Background. In early 2020, the novel coronavirus pandemic forced communities around the globe to shut down and isolate. Routine graduate medical education activities have also been suspended as ...resident and fellow physicians-in-training have been re-deployed to support critical patient care services.
Innovation. We developed a two-part hybrid telesimulation model to teach COVID-19 ventilator management strategies while physically separating a group of learners and an instructor from one another. Learners consisted of non-ICU health care providers with limited experience in ventilator management being redeployed to manage ICU level COVID-19 infected patients. In the first week, the video tutorial has been viewed over 500 times and we have facilitated 14 telesimulation sessions, including 48 participants comprised of hospitalists, emergency medicine physicians and physician assistants, pediatric residents, nurses, and a nurse educator.
Conclusion. We believe that the combination of a video tutorial followed by an interactive telesimulation was successful in providing timely education during a coronavirus pandemic. Furthermore, it reinforced the value and flexibility in which simulation education could continue conveniently for learners despite significant restrictions in place during the coronavirus pandemic. Research is needed to assess the efficacy of this hybrid intervention in preparing healthcare workers and to determine if the knowledge is successfully transferred to the clinical setting.
Introduction: Malignant middle cerebral artery (MCA) infarction is associated with up to 80% mortality in the first week, despite maximal medical therapy. Decompressive craniectomy (DC) has been ...shown to improve survival rates in these patients. However, there are concerns that DC prolongs poor quality of life by increasing the number of survivors with major disability. This review will assess if DC in patients with malignant MCA infarction improves functional outcomes compared to maximal medical therapy. It will estimate the optimal time for surgery following stroke onset and ask if DC is effective in older patients (>60 years).
Methods: A literature search was conducted using Medline, Embase, PubMed and the Cochrane Library. Randomised controlled trials and meta-analysis that fulfilled the inclusion criteria and answered the clinical question were evaluated.
Results: Twelve papers were identified and considered appropriate to answer the clinical question. These included 8 prospective randomised controlled trials and 4 meta-analysis. A critical review of these papers was conducted.
Conclusions: In patients 60 years of age or younger, DC within 48 hours of stroke onset significantly reduced risk of death and major disability (mRS >3) compared to maximal medical therapy only. In older patients (>60 years) DC also significantly improved survival but the majority of survivors were left with major disability (mRS 4-5). DC performed more than 48 hours after symptom onset does not appear to be superior to best medical management. The decision to perform decompressive surgery needs to be made on a case-by-case basis, taking into account the degree of disability patients and their carers are willing to accept.
Objective:
The coronavirus disease 2019 (COVID-19) pandemic reached New York City in March 2020, leading to a state of emergency that affected many lives. Patients who contracted the disease ...presented with different phenotypes. Multiple reports have described the findings of computed tomography scans of these patients, several with pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Our aim was to describe the incidence and management of pneumothorax, pneumomediastinum, and subcutaneous emphysema related to COVID-19 found on radiologic imaging.
Methods:
A retrospective chart review was conducted of all confirmed COVID-19 patients admitted between early March and mid-May to two hospitals in New York City. Patient demographics, radiological imaging, and clinical courses were documented.
Results:
Between early March and mid-May, a total of 1866 patients were diagnosed with COVID-19 in the two hospitals included in the study, of which 386 were intubated. The majority of these patients were men (1090, 58.4%). The distribution of comorbidities included the following: hypertension (1006, 53.9%), diabetes (544, 29.6%), and underlying lung disease (376, 20.6%). Among the 386 intubated patients, 65 developed study-specific complications, for an overall incidence of 16.8%; 36 developed a pneumothorax, 2 developed pneumomediastinum, 1 had subcutaneous emphysema, and 26 had a combination of both. The mean time of invasive ventilation was 14 days (0–46, interquartile range = 6–19, median 11). The average of highest positive end expiratory pressure within 72 h of study complication was 11 (5–24) cmH20. The average of the highest peak inspiratory pressure within 72 h of complication was 35.3 (17–52) cmH2O. In non-Intubated patients, 9/1480 had spontaneous pneumothorax, for an overall incidence of 0.61 %.
Conclusion:
Intubated patients with COVID-19 pneumonia are at high risk of pneumothorax, pneumomediastinum, and subcutaneous emphysema. These should be considered in differential diagnosis of shortness of breath or hypoxia in a patient with a new diagnosis of COVID-19 or worsening hemodynamics or respiratory failure in an intensive care unit setting.
Abstract
Deep-seated brain tumours are surgically challenging to access. When planning approaches to these lesions, it is important to take into account eloquent cortical areas, grey matter nuclei, ...and subcortical white matter tracts. Traditionally, access to deep-seated lesions would require brain retraction; however, this is associated with secondary brain damage, which may impair neurological function. A trans-sulcal minimally invasive parafascicular approach allows gentle splitting of brain fibres and is thought to splay rather than sever white matter tracts. This is particularly important when approaching medially located, language-eloquent tumours, which lack brain surface expression. This video describes a minimally invasive approach to a deep-seated, language-eloquent brain tumour. We utilized preoperative cortical and subcortical planning to define a safe surgical corridor. We then demonstrate using intraoperative neuro-monitoring and mapping of the motor and language functions to define the boundaries of surgical resection. We find trans-sulcal minimally invasive parafascicular approach to be a safe and effective technique when approaching language-eloquent lesions medial to the main language subcortical networks.
Background and Objectives. The code team course is a 3-hour, interactive course that follows a 4-phase brain-based lesson plan for simulation. Interprofessional teams receive instruction and practice ...in evidence-based teamwork, communication, and individual skills.
Methods. This quantitative research included a pre-test and post-test design in an urban Department of Medicine. Sixteen groups (n=109) participated in the course over a period of eight weeks. Classroom metrics included pre- and post-course High-Quality cardiopulmonary resuscitation (CPR) and code team didactic knowledge assessed by Wilcoxon rank-sum tests. In addition, four in-situ mock code simulations were conducted to provide the researchers with baseline and post-intervention data. Code team performance assessment scores were tallied and compared between baseline and post-intervention by Fisher’s Exact Test.
Results. The classroom metrics produced significant results. High-Quality CPR scores were higher post-training than pre-training (median score 4 vs. 3, respectively; p=0.006). Didactic knowledge test scores were also significantly higher (median score 90 vs. 70, respectively; p <0.001). In-situ team performance improved in several areas. There was a significant improvement in the area of cardiac code management in the day shift group. The percent “done well” improved from 25% (5/20) to 100% (20/20) (p= <0.001).
Conclusion. The results of this pilot study suggest that code team training using the 4-phase BBL plan for simulation is associated with improvements in interprofessional team knowledge and performance during cardiac emergencies. It is equally important that the training is conducted over a short period in order to ensure that all team members are properly prepared.
Simulation played a critical role in our institution's response to the COVID-19 pandemic in New York City. With the rapid influx of critically ill patients, resource limitations, and presented safety ...concerns, simulation became a vital tool that provided solutions to the many challenges we faced. In this article, we describe how simulation training was deployed at our institution throughout the course of the pandemic, which included the period of our medical surge. Simulation helped refine protocols, facilitate practice changes, uncover safety gaps, and train redeployed healthcare workers in unfamiliar roles. We also discuss the obstacles we encountered with implementing simulations during the pandemic, the measures we took to adapt to our limitations, and the simulation strategies and end products that were derived from these adaptations.
Clinical opportunities to practice or perform a cricothyrotomy are limited. We developed an evidence-based cricothyrotomy course following the 4-phase lesson plan for simulation that provides ...pulmonary and critical care medicine fellows with demonstrations, practice, and feedback to increase their confidence and competence. Survey results demonstrated an improvement in perceived confidence (p<0.005) and competence (p<0.002) following this educational intervention. Fellows also achieved significant improvement in knowledge (p<0.003) and performance in two cricothyrotomy techniques (Seldinger and MacIntyre) (p<0.004). It is important that we provide fellows with practice opportunities that can be used to develop and maintain proficiency, particularly in low frequency events.
Abstract A best evidence topic was constructed according to a structured protocol. The question addressed was: In children undergoing umbilical hernia repair is a rectus sheath block (RSB) better ...than local anaesthetic infiltration of the surgical site, at reducing post-operative pain? From a total of 34 papers, three studies provided the best available evidence on this topic. One randomised clinical trial showed RSB had a better analgesic effect in the immediate post-operative period. In another randomised trial opioid consumption in the peri-operative period was found to be significantly lower in patients administered RSB. These improvements in pain and analgesia consumption need to be balanced against the expertise, training, equipment required, time implications and complications of performing a RSB.
Debriefing in critical care Rajwani, Kapil
Qatar medical journal,
02/2020, Volume:
2019, Issue:
2
Journal Article
Peer reviewed
Open access
Debriefing after critical events is a well-known practice in medicine, utilized in both simulated and real-life situations. In addition to reviewing the medical aspects of the care, debriefing allows ...for examination of team performance and human factors involved in the event. Various methods, locations, and time intervals can be utilized to debrief to meet the team's needs. Some proven methods of debriefing include plus-delta, directive feedback, the Socratic Method, and advocacy and inquiry.
1
Each method has its benefits and limitations and can be applied during various segments of a debriefing to achieve the debriefer's goals. These goals usually include identifying and addressing knowledge gaps, uncovering participants' beliefs and thought processes, reflecting on the team's performance, and synthesizing the information to improve future performance.
2
Debriefing should be a planned follow-up to every critical event. This standardizes the process and expectation for teams to share their experiences and work towards an improved performance. The debriefing environment should be a safe space for team members to express their emotions while sharing successes and challenges without fear of repercussion or blame. Allowing team members to share their decision-making process and knowledge level lets the debriefer tailor learning points to address appropriate deficits rather than assuming and targeting areas that may not need improvement. In addition, involving team members from all involved disciplines can enhance the outcomes of the debriefing. There is evidence that handoffs with more team members can improve efficiency, documentation, and future patient outcomes.
3
The timing of these debriefs can be varied based on the clinical scenario and even the emotional state of the team members. Immediately debriefing after an event, also known as the “hot” debrief, allows most team members to participate and capitalizes on a clear memory of events to identify successes and opportunities for improvement. In addition to performance improvements, these sessions may help team members express their emotions and offer some coping skills to deal with unfortunate outcomes including the death of a patient. However, sometimes the debriefer may assess the emotional state of the team and deem it not appropriate to conduct the debriefing immediately after the event. In these settings a delayed debriefing session, or “warm” or “cold” debrief, may allow team members to process their emotions and reflect on the clinical event prior to coming together as a group to discuss their performance.
Despite the well described benefits of debriefing, there continues to remain a disconnect between knowing to conduct debriefs and their actual implementation. This can be due to various circumstances including, time pressures, patient care, or limited training in how to debrief a team. These failures to debrief can lead to communication breakdowns within the team.
4
The absence of a debriefing can also lead to improper or inadequate documentation, which can result in clinical error and increased litigation.
5
Organizations such as the Agency for Healthcare Research and Quality advocate for clinical event debriefing; this attention and effort on research and training can hopefully increase the frequency of and comfort with clinical event debriefing.
PDF
