Alice Edler

Leadership lessons from military education for postgraduate medical curricular improvement

Background:  Quality medical education includes both teaching and learning of data‐driven knowledge, and appropriate technical skills and tacit behaviours, such as effective communication and professional leadership. But these implicit behaviours are not readily adaptable to traditional medical curriculum models. This manuscript explores a medical leadership curriculum informed by military education.

Affordable simulation for small-scale training and assessment.

Introduction: High-fidelity patient simulation is increasingly recognized as an effective means of team training, acquisition and maintenance of technical and professional skills, and reliable performance assessment; however, finding a cost effective solution to providing such instruction can be difficult. This report describes the rationale, design, and appropriateness of a portable simulation model and example of its successful use at national meetings. Methods: The Stanford Simulation Group, in association with several other centers, developed a portable Pediatric Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) and presented it at two national meetings. The technical challenges and costs of development are outlined, and a satisfaction survey was conducted at the completion of the program. Results: All respondents (100%) either agreed or strongly agreed that the course was useful, met expectations, was enjoyable, and that the scenarios were realistic. Conclusions: The Portable Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) presents innovative educational and financial opportunities to assist in both training and assessment of critical emergency response skills at smaller institutions and allows specialized instruction in an in situ setting.

Avian flu (H5N1): its epidemiology, prevention, and implications for anesthesiology.

Abstract Avian flu, influenza A subtype H5N1, is an emergent and virulent disease that poses a threat to the health and safety of the world community. Avian flu is 1 of more than 25 influenza A viruses that reside primarily in birds but also infect humans and other mammals. Avian flu is responsible for the current outbreak in Asia; H5N1 has now displayed probable human-to-human transmission; it could be a harbinger of a global epidemic. Anesthesiologists are exposed to a risk for infection when they are involved in airway instrumentation of infected patients. Given the evidence of emerging resistance to common antiviral agents used to treat H5N1 influenza virus and limited supply of H5N1 vaccine, prevention is our best protection. The following article will detail the virology and preventive public health practices for H5N1. This knowledge can also be used to define and prevent other yet unidentified infectious threats.

Action research in medical education: a shifting paradigm or old wine in new skins?

A recent publication by Arena, Arnolda and Lake is a welcome contribution to our repertoire of educational research methods. Action research (AR), a method of systematic social science inquiry, has become a well-accepted educational research tool. Its strength lies in the ability to make grass-root changes in pedagogical methods through reflective practice. Introduced almost a century ago, Lewin’s conception of AR described the application of key physiological behaviours to the analysis and resolution of problems in practice. AR quickly incorporated reflective and participatory methods. In the midtwentieth century, an early application of AR to health care education can be seen in the work of John Elliot, and Titchen et al have championed the introduction of AR to the educational milieu.

Building faculty community: fellowship in graduate medical education administration.

INTRODUCTION The Department of Graduate Medical Education at Stanford Hospital and Clinics has developed a professional training program for program directors. This paper outlines the goals, structure, and expected outcomes for the one-year Fellowship in Graduate Medical Education Administration program. BACKGROUND The skills necessary for leading a successful Accreditation Council for Graduate Medical Education (ACGME) training program require an increased level of curricular and administrative expertise. To meet the ACGME Outcome Project goals, program directors must demonstrate not only sophisticated understanding of curricular design but also competency-based performance assessment, resource management, and employment law. Few faculty-development efforts adequately address the complexities of educational administration. As part of an institutional-needs assessment, 41% of Stanford program directors indicated that they wanted more training from the Department of Graduate Medical Education. INTERVENTION To address this need, the Fellowship in Graduate Medical Education Administration program will provide a curriculum that includes (1) readings and discussions in 9 topic areas, (2) regular mentoring by the director of Graduate Medical Education (GME), (3) completion of a service project that helps improve GME across the institution, and (4) completion of an individual scholarly project that focuses on education. RESULTS The first fellow was accepted during the 2008-2009 academic year. Outcomes for the project include presentation of a project at a national meeting, internal workshops geared towards disseminating learning to peer program directors, and the completion of a GME service project. The paper also discusses lessons learned for improving the program.

Scenario and checklist for airway rescue during pediatric sedation.

SECTION 1: DEMOGRAPHICS Module: Airway Rescue for Sedation in Pediatric Patients Patient File Name: Onka Hemmer Scenario Name: Pediatric Sedation Simulation Developers: Michael Chen, MD; Alice Elder, MD, MA (education), MPH; Samuel Wald, MD; Yue Ming Huang, EdD, MHS Simulator: Laerdal Simbaby Date of Development: October 22, 2006 Appropriate for the Following Learning Groups: ▪ Faculty ▪ Residents: Postgraduate years 1–7 ▪ Specialties (for faculty and residents): Anesthesia, Pediatrics, Radiology, Surgery, Dentistry, and Emergency Medicine ▪ Nurse Anesthesia Faculty ▪ Nurse Anesthesia Student: Years 1–2 ▪ Other: Dentists, dental students, and nurse practitioners

A case series of airway management for wireless capsule endoscopy in pediatric patients.

mask airway in 100 children (3). Sinha (2) states they have been using the Proseal laryngeal mask airway (PLMA) for over 5 years – by that we assume they mean the adult model since pediatric versions did not become available in most areas of the world until late 2004 or 2005. There is much published on the adult PLMA (4) and our paper’s focus was exclusively on the use of the PLMA in children. Without knowing the proportion of Sinha and Sunder’s patient who were small children it is not clear how relevant their results are to pediatric practice. Our results showed a high insertion success rate is still possible for anesthetists unfamiliar with the PLMA device, thereby making it easy to introduce into an institution. Sinha and Sunder suggest that using the metal introducer may improve our insertion success rate (2). Use of the gumelastic bougie (GEB) has also been reported to improve insertion success compared with the digital technique in both adults and children (4,5). Further, a randomised controlled trail of 124 children comparing the metal introducer tool (IT) with the GEB found similar insertion success with either technique but a higher seal in the GEB group while the PLMA position was better in the IT group (6). We agree with Cook et al. (1) that adult experience in PLMA use may not transfer seamlessly to pediatric practice. This may be especially so given the different design characteristics of the smaller pediatric PLMA (namely lack of dorsal cuff) and the anatomical differences between the pediatric and adult airway. The anesthetists in our study were all experienced pediatric anesthetists but almost complete novices in regard to PLMA use, yet a high insertion success rate was achieved. We also agree with Cook et al. that their study (1) adds to the evidence that the drain tube of the paediatric PLMA, just as in adults, can allow early identification of regurgitation and prevent aspiration. Michelle White Fiona Kelly Department of Anaesthesia, Bristol Royal Hospital for Children, Bristol, UK (email: mcwdoc@doctors.org.uk)

Improving electrical safety for patients with Epidermolysis bullosa.

administered intravenously in boluses of 10 mg up to 40 mg in total. The right nostril was sprayed with 0.6 ml of 1 in 10 000 adrenaline and a Rusch Nasopharyngeal Airway inserted. To the airway was attached a size 5 portex connecter to which an Ayre’s T-piece was connected, allowing improved oxygenation. The patient relaxed sufficiently for a size 2 standard Laryngeal Mask Airway to be inserted. The surgeon was then able to remove the toothbrush without incident or bleeding, allowing intubation of the trachea. On transfer to theatre the wound in the patient’s cheek was explored and sutured. There were no postoperative complications. Penetrating oral trauma in children is not uncommon and many minor cases may not even present for treatment (2). Reported complications include retropharyngeal abscess, mediastinitis, emphysema (4), internal carotid artery aneurysm (3) and airway obstruction (2). An impacted foreign body occluding access to the airway is rare. Similar reports exist in the dental literature, but to our knowledge, there has been no examination of this issue in an anaesthetic journal. Younessi describes a 4-year-old girl with a similarly impacted toothbrush. Induction was intravenous after preoxygenation with nasal prongs. After the child was anaesthetised the handle of the toothbrush was removed with the aid or orthopaedic bolt cutters. The child was then ventilated and intubated without difficulty (5). This ingenious solution would require reasonable access to the oropharynx, which was not available in either of the two cases that we have presented. In addition, failure in this technique could risk loss of the airway in an apnoeic child. The management of both of our cases relied on a cautious approach with spontaneous ventilation maintained as a priority. As both of the toothbrush heads were lodged lateral to the mandible of the ramus the possibility of serious complications was low (5). However, the difficulty remained of maintaining the airway when access to it was compromised. The use of ketamine and the Laryngeal Mask Airway was central to the management of both cases. James Ellwood Oliver Dearlove Vesna Colovic Rita Vashisht Department of Anaesthesia, Royal Manchester Children’s Hospital, Pendlebury, Manchester, UK (email: jamesellwood@doctors.net.uk)