey was administered to reassess resident and ED staff perceptions of team dynamics and, specifically, residents as patient care team leaders. A relational coordination survey analysis was performed, dichotomized by professional domain. Results A total of 20 participants completed surveys before and after the in situ simulations, covering the professional domains with matched pre-simulation and post-simulation data showing significant improvement in communication and team dynamics for residents (p = 0.029) and other ED staff in medical resuscitations. Using residents as the team leaders for the simulation improved perceived leadership during resuscitation (p = 0.006). Conclusions Our study suggests that in situ simulation within the ED leads to improved team dynamics and defined roles while emphasizing the resident as a resuscitation leader.

In-Situ Simulation in Interdisciplinary Family Practice Improves Response to In-Office Emergencies.

Background Medical emergencies can present to family medicine offices. For optimal patient outcomes, multiple team members must come together to provide emergency care and mobilize the appropriate resources. In-situ simulation has been used to improve provider knowledge, skills, and attitudes as well as identify latent safety threats. The aim of this training was to provide family medicine physicians, nurses, and office staff education about how to manage in-office emergencies. Specifically, we sought to clarify team members' roles, improve communication, and identify latent safety threats. Methodology Two different in-situ simulations were performed with debriefing sessions. The first was a pediatric patient in respiratory distress. The second was a patient who presented for shortness of breath and became unresponsive in the lobby. Physicians, nurses, and office staff responded to the emergencies and used existing equipment and protocols to medically manage each patient. A standardized return on investment in learning survey evaluating the learners' confidence in managing in-office emergencies was completed by all learners immediately prior to and after the training. Results The training improved the participants' self-reported confidence in their ability to manage in-office emergencies. Additionally, participants believed they were better able to identify other team members' roles when responding to an in-office emergency. Learners were able to identify where knowledge gaps existed in current protocols, as well as aspects of the protocols that required updating. Lastly, the teams identified latent safety threats that were able to be mitigated by the practice. Conclusions In-situ simulation for high-risk, low-frequency in-office emergencies is a valuable tool to improve team members' confidence, identify knowledge gaps, and mitigate latent safety threats.

A Novel Simulation-Based Multidisciplinary Verbal De-escalation Training.

Background Agitated or aggressive patients pose a high risk of emotional and physical harm to hospital staff. Healthcare associates have the highest rate of workplace violence among studied fields. Learning to effectively de-escalate a patient who is a danger to self or others is key to reducing these incidents. This course was designed to improve education and communication among staff on a hospital surgical floor when verbal de-escalation is needed. Methods A ninety-minute simulation-based multidisciplinary curriculum was developed. This included a 30-minute didactic discussion, 10-minute simulation, and 50-minute debrief. Learners included nurses, patient service associates, and protective services officers from a medical/surgical unit. Data were collected using a validated return on investment in learning protocol and the Management of Aggression and Violence Attitude Scale (MAVAS) tool. Results Our return on investment in learning showed that more than 97% of learners felt safer in managing agitated patients after participating in the training. The MAVAS tool was used in pre- and post-format and showed a significant trend toward the importance of clear communication and role clarity when de-escalating a patient. Conclusions A combination of didactic teaching and simulated experience allowed for greater confidence, communication, and teamwork in de-escalating an agitated patient in a community hospital surgical unit.

Improving bariatric patient transport and care with simulation.

INTRODUCTION: Obesity is prevalent in the United States. Obese patients have physiologic differences from non-obese individuals. Not only does transport and maintenance of these patients require use of specialized equipment, but it also requires a distinct skill set and knowledge base. To date, there is no literature investigating simulation as a model for educating pre-hospital providers in the care of bariatric patients. The purpose of this study was to determine if a 3-hour educational course with simulation could improve paramedics' knowledge and confidence of bariatric procedures and transport. This study also examined if prior experience with bariatric transport affected training outcomes. METHODS: Our study took place in August 2012 during paramedic training sessions. Paramedics completed a pre- and post-test that assessed confidence and knowledge and provided information on previous experience. They had a 30-minute didactic and participated in 2 20-minute hands-on skills portions that reviewed procedural issues in bariatric patients, including airway procedures, peripheral venous and intraosseous access, and cardiopulmonary resuscitation. Study participants took part in one of two simulated patient encounters. Paramedics were challenged with treating emergent traumatic and/or medical conditions, as well as extricating and transporting bariatric patients. Each group underwent a debriefing of the scenario immediately following their case. We measured confidence using a 5-point Likert-type response scale ranging from 1 (strongly disagree) to 5 (strongly agree) on a 7-item questionnaire. We assessed knowledge with 12 multiple choice questions. Paired-sample t-tests were used to compare pre- and post-simulation confidence and knowledge with a significance level of p≤0.05. We used analysis of covariance to examine the effect of previous experiences on pre-and post-educational activity confidence and knowledge with a significance level of p ≤0.05. Proportions and 95% confidence intervals are presented as appropriate. We determined the magnitude of significant pre-post differences with Cohen's d. We assessed scale reliability using Cronbach's alpha and was found to be reliable with scores of 0.83 and 0.88 across pre- and post-test responses, respectively. RESULTS: Participants exhibited a significant increase in confidence in performing procedures (p<0.01) and knowledge of bariatric patient management (p<0.001) after the simulation. The current study also found an increase in knowledge of transport, vascular access/circulation and airway management (p<0.001). Participant background showed no effects on these changes. CONCLUSION: This study suggests that simulation paired with a didactic is an effective method of education for paramedics caring for and transporting bariatric patients. The data show a significant increase in knowledge and confidence with a 3-hour training session, irrespective of previous training or experience with bariatric patients. This is the first study of its kind to apply simulation training for the pre-hospital care of bariatric patients.

Predictors of epinephrine autoinjector needle length inadequacy.

BACKGROUND: Self-administered epinephrine is the primary out-of-hospital treatment of anaphylaxis. Intramuscular injection of epinephrine results in higher peak plasma concentration than subcutaneous injection. With the prevalence of obesity, autoinjectors may not have an adequate needle length for intramuscular injection. OBJECTIVES: To measure muscle depth and evaluate predictors of autoinjector needle length inadequacy. METHODS: We performed a prospective cross-sectional study of a convenience sample of low acuity emergency department patients aged 18 to 55 years. We recorded demographic data, measured thigh circumference, and calculated body mass index (BMI). Using ultrasound, we took depth-to-muscle measurements of the vastus lateralus in a standing position, with and without gentle pressure to simulate muscle compression that occurs with correct autoinjector use. We conducted univariate analyses using χ(2) and t tests with P ≤ .05 and 95% confidence intervals. We considered the patient a potential "failure" risk if his/her muscle depth exceeded 15.9 mm (longest available epinephrine autoinjectors needle). RESULTS: We enrolled 120 subjects with a mean BMI of 29.2 kg/m(2). Thirty-one percent (31%) of our sample were found to be failure risks (36/116; confidence interval, 22.6%-39.5%). Women were 6.4 times more likely than men to be a failure risk (54.4% vs 5% for men failure rate; P < .001). Failures were more likely to be shorter, have a higher BMI, and have larger thigh circumference (P < .001). We did not find any statistical difference in muscle depth for race, age, or weight. CONCLUSION: The current epinephrine autoinjector needle length is inadequate for intramuscular injection, especially among women.

The sonographic digital portfolio: a longitudinal ultrasound image tracking program.

BACKGROUND: Ultrasonography (US) at the medical student level is developing. As clinical skills and simulation centers expand, US equipment miniaturizes, and more students are exposed to ultrasound; a digital portfolio comprised of US images and videos may be useful in demonstrating experience and possibly competency. METHODS: Medical students participated in US curricula consisting of didactics and hands-on training. From 1 July 2006 to 30 June 2008, student images and videos were saved. Total images and videos were evaluated and catalogued. RESULTS: A total of 10,074 images and 1,227 videos were saved during the 2-year period. For the academic year 2006 to 2007, 159 medical students obtained 3,641 of the images (84.9%) and 270 of the videos (86.0%). First year students obtained 778 images and 20 videos; second year students, 1,174 images and 64 videos; third year students, 211 images and 20 videos; and fourth year students, 1,478 images and 166 videos.For the academic year 2007 to 2008, 222 medical students obtained 4,340 images (75%) and 619 videos (67.8%). First year students obtained 624 images and 109 videos; second year students, 555 images and 81 videos; third year students, 132 images and 14 videos; and fourth year students, 3,029 images and 415 videos. CONCLUSIONS: The ultrasound digital portfolio allows medical students to collate and document their ultrasound experience. Currently, there is no requirement for ultrasound training, documentation of competency, or minimum numbers of US exams for medical education. The ultrasound digital portfolio may be a useful tool in documenting ultrasound proficiency.

Propofol increases contractility during alpha1a-adrenoreceptor activation in adult rat cardiomyocytes.

BACKGROUND: The objective of this study was to identify the extent to which propofol alters intracellular free Ca2+ concentration ([Ca2+]i), myofilament Ca sensitivity, and contraction of individual cardiomyocytes during activation of alpha1a adrenoreceptors and to determine the cellular mechanism of action. METHODS: Freshly isolated ventricular myocytes were obtained from adult rat hearts. Myocyte shortening and [Ca2+]i were simultaneously monitored in individual cardiomyocytes exposed to phenylephrine after treatment with chloroethylclonidine (alpha1b-adrenoreceptor antagonist) and BMY 7378 (alpha1d-adrenoreceptor antagonist). Data are reported as mean +/- SD. RESULTS: Phenylephrine increased myocyte shortening by 124 +/- 9% (P = 0.002), whereas peak [Ca2+]i only increased by 8 +/- 3% (P = 0.110). Inhibition of phospholipase A2 and phospholipase C attenuated the phenylephrine-induced increase in shortening by 84 +/- 11% (P = 0.004) and 15 +/- 6% (P = 0.010), respectively. Inhibition of protein kinase C (PKC) and Rho kinase attenuated the phenylephrine-induced increase in shortening by 17 +/- 8% (P = 0.010) and 74 +/- 13% (P = 0.006), respectively. In the presence of phenylephrine, propofol increased shortening by 40 +/- 6% (P = 0.002), with no concomitant increase in [Ca2+]i. PKC inhibition prevented the propofol-induced increase in shortening. Selective inhibition of PKCalpha, PKCdelta, PKCepsilon, and PKCzeta reduced the propofol-induced increase in shortening by 12 +/- 5% (P = 0.011), 36 +/- 8% (P = 0.001), 32 +/- 9% (P = 0.007), and 19 +/- 5% (P = 0.008), respectively. Na+ - H+ exchange inhibition reduced the propofol-induced increase in shortening by 56 +/- 7% (P = 0.001). CONCLUSION: Activation of alpha1a adrenoreceptors increases cardiomyocyte shortening primarily via a phospholipase A2-dependent, Rho kinase-dependent increase in myofilament Ca2+ sensitivity. Propofol further increases myofilament Ca2+ sensitivity and shortening via a PKC-dependent pathway and an increase in Na+ - H+ exchange activity.