Christian Bjerre Høyer

Junior physician skill and behaviour in resuscitation : A simulation study

INTRODUCTION Physicians are expected to manage their role as teamleader during resuscitation. During inter-hospital transfer the physician has the highest medical credentials on a small team. The aim of this study was to describe physician behaviour as teamleaders in a simulated cardiac arrest during inter-hospital transfer. Our goal was to pinpoint deficits in knowledge and skill integration and make recommendations for improvements in education. METHOD An ambulance was the framework for the simulation; the scenario a patient with acute coronary syndrome suffering ventricular fibrillation during transportation. Physicians (graduation age < or =5 years) working in internal medicine departments in Denmark were studied. The ambulance crew was instructed to be passive to clarify the behaviour of the physicians. RESULTS 72 physicians were studied. Chest compressions were initiated in 71 cases, ventilation and defibrillation in 72. The median times for arrival of the driver in the patient cabin, initiation of ventilation and chest compressions, and first defibrillation were all less than 1min. Medication was administered in 63/72 simulations (88%), after a median time of 210 s. Adrenaline was the preferred initial drug administered (58/63, 92%). Tasks delegated were ventilations, chest compressions, defibrillation, and administration of medication (97%, 92%, 42%, and 10% of cases, respectively). DISCUSSION AND CONCLUSION Junior physicians performed well with respect to the treatment given and the delegation of tasks. However, variations in the time of initiation it took for each treatment indicated lack of leadership skills. It is imperative that the education of physicians includes training in leadership.

Long-term survival and health-related quality of life 6 to 9 years after trauma.

BACKGROUND Trauma systems have improved short-term survival of the severely injured but knowledge on long-term outcome is limited. This study aimed to assess outcome 6 years to 9 years after moderate to severe injury in terms of survival, Health-Related Quality of Life (HRQOL) and employment status. METHODS Patients admitted to Aarhus Level I Trauma Center in 1998 to 2000, aged 15 years or more, with an Injury Severity Score (ISS) ≥9 were included. Patients were divided into three groups based on ISS (ISS, 9-15; ISS, 16-24; ISS >24). Survival status was obtained from the Danish Central Person Registry. HRQOL was measured with the Short Form 36 (SF-36) questionnaire, which was mailed to survivors 6 years to 9 years after admission and compared with a matched control group. RESULTS Three hundred twenty-two patients were included. Seventy-one percentage were men, median age was 34 years (range, 15-89 years), median ISS was 17 (range, 9-75). In-hospital survival was 85%. After a median of 7.3 years, overall survival was 78%. After hospital discharge, no difference in survival was found between the three patient groups.Sixty-nine percentage of the contacted patients completed the SF-36. Mean SF-36 scores were significantly lower in the patient group than in the control group in all eight SF-36 domains (p < 0.001). Return to employment or education was 52%, whereas 20% of the patients reported to be on early retirement. CONCLUSION Six years to nine years after traumatic injury, 78% of the patients were alive. HRQOL was significantly lower for injured patients than a matched control group. Twenty percentage of the patients retired early.

Time matters – Realism in resuscitation training

BACKGROUND The advanced life support guidelines recommend 2min of cardiopulmonary resuscitation (CPR) and minimal hands-off time to ensure sufficient cardiac and cerebral perfusion. We have observed doctors who shorten the CPR intervals during resuscitation attempts. During simulation-based resuscitation training, the recommended 2-min CPR cycles are often deliberately decreased in order to increase the number of scenarios. The aim of this study was to test if keeping 2-min CPR cycles during resuscitation training ensures better adherence to time during resuscitation in a simulated setting. METHODS This study was designed as a randomised control trial. Fifty-four 4th-year medical students with no prior advanced resuscitation training participated in an extra-curricular one-day advanced life support course. Participants were either randomised to simulation-based training using real-time (120s) or shortened CPR cycles (30-45s instead of 120s) in the scenarios. Adherence to time was measured using the European Resuscitation Councils Cardiac Arrest Simulation Test (CASTest) in retention tests conducted one and 12 weeks after the course. RESULTS The real-time group adhered significantly better to the recommended 2-min CPR cycles (time-120s) (mean 13; standard derivation (SD) 8) than the shortened CPR cycle group (mean 45; SD 19) when tested (p<0.001.) CONCLUSION This study indicates that time is an important part of fidelity. Variables critical for performance, like adherence to time in resuscitation, should therefore be kept realistic during training to optimise outcome.

Adverse Design of Defibrillators: Turning Off the Machine When Trying to Shock

A recent publication demonstrated the possibility of erroneous operation of 2 widely used monitor-defibrillators and observed that the design of user interfaces might contribute to error during operation. During an ambulance simulation training exercise for 72 junior internal medicine physicians that called for defibrillation in the management of cardiac arrest, we observed that in 5 of 192 defibrillation attempts by the physicians, the monitor-defibrillator was inadvertently powered off. When the device is inadvertently powered off, recognition and subsequent steps to defibrillate delayed defibrillation an average of 24 seconds (range 14 to 32 seconds). Our analysis of the controls of this monitor-defibrillator found that the device could be powered off even if fully charged and ready to shock. Redesign of the equipment might prevent this inadvertent event.

Investigation of a fatal airplane crash: autopsy, computed tomography, and injury pattern analysis used to determine who was steering the plane at the time of the accident. A case report.

A fatal accident is reported in which a small single-engine light airplane crashed. The airplane carried two persons in the front seats, both of whom possessed valid pilot certificates. Both victims were subject to autopsy, including post-mortem computed tomography scanning (PMCT) prior to the autopsy. The autopsies showed massive destruction to the bodies of the two victims but did not identify any signs of acute or chronic medical conditions that could explain loss of control of the airplane. PMCT, histological examination, and forensic chemical analysis also failed to identify an explanation for the crash. A detailed review of an airplane identical to the crashed airplane was performed in collaboration with the Danish Accident Investigation Board and the Danish National Police, National Centre of Forensic Services. The injuries were described using the abbreviated injury scale, the injury severity score, 3-dimensional reconstructions of the PMCT, and an injury pattern analysis. We describe how, on basis of these data, we reached a conclusion about which of the two victims was the most likely to have been in control of the airplane at the time of accident. Furthermore, we argue that all victims of fatal airplane crashes should be subject to forensic autopsy, including PMCT and forensic chemical analysis. The continuous accumulation of knowledge about injury patterns from “simple” accidents is the foundation for the correct analysis of “difficult” accidents.

Comparison of the quality of chest compressions on a dressed versus an undressed manikin: A controlled, randomised, cross-over simulation study

BackgroundUndressing the chest of a cardiac arrest victim may delay the initiation of chest compressions. Furthermore, expecting laypeople to undress the chest may increase bystander reluctance to perform cardiopulmonary resuscitation (CPR). Both of these factors might conceivably decrease survival following cardiac arrest. Therefore, the aim of this study was to examine if the presence or absence of clothes affected the quality of chest compressions during CPR on a simulator manikin.MethodsThirty laypeople and 18 firefighters were randomised to start CPR on the thorax of a manikin that was either clothed (three layers) or not. Data were obtained via recordings from the manikin and audio- and video-recordings. Measurements were: maximum compression depth; compression rate; percentage of compressions with correct hand positioning; percentage of compressions with complete release (≤ 10 mm), and percentage of compressions of the correct depth (range 40-50 mm). Laypeople were given a four-hour European Resuscitation Council standardised course in basic life support and tested immediately after. Firefighters were tested without additional training. Mock cardiac arrest scenarios consisted of three minutes of CPR separated by 15 minutes of rest.ResultsNo significant differences were found between CPR performed on an undressed manikin compared to a dressed manikin, for laypeople or firefighters. However, undressing the manikin was associated with a mean delay in the initiation of chest compressions by laypeople of 23 seconds (N = 15, 95% CI: 19;27).ConclusionsIn this simulator manikin study, there was no benefit gained in terms of how well CPR was performed by undressing the thorax. Furthermore, undressing the thorax delayed initiation of CPR by laypeople, which might be clinically detrimental for survival.

What you see is not what you get in the PDF document format

The sharing and storage of scientific knowledge, information and data are today mainly in digitized form, which will become the predominant means of communicating scientific work in the future. One of the best-established formats is the open standard of PDF (Portable Document Format), which is renowned for its flexibility and stability. In this article, we expose a major flaw in the format with respect to the security of confidential information, such that even organizations responsible for safeguarding and setting the standards for data management were unintentionally revealing confidential patient data. By collecting and analysing a random sample of files from a health informatics organization, we demonstrate the extent of the problem and determine its cause by code analysis of an example. In conclusion, we suggest the development of a knowledge-sharing format that does not demand expert skills for safe usage: WYSIWYS (What You See Is What You Store).

Rigor mortis and livor mortis in a living patient: A fatal case of acute total occlusion of the infrarenal abdominal aorta following renal surgery

Abstract A 63-year-old woman underwent a nephrectomy on the right side for renal cancer. Postoperatively she developed abdominal and lower back pain, which was treated with an injection of analgesics in an epidural catheter. The following morning it was discovered that the patient had cold legs with pallor and no palpable femoral pulse. Rigor mortis and livor mortis were diagnosed in both legs, even though the patient was still alive and awake. Doppler ultrasound examination revealed the absence of blood flow in the lower part of the abdominal aorta and distally. A cross disciplinary conference including specialists in urology, orthopaedics, vascular surgery, anaesthesiology, internal medicine, and intensive care concluded that no lifesaving treatment was possible, and the patient died the following day. A forensic autopsy revealed severe atherosclerosis with thrombosis and dissection of the abdominal aorta. This case clearly demonstrates that a vascular emergency should be considered when patients complain about pain in the lower back, abdomen or limbs. Clinicians should be especially aware of symptoms of tissue death that can be masked by epidural analgesia.