John Michael Criley

Using Virtual Patients to Improve Cardiac Examination Competency in Medical Students

Cardiac examination (CE) skills are in decline. Most prior studies employed audio recordings, evaluating only one aspect of CE (i.e., auscultation) that precluded correlation with visible observations. To address these deficiencies, we developed a curriculum using virtual patient examinations (VPEs); bedside recordings of patients with visible and audible cardiovascular findings presented as interactive multimedia.

Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: A multicenter study

Many reported studies of medical trainees and physicians have demonstrated major deficiencies in correctly identifying heart sounds and murmurs, but cardiologists had not been tested. We previously confirmed these deficiencies using a 50‐question multimedia cardiac examination (CE) test featuring video vignettes of patients with auscultatory and visible manifestations of cardiovascular pathology (virtual cardiac patients). Previous testing of 62 internal medical faculty yielded scores no better than those of medical students and residents.

Cough Cardiopulmonary Resuscitation Revisited

Testing implantable cardioverter-defibrillators requires induction of ventricular fibrillation (VF) to assess detection and termination of the arrhythmia. A 64-year-old man had spontaneous coughing on induction of VF on 3 occasions but did not cough after more sedation. The ECG and femoral artery pressure recording during these episodes are shown in the Figure. Automatic defibrillation occurred after 7 to 10 seconds. Rapid, regular coughing produced arterial blood pressure as high as 176/51 mm Hg …

Dynamic nature of coronary collateral blood flow

Abstract How coronary collateral blood flow is turned on and turned off is not known. Moreover, the rapidity with which coronary blood flow can become evident after total occlusion of a coronary artery and then become nondetectable again after resolution of the coronary artery occlusion has been reported infrequently. 1,2 Recent studies 3,4 showed that collateral channel filling may improve within 60 to 90 seconds after sudden coronary occlusion by an angioplasty balloon in certain patients with severe coronary stenosis. This report demonstrates the dynamic nature of coronary collateral flow. Collateral blood flow appeared immediately after total occlusion of a coronary artery. After transluminal disobliteration, 5 anterograde blood flow returned and collateral blood flow was no longer seen.

Left ventricular derived cardiac output

Measurement of cardiac output (CO) requires right-sided cardiac catheterization. However, to save time and reduce costs, only left-sided cardiac catheterization is usually performed in most patients with suspected coronary artery disease. Thus, CO is not measured. To determine if CO can be measured from the left side of the heart, 24 patients undergoing cardiac catheterization had near-simultaneous determination of CO after indocyanine green dye was injected into the pulmonary artery and left ventricular (LV) cavity. There was close agreement between pulmonary artery and LV derived cardiac outputs (Pulmonary artery = 0.93 LV + 0.12). The pulmonary artery derived CO was 5.7 +/- 2.0 liters/min and the LV derived CO was 6.1 +/- 2.2 liter/min. Also, there was a close relation between pulmonary artery derived stroke volume (82 +/- 33 ml) and LV derived stroke volume (86 +/- 36 ml). Thus, CO can be accurately measured after injection of indocyanine green dye into the LV cavity.

Response to Letter Regarding Article, “Cough Cardiopulmonary Resuscitation Revisited”

We are grateful for the opportunity to respond to McLachlan et al, because the brevity of our communication1 precluded anticipating misunderstandings about cough cardiopulmonary resuscitation in ventricular fibrillation (VF). Our response to their statement that “humans cannot physically cough” every 0.42 seconds is that our recordings were consistent with documented episodes of cough cardiopulmonary resuscitation in human …