Ethan O. Bryson

The utility of simulation in medical education: what is the evidence?

Medical schools and residencies are currently facing a shift in their teaching paradigm. The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum. As patients become increasingly concerned that students and residents are practicing on them, clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed learning and independent research. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Many students feel that they are inadequately trained in history taking, physical examination, diagnosis, and management. Medical simulation has been proposed as a technique to bridge this educational gap. This article reviews the evidence for the utility of simulation in medical education. We conducted a MEDLINE search of original articles and review articles related to simulation in education with key words such as simulation, mannequin simulator, partial task simulator, graduate medical education, undergraduate medical education, and continuing medical education. Articles, related to undergraduate medical education, graduate medical education, and continuing medical education were used in the review. One hundred thirteen articles were included in this review. Simulation-based training was demonstrated to lead to clinical improvement in 2 areas of simulation research. Residents trained on laparoscopic surgery simulators showed improvement in procedural performance in the operating room. The other study showed that residents trained on simulators were more likely to adhere to the advanced cardiac life support protocol than those who received standard training for cardiac arrest patients. In other areas of medical training, simulation has been demonstrated to lead to improvements in medical knowledge, comfort in procedures, and improvements in performance during retesting in simulated scenarios. Simulation has also been shown to be a reliable tool for assessing learners and for teaching topics such as teamwork and communication. Only a few studies have shown direct improvements in clinical outcomes from the use of simulation for training. Multiple studies have demonstrated the effectiveness of simulation in the teaching of basic science and clinical knowledge, procedural skills, teamwork, and communication as well as assessment at the undergraduate and graduate medical education levels. As simulation becomes increasingly prevalent in medical school and resident education, more studies are needed to see if simulation training improves patient outcomes.

The use of multi-modality simulation in the retraining of the physician for medical licensure

Patient simulation has been widely incorporated into the educational programs of many anesthesiology residencies. These educational tools have been validated by a number of studies and have been recognized by the Accreditation Council for Graduate Medical Education (ACGME) as effective means of teaching domains of competency. The ACGME and the American Board of Medical Specialties (ABMS) have also recognized that these tools are effective devices for competency evaluation of resident and attending physicians. The use of simulation for both retraining and evaluation of a physician for medical licensure is presented.

Neurologic, psychiatric, and other medical manifestations of nitrous oxide abuse: A systematic review of the case literature

BACKGROUND/OBJECTIVESnNitrous oxide (N2 O) is known to have abuse potential, although debate regarding the toxic effects of such abuse continues. Our objective was to review the case literature and present the neurologic, psychiatric and medical consequences of N2 O abuse.nnnMETHODSnA systematic literature review was completed for case reports using keywords nitrous oxide with abuse/abusing or misuse/misusing or overuse/overusing or addiction. Non-English-language cases and cases not involving direct toxic effects of N2 O were excluded as were commentaries or personal essays. Clinical presentation, frequency of N2 O abuse, laboratory studies, imaging, ancillary tests, treatments and outcomes were collected from case reports.nnnRESULTSnOur review returned 335 Pubmed, 204 Web of Science, 73 PsycINFO, 6 CINAHL, 55 EMBASE and 0 Grey Literature results, and after exclusion and removal of duplicates, 91 individual cases across 77 publications were included. There were also 11 publications reporting 29 cases of death related to N2 O abuse. The majority of cases (Nu2009=u200972) reported neurologic sequelae including myeloneuropathy and subacute combined degeneration, commonly (Nu2009=u200939) with neuroimaging changes. Psychiatric (Nu2009=u200911) effects included psychosis while other medical effects (Nu2009=u20098) included pneumomediastinum and frostbite. Across all cases N2 O abuse was correlated with low or low-normal Vitamin B12 (cyanocobalamin) levels (Nu2009=u200952) and occasionally elevated homocysteine and methylmalonic acid.nnnCONCLUSIONS/SCIENTIFIC SIGNIFICANCEnN2 O abuse represents a significant problem because of the difficulty involved with identification and the toxicity related to chronic abuse including possible death. Health professionals should be aware of the toxic effects of N2 O and be able to identify potential N2 O abuse. (Am J Addict 2016;25:358-369).

Rocuronium as muscle relaxant for electroconvulsive therapy in a patient with adult-onset muscular dystrophy.

Abstract Adult-onset muscular dystrophy is an inherited myopathy characterized by a variable degree of progressive muscle weakness and degeneration. Although not usually fatal, significant muscle weakness results in an up-regulation of acetylcholine receptors on the less responsive postjunctional muscles. The resulting profound potassium release when these receptors are stimulated by the depolarizing muscle relaxant succinylcholine can result in potentially fatal cardiac arrhythmias. We report a case of electroconvulsive therapy safely administered in a 61-year-old man with adult-onset muscular dystrophy requiring muscle relaxation with rocuronium.

Dosing and effectiveness of ketamine anesthesia for electroconvulsive therapy (ECT): a case series

Objective: To provide additional data about the clinical efficacy and dosing range for ketamine used as the induction agent in electroconvulsive therapy (ECT). Method: We reviewed the clinical data in our academic hospital ECT service over the last four years for patients who had received ketamine as the sole, or adjunctive, anesthesia induction agent. We extracted clinical data about antidepressant response as well as absolute and weight-based dosing for ketamine. Results: We found nine patients who were treated with ketamine as the anesthetic at some point during the course of their treatment (eight as the sole agent, one as adjunctive). The median induction dose for ketamine was 1.1 mg/kg. For most patients, there was demonstrable clinical benefit. Conclusions: Ketamine has a role as an alternative induction anesthetic agent in ECT. Our case series adds to the literature on the concomitant use of ECT and ketamine.

Safe resumption of electroconvulsive therapy (ECT) after vertebroplasty

Vertebral compression fractures are a common injury affecting older individuals, predominantly women with osteoporosis. Although compression fractures may be asymptomatic, they frequently result in moderate-to-severe acute and chronic back pain. Fortunately, they are rarely associated with neurological dysfunction. They may occur spontaneously, or result from direct trauma, falls, or seemingly innocuous occurrences such as coughing, sneezing, or rolling over in bed. In the past, thoracic compression fractures occurred as a side effect of unmodified electroconvulsive therapy (ECT) (Kalinowsky and Hoch, 1952; Fink, 1979). With modern anesthesia techniques for ECT, compression fractures have virtually been eliminated. An 85-year-old woman with a history of treatment refractory depression was referred for ECT. This episode of depression was characterized by decreased activity, decreased energy, anhedonia, and decreased appetite. Her medical history included congestive heart failure, paroxysmal atrial fibrillation, hypertension, hypothyroidism, dementia, and alcohol abuse. Medications included donepezil, valsartan, metoprolol, digoxin, furosemide, levothyroxine, buproprion, and mirtazapine. Prior to ECT, she had complained of severe lower back pain. She reported her back pain had worsened after a fall from bed several weeks earlier. The patient underwent seven ECTs with right unilateral electrode placement. For each treatment, she received 50mg of methohexital and 60mg of succinylcholine. Excellent muscle relaxation was achieved; she evidenced minimal convulsive activity during treatment. Prior to treatment 8, she had spine X rays and a bone scan to evaluate her ongoing back pain. The X rays showed a T12 compression fracture; the bone scan showed uptake in T12, indicating an acute process. Review of computed tomography angiogram from 2weeks prior to ECT showed the compression fracture had already occurred, providing documentation that it preceded the start of ECT and was most likely from her fall from bed (Figure 1a). It was determined that she would benefit from a vertebroplasty, both to control pain and to reduce risk of further collapse. Given the presence of the compression fracture and the need to continue ECT prior to scheduling the vertebroplasty, succinylcholine was increased to 80mg for treatment 8. Two days after treatment 8, the patient underwent a vertebroplasty of the T12 vertebral body. Cement deposition into the vertebral body under anterior/ posterior and lateral fluorography was accomplished. The patient’s acute course of ECT was resumed 5 days after the vertebroplasty, and she received four additional treatments with bilateral electrode placement. For each of these treatments, she received 50mg of methohexital and 80mg of succinylcholine. She exhibited complete muscle relaxation. In total, she received 12 treatments, showing partial response, with improvement in mood and functionality, but some residual symptoms. A repeat chest X ray 1month later revealed no change (Figure 1b). We present a patient with a pre-existing vertebral compression fracture, not identified until after her course of ECT had begun. Because of ongoing pain, a decision was made to interrupt her ECT course to perform a vertebroplasty. Almost immediately following her vertebroplasty, she experienced pain relief, and we were confident that ECT could be resumed shortly after her procedure, provided complete muscle relaxation was achieved. Follow-up radiographic examination confirmed no changes from the subsequent treatments. Before the use of general anesthesia and muscle relaxation, compression fractures were a common occurrence during ECT. Spinal films were a routine component of the pre-ECT work-up. However, with the advent of modern anesthesia techniques in ECT, vertebral compression fractures are now a rare complication, resulting from sub-optimal neuromuscular blockade in at-risk patients when they occur (Weiner, 1983). Despite this, careful attention must be paid to muscular relaxation, particularly in high-risk patients with osteoporosis. Increasing the dose of succinylcholine by 40–50% (to the1.5mg/kg range) is enough to produce complete muscle relaxation in virtually any patient. Higher doses of succinylcholine may induce moderate prolongation of apnea. For maximal neuromuscular

Case Report: Transient Left Bundle Branch Block Associated with Ect

We present the first reported case of transient left bundle branch block (LBBB) occurring during electroconvulsive therapy (ECT). LBBB is an important clinical finding, as it is associated with a significant increase in mortality. Physicians providing ECT should be aware of the significance of new-onset LBBB; it may occur during treatment.

Management of prolonged seizures during electroconvulsive therapy

220 Indian Journal of Psychological Medicine | Apr Jun 2014 | Vol 36 | Issue 2 mood disorders. The most recent study by Fan et al.[16] had negative outcomes, but the fact that the caffeine users and non-users had differential response to allopurinol corroborates the hypothesis. Recent evidence of increased uric acid levels in drug-naïve subjects with bipolar disorder during first manic episode further warrants the attention of researchers to this novel mechanism in pathophysiology of bipolar mood disorder.[17]

Febrile Reaction With Elevated CPK After a Single Electroconvulsive Therapy (ECT) in an Adolescent Patient With Severe Bipolar Disorder

This report describes the electroconvulsive therapy (ECT) course of a 15-year-old male with severe bipolar disorder unresponsive to medical management. After his first treatment, the patient exhibited fever, elevated creatine phosphokinase levels, and leukocytosis. Treatment was halted although the patient reported an improvement in symptoms, which was not maintained with pharmacotherapy alone. Subsequent treatments were completed without adverse reactions, and the patient entered remission. We discuss the possible causes of this reaction and remind the reader that a single adverse event does not always require the abandonment of a treatment modality.

Prolonged succinylcholine action during electroconvulsive therapy (ECT) after cytarabine, vincristine, and rituximab chemotherapy.

Succinylcholine is a depolarizing neuromuscular blocker frequently used during electroconvulsive therapy. In most patients, the duration of paralysis is brief, allowing for spontaneous respiration shortly after the therapy. We report a case of delayed return of neuromuscular function after succinylcholine administered during electroconvulsive therapy in a 72-year-old man receiving cytarabine, vincristine, and rituximab chemotherapy for chronic lymphocytic leukemia. We hypothesize that an interaction between succinylcholine and one of the chemotherapeutic agents caused the prolongation of paralysis and believe that this is the first reported case of prolonged duration of succinylcholine following this regimen of chemotherapy. Despite this unexpected prolonged neuromuscular blockade, the patient could be treated uneventfully, with attention paid to his respiratory support and with subsequent succinylcholine dose titration to effect.