Donald V. Byars

Comparison of traditional versus high-fidelity simulation in the retention of ACLS knowledge

OBJECTIVE We performed a single-blinded, randomized controlled trial to evaluate the retention of advanced cardiac life support (ACLS) knowledge between high-fidelity simulation training (HFST) and traditional training (TT) in medical students. METHODS Medical students were randomized to HFST or TT for their ACLS training. Students were then tested on 2 different mega-code scenarios immediately after their training and then 1-year later. A survey was performed asking their satisfaction of ACLS training and confidence of ACLS knowledge with a 10-point rating scale. RESULTS 93 students were randomized with 86 completing the study (HFST=45, TT=41). The HFST group scored a higher percentage correct on initial testing than the TT group (83% vs. 70%, P<0.0001). However at 1-year follow up, both groups performed the same (66% vs. 66%, P=0.84). Satisfaction with training was higher with the HFST compared to the TT group (9.0 vs. 7.8, P<0.0001). Confidence in ACLS knowledge between HFST and TT groups were similar at baseline (6.9 vs. 6.5, P=0.18) and at 1-year (4.8 vs. 4.5, P=0.46). CONCLUSION Students demonstrated greater ACLS knowledge initially with HFST than with TT. However, after 1-year, both groups performed the same. Satisfaction with training was higher with HFST compared to TT. Confidence in ACLS knowledge was the same initially and decreased similarly over a 1-year time period regardless of the type of ACLS training. Further studies will need to determine optimal strategies to retain ACLS knowledge.

Evaluation of Success Rate and Access Time for an Adult Sternal Intraosseous Device Deployed in the Prehospital Setting

INTRODUCTION Access to the vascular system of the critically ill or injured adult patient is essential for resuscitation. Whether due to trauma or disease, vascular collapse may delay or preclude even experienced medical providers from obtaining standard intravenous (IV) access. Access to the highly vascular intramedullary space of long bones provides a direct link to central circulation. The sternum is a thin bone easily identified by external landmarks that contains well-vascularized marrow. The intraosseous (IO) route rapidly and reliably delivers fluids, blood products, and medications. Resuscitation fluids administered by IV or IO achieve similar transit times to central circulation. The FAST-1 Intraosseous Infusion System is the first FDA-approved mechanical sternal IO device. The objectives of this study were to: (1) determine the success rate of FAST-1 sternal IO device deployment in the prehospital setting; (2) compare the time of successful sternal IO device placement to published data regarding time to IV access; and (3) describe immediate complications of sternal IO use. METHODS All paramedics in the City of Portsmouth, Virginia were trained to correctly deploy the FAST-1 sternal IO device during a mandatory education session with the study investigators. The study subjects were critically ill or injured adult patients in cardiac arrest treated by paramedics during a one-year period. When a patient was identified as meeting study criteria, the paramedic initiated standard protocols; the FAST-1 sternal IO was substituted for the peripheral IV to establish vascular access. Time to deployment was measured and successful placement was defined as insertion of the needle, with subsequent aspiration and fluid flow without infiltration. RESULTS Over the one-year period, paramedics attempted 41 FAST-1 insertions in the pre-hospital setting. Thirty (73%) of these were placed successfully. The mean time to successful placement was 67 seconds for 28 attempts; three of the 31 insertions did not have times recorded by the paramedic. Paramedics listed the problems with FAST-1 insertion, including: (1) difficulty with adhesive after device placement (3 events); (2) failure of needles to retract and operator had to pull the device out of the skin (2 events); and (3) slow flow (1 event). Emergency department physicians noted two events of minor bleeding around the site of device placement. CONCLUSION This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.

A low cost, high fidelity nerve block model

BackgroundWe have constructed a simple, inexpensive simulation model for ultrasound guided nerve blocks. To date there are no low cost, high fidelity models for nerve block simulations. The models that do exist are expensive and vaguely resemble actual anatomy. As ultrasound guided nerve blocks become more common in medical education it is essential to develop better training models to help increase the comfort level of the individual provider and increase the chances for success during live-patient procedures [Anaesth Intensive Care 37: 824-829, 2009].MethodsThe nerve block model was produced with a single pork loin with pressure-injected ultrasound gel through both CAT 5 cable and IV tubing inserted length-wise into the pork loin.ResultsOur nerve block model had a realistic, life-like feel simulating human tissue.ConclusionThis ultrasound nerve block model was inexpensive with life-like feel allowing resident trainees to develop more confidence and tactile skill to increase the chance for success.

Learner Improvement From a Simulation-Enhanced Ultrasonography Curriculum for First-Year Medical Students: Simulation-Enhanced Ultrasonography Curriculum for First-Year Medical Students

We describe a simulation‐enhanced ultrasonography (US) curriculum for first‐year medical students as part of a comprehensive curricular integration of US skills. Our goal was to assess student knowledge and performance of US and determine their satisfaction with the integrated curriculum.

Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios

INTRODUCTION Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting. Hypothesis The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year. METHODS This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session. RESULTS Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%). CONCLUSIONS In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.

Comparison of Direct Laryngoscopy to Pediatric King LT-D in Simulated Airways

Objectives Previous reports have shown a high rate of ventilation failure via direct laryngoscopy as compared with the King LT-D airway. This difference is further divergent in the pediatric population. The goal of this study was to compare the difference in efficacy of ventilation by prehospital providers in a simulated environment between direct laryngoscopy and Pedi-King LT-D. Methods In this study, 37 paramedics were exposed to 2 identical 5-minute clinical scenarios in a simulation center using a pediatric simulation tool. In the first scenario, the provider was given all of the standard laryngoscopy equipment. In the second scenario, they were given access only to the Pedi-King LT-D. A comparison of adequate ventilation time between the scenarios was performed. Results A mean improvement of 102 seconds was found when using the Pedi-King airway, with a clinically significant P < 0.0001. Conclusions With a significant improvement in ventilation time in these simulated airways, consideration should be made to practice placement of the King Airway Device as first-line airway stabilization. Further live prospective studies would aid in this recommendation.

BRIPPED scan for evaluation of ED patients with shortness of breath.

OBJECTIVE The BRIPPED scan is an ultrasound evaluation of pulmonary B-lines, right ventricle size, inferior vena cava collapsibility, pleural and pericardial effusion, pneumothorax, left ventricle ejection fraction, and lower extremity deep venous thrombosis. The primary goal was to evaluate the effect of the BRIPPED scan on the physicians list of differential diagnoses for patients presenting with shortness of breath. METHODS This prospective randomized control trial was performed on patients presenting to the emergency department with shortness of breath. Primary data analysis was performed using an ordinal quasi-symmetry model to compare the magnitude of change in the differential diagnoses between 2 groups. Secondary outcome measures included changes in physician orders or interventions, time to disposition, time to perform the BRIPPED scan, and the interrater reliability of the interpretation of the scan. RESULTS A total of 104 patients and 24 physicians were enrolled in this study. Fifty-two patients were randomly assigned to each cohort. Among the BRIPPED cohort, there was significant movement of likelihood for several etiologies of shortness of breath on the physician differential. There was no significance in the change of differential diagnosis between the BRIPPED and control cohorts. The average (SD) time to perform the scan was 5.7 (1.3) minutes (95% confidence interval, 5.4-6 minutes). CONCLUSION The BRIPPED scan is a rapid ultrasound evaluation of shortness of breath in the emergency department. BRIPPED influenced physician differential diagnoses to the same degree as laboratory and radiographic testing. BRIPPED did not alter the final diagnosis in this patient population.

Proton pump inhibitors are associated with a reduced likelihood for sexually transmitted diseases in women in the emergency department

Background: Proton pump inhibitors (PPIs) have been shown in cell culture to kill Trichomonas vaginalis (TV) at lower half maximal inhibitory concentration values than metronidazole (Flagyl), the most common medication used to treat the infection. However, there have been no previous clinical investigations to determine if PPIs are associated with reduced risk for TV. Materials and Methods: We examined the records of female patients who received testing in the emergency department for TV, Neisseria gonorrhoea (GC), and Chlamydia trachomatis (CT) between 2010 and 2014 at two academic medical centers to determine if PPI and histamine type 2 receptor antagonist (H2RA) drugs were associated with TV and GC/CT infections. Results: We found that H2RAs were associated with an increased likelihood for TV (odds ratio [OR]: 2.0, P< 0.0001) and GC and/or CT infections (OR: 1.49, P< 0.0001). PPIs were associated with a reduced likelihood for TV (OR: 0.75, P< 0.0001) and GC and/or CT infections (OR: 0.57, P< 0.0001). In patients infected with GC and/or CT, the likelihood of coinfection with TV was reduced in those taking a PPI (OR: 0.64, P = 0.054) and increased in those taking an H2RA (OR: 1.62, P = 0.003). Conclusions: PPIs are associated with a reduced risk for TV and GC/CT infection.