Richard L. Lammers

Soft tissue foreign bodies

Foreign bodies embedded in soft tissue can cause toxic and allergic reactions, inflammation, or infection, but the severity of these complications varies widely. Removal can be difficult and time consuming, and the potential damage to tissues caused by the procedure must be weighed against the risk posed by a particular foreign body. Plain and mammographic radiography, xeroradiography, computed tomography, and ultrasonography can be used to detect foreign bodies suspected during clinical evaluation. The exact position of an object buried in soft tissue is difficult to determine using two-dimensional imaging techniques. Surface markers, multiple-projection radiographs, wire grids, fluoroscopy, or stereotaxic devices may help to locate it. Not all foreign bodies are discovered during the initial patient encounter; several signs reveal the presence of a retained foreign body in a wound.

Teaching and Assessing Procedural Skills Using Simulation: Metrics and Methodology

Simulation allows educators to develop learner-focused training and outcomes-based assessments. However, the effectiveness and validity of simulation-based training in emergency medicine (EM) requires further investigation. Teaching and testing technical skills require methods and assessment instruments that are somewhat different than those used for cognitive or team skills. Drawing from work published by other medical disciplines as well as educational, behavioral, and human factors research, the authors developed six research themes: measurement of procedural skills; development of performance standards; assessment and validation of training methods, simulator models, and assessment tools; optimization of training methods; transfer of skills learned on simulator models to patients; and prevention of skill decay over time. The article reviews relevant and established educational research methodologies and identifies gaps in our knowledge of how physicians learn procedures. The authors present questions requiring further research that, once answered, will advance understanding of simulation-based procedural training and assessment in EM.

Root causes of errors in a simulated prehospital pediatric emergency.

OBJECTIVES Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency. METHODS Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods. RESULTS Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners. CONCLUSIONS Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care.

Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds

It is common practice to soak acute traumatic wounds in dilute povidone-iodine solution before definitive wound cleaning and debridement. The effectiveness of soaking wounds is unknown. Using quantitative wound bacterial counts as a measure of efficacy, we compared wounds soaked in 1% povidone-iodine solution or in normal saline with wounds receiving no treatment. Adult patients were eligible for the study if they were seen in the emergency department with visibly contaminated traumatic wounds within 12 hours of injury. Patients were excluded if they refused consent, were allergic to iodine, or had taken antibiotics within five days; if the wound did not require debridement; if the wound had been previously cleaned; or if subsequent cultures were sterile. Thirty-three heavily contaminated acute traumatic wounds in 29 patients were included in the study. Wounds were randomly assigned to one of three groups. Tissue samples were taken before and after a ten-minute period of soaking in either povidone-iodine or saline; controls were covered with gauze during the ten-minute period. The mean bacterial count per gram of tissue decreased 6.4 x 10(5) (standard deviation, 1.68 x 10(6)) after no soak, increased 3.39 x 10(7) (1.05 x 10(8)) after saline soak, and decreased 9.19 x 10(6) (1.72 x 10(7)) after povidone-iodine soak. Wounds with counts of less than 10(5) bacteria/g tissue are unlikely to become infected. Multiple regression analysis was used to analyze the changes in bacterial count after treatment as a function of experimental group and initial bacterial count. There was no significant difference between the control and povidone-iodine groups.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of a new emergency medicine residency program on patient length of stay in a community hospital emergency department.

OBJECTIVES It is not clear how emergency medicine residents affect emergency department (ED) efficiency. The objective of this study was to determine whether a new emergency medicine residency program affected the length of stay (LOS) of patients in a community hospital ED. METHODS A before-and-after observational study was conducted during a one-year period prior to, and for three years after, the start of a new residency. An additional years worth of data were collected during the fifth year after the residency started. Patients were excluded if their LOS was less than 30 minutes and they were admitted directly to the hospital. Explanatory variables included scheduled resident and student hours/day; scheduled faculty hours/day; nursing plus clerk hours/day; patients/day; ambulances/day; and admissions/day. The data were analyzed using descriptive and correlation statistics and regression analysis. RESULTS Average patient LOS prior to the residency was 122.9 minutes. During the first year of residency, it was 126.6 minutes; second year, 129.9 minutes; third year, 158.9 minutes; and fifth year, 162.4 minutes. There was a positive correlation between LOS and third-postgraduate-year resident (PGY-3) hours (rho = 0.43), and between LOS and PGY-3 hours/patients/day (rho = 0.42). All other correlations were poor (rho < 0.4). CONCLUSIONS In this ED, there was a weak, positive correlation between ED patient length of stay and the presence of PGY-3 emergency medicine residents.

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward.

Since the publication of To Err is Human, health care professionals have looked to high-reliability industries such as commercial aviation for guidance on improving system safety. One of the most widely adopted aviation-derived approaches is simulation-based team training, also known as crew resource management (CRM) training. In the health care domain, CRM training often takes place in custom-built simulation laboratories that are designed to replicate operating rooms or labor and delivery rooms. Unlike these traditional CRM training programs, in situ simulation occurs on actual patient care units, involves actual health care team members, and uses actual organization processes to train and assess team performance. During the past 24 months, our research team has conducted nearly 40 in situ simulations. In this paper, we present the results from one such simulation: a patient who experienced a difficult labor and delivery resulting in an emergency caesarean section and a hysterectomy. During the simulation, a number of latent environmental threats to safety were identified. The following article presents not only the latent threats but also the steps that the hospital has taken to remedy them. Results from clinical simulations in operational health care settings can help identify and resolve latent environmental threats to patient safety.

Medication Errors in Prehospital Management of Simulated Pediatric Anaphylaxis

Abstract Background. Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. Objective. The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. Methods. Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. Results. One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. Conclusion. Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery. Key words: Emergency medical services; pediatric emergencies; anaphylaxis; competency assessment; simulation

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward.

Since the publication of “To Err Is Human” in 1999, health care professionals have looked to high-reliability industries such as aviation for guidance on improving system safety. One of the most widely adopted aviation-derived approaches is simulation-based team training, also known as crew resource management training. In the health care domain, crew resource management training often takes place in custom-built simulation laboratories that are designed to replicate operating rooms or labor and delivery rooms. Unlike these traditional crew resource management training programs, “in situ simulation” occurs on actual patient care units, involves actual health care team members, and uses actual organization processes to train and assess team performance. During the past 24 months, our research team has conducted nearly 40 in situ simulations. In this article, we present the results from 1 such simulation: a patient who experienced a difficult labor that resulted in an emergency caesarian section and hysterectomy. During the simulation, a number of latent environmental threats to safety were identified. This article presents the latent threats and the steps that the hospital has taken to remedy them.

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

Introduction Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. Methods Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects’ explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. Results One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. Conclusions We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors.