Selim Suner

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

Objective: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Setting: Level 1 trauma center and academic emergency medicine training program. Participants: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. Intervention: : ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC®) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Design: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. Results: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. Conclusion: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

Dynamic organization of primary motor cortex output to target muscles in adult rats. II. Rapid reorganization following motor nerve lesions.

SummaryIn the accompanying paper (Sanes et al. 1989), we demonstrated that the map of motor cortex (MI) output was reorganized when examined 1 week to 4 months after a motor nerve lesion in adult rats. The present experiments measured the extent of functional reorganization that occurs within the first hours after this lesion. Shifts in MI output were examined by testing the effect of stimulation at a site in MI vibrissa area before and up to 10 h after nerve section of the branches of the facial nerve that innervate the vibrissa. Immediately following nerve transection, no movement or forelimb EMG activity was evoked by intracortical electrical stimulation within the vibrissa area. Within hours of the nerve transection, however, stimulation elicited forelimb EMG responses that were comparable to those obtained by stimulating within the pre-transection forelimb area. Remapping of MI after nerve transection indicated that the forelimb boundary had shifted about 1 mm medially from its original location into the former vibrissa territory. Forelimb EMG could be evoked for up to 10 h within this reorganized cortex. These results indicated that the output circuits of MI can be quickly reorganized by nerve lesions in adult mammals.

Reliability of signals from a chronically implanted, silicon-based electrode array in non-human primate primary motor cortex

Multiple-electrode arrays are valuable both as a research tool and as a sensor for neuromotor prosthetic devices, which could potentially restore voluntary motion and functional independence to paralyzed humans. Long-term array reliability is an important requirement for these applications. Here, we demonstrate the reliability of a regular array of 100 microelectrodes to obtain neural recordings from primary motor cortex (MI) of monkeys for at least three months and up to 1.5 years. We implanted Bionic (Cyberkinetics, Inc., Foxboro, MA) silicon probe arrays in MI of three Macaque monkeys. Neural signals were recorded during performance of an eight-direction, push-button task. Recording reliability was evaluated for 18, 35, or 51 sessions distributed over 83, 179, and 569 days after implantation, respectively, using qualitative and quantitative measures. A four-point signal quality scale was defined based on the waveform amplitude relative to noise. A single observer applied this scale to score signal quality for each electrode. A mean of 120 (/spl plusmn/17.6 SD), 146 (/spl plusmn/7.3), and 119 (/spl plusmn/16.9) neural-like waveforms were observed from 65-85 electrodes across subjects for all recording sessions of which over 80% were of high quality. Quantitative measures demonstrated that waveforms had signal-to-noise ratio (SNR) up to 20 with maximum peak-to-peak amplitude of over 1200 /spl mu/v with a mean SNR of 4.8 for signals ranked as high quality. Mean signal quality did not change over the duration of the evaluation period (slope 0.001, 0.0068 and 0.03; NS). By contrast, neural waveform shape varied between, but not within days in all animals, suggesting a shifting population of recorded neurons over time. Arm-movement related modulation was common and 66% of all recorded neurons were tuned to reach direction. The ability for the array to record neural signals from parietal cortex was also established. These results demonstrate that neural recordings that can provide movement related signals for neural prostheses, as well as for fundamental research applications, can be reliably obtained for long time periods using a monolithic microelectrode array in primate MI and potentially from other cortical areas as well.

Non-Invasive Pulse CO-oximetry Screening in the Emergency Department Identifies Occult Carbon Monoxide Toxicity

As carbon monoxide (CO) toxicity may present with non-specific signs and symptoms and without history of exposure, screening for CO toxicity may identify occult cases. The objective of this study was to determine whether non-invasive screening for CO exposure could be performed in all patients presenting to a high-volume urban emergency department (ED) and would identify patients with unsuspected CO toxicity. A study of adult patients, who presented to the ED for any complaint, prospectively screened for carboxyhemoglobin concentration by a pulse CO-oximeter (SpCO). ED triage staff recorded SpCO on the patients chart at triage. Data, including SpCO and vital signs, were recorded in a database by two trained research assistants. When available, carboxyhemoglobin concentration obtained by venous blood was also included in the data set. There were 14,438 patients who presented to the ED and were entered in the study. Data from 10,856 (75%) patients receiving screening for SpCO were analyzed. Patients were 44 +/- 19 years old and 51% female; 32% of the patients smoked. The mean SpCO was 5.17% +/- 3.78% among smokers and 2.90% +/- 2.76% among non-smokers. During the study period, 11 patients with presenting signs and symptoms not consistent with CO toxicity were identified through SpCO screening. Screening for CO toxicity using a non-invasive pulse CO-oximeter can be conducted even in a busy tertiary center ED and identify patients with occult CO toxicity.

Fatal spontaneous rupture of a gravid uterus: Case report and literature review of uterine rupture

Spontaneous uterine rupture is a life-threatening obstetrical emergency encountered infrequently in the emergency department. The diagnosis of spontaneous uterine rupture is often missed or delayed, leading to maternal and fetal mortality. Emergency physicians must consider this diagnosis when presented with a pregnant patient in shock with abdominal pain. We present the case of a 38-year-old gravid female who presented to the emergency department in cardiac arrest 24 hours after an initial complaint of abdominal pain. We review the uterine rupture literature with specific focus on risk factors, signs and symptoms, diagnosis, treatment, and outcome.

THE NONTRAUMATIC, ACUTE SCROTUM

Regardless of age, any presentation of an acute scrotum requires prompt triage and immediate evaluation. The potential for significant reduction in morbidity and mortality exists if timely diagnosis and treatment are provided. Often overlooked, an early scrotal examination in the emergency department may produce the most accurate information into the underlying pathologic process, be it systemic or localized to the scrotum. Although the immediately lethal conditions presenting as acute scrotal pain should be considered, the combined incidence and morbidity associated with testicular torsion make its exclusion paramount in acute scrotal presentations. Similarly, a painless scrotal mass must be assumed to be a testicular neoplasm until proven otherwise, with appropriate work-up and rapid urologic follow-up assured.

Finding needles in a haystack: a case series of carbon monoxide poisoning detected using new technology in the emergency department.

Introduction. The diagnosis of carbon monoxide poisoning can be difficult because the symptoms are nonspecific and may mimic other illnesses. If carbon monoxide poisoning is suspected, the standard test at this time is venous or arterial carboxyhemoglobin levels. A new device, the Rad-57 pulse CO-oximeter (Masimo Inc.), can measure carboxyhemoglobin levels non-invasively at emergency department triage. Methods. The pulse CO-oximeter was utilized in our emergency department triage to measure carboxyhemoglobin levels on all patients. A retrospective chart review was then conducted to identify all patients with elevated levels. Case Series. Out of an estimated 74,880 patients who had their SpCO measured and documented at triage, seven patients who presented with vague complaints were diagnosed with occult carbon monoxide poisoning. Their diagnosis was facilitated by the non-invasive pulse CO-oximeter, which measured their carboxyhemoglobin levels when the standard vital signs were also documented at triage. Conclusions. The non-invasive pulse CO-oximeter could be a major triage tool for identifying unsuspected carbon monoxide poisoning among patients with nonspecific symptoms.

Diffuse reflectance spectra of the palpebral conjunctiva and its utility as a noninvasive indicator of total hemoglobin

The palpebral conjunctiva is an attractive location to qualitatively examine for the presence of anemia; however, this method of diagnosis has not been shown to be accurate. A spectroscopic examination of the palpebral conjunctiva enables the use of a quantitative parameter as a basis for diagnoses. Visible range diffuse reflectance spectra from the palpebral conjunctiva are examined from 30 patients and hemoglobin levels are extracted from these signatures using both a partial least-squares (PLS) multivariate regression model and a discrete spectral region model. Hemoglobin concentration derived from both these models is compared to an in vitro measurement of hemoglobin. Root mean squared errors of cross validation for the two analytical methods are 0.67 g/dL and 1.07 g/dL, respectively. Conjunctival reflectance spectra coupled with a PLS analysis achieve an enhanced specificity and sensitivity for anemia diagnoses over reported observational studies using the palpebral conjunctiva and achieve improved accuracy to other reported methods of noninvasive hemoglobin measurement.

Photonics-based In Vivo total hemoglobin monitoring and clinical relevance

Anemia is a serious disorder which, as a result of antiquated invasive blood testing, is undiagnosed in millions of people in the U.S. As a result of the clinical need, many technological solutions have been proposed to measure total blood hemoglobin, and thus diagnose anemia, noninvasively. Because hemoglobin is the strongest chromophore in tissue, spectroscopic methods have been the most prevalently investigated. Difficulties in extracting a quantitative estimation of hemoglobin based on tissue absorption include variability in the absorption spectra of hemoglobin derivatives, interference from other tissue chromophores, and interpatient physiological variations affecting the effective optical path length of light propagating in tissue. In spite of these challenges, studies with a high degree of correlation between in vitro and in vivo measured total hemoglobin have been disclosed using variants of transmission and diffuse reflection spectroscopy in assorted physiological locations. A review of these technologies and the relevant advantages/disadvantages are presented here.

C-reactive protein as predictor of bacterial infection among patients with an influenza-like illness

OBJECTIVE During the influenza season patients are labeled as having an influenza-like illness (ILI) which may be either a viral or bacterial infection. We hypothesize that C-reactive protein (CRP) levels among patients with ILI diagnosed with a bacterial infection will be higher than patients diagnosed with an influenza or another viral infection. METHODS We enrolled a convenience sample of adults with ILI presenting to an urban academic emergency department from October to March during the 2008 to 2011 influenza seasons. Subjects had nasal aspirates for viral testing, and serum CRP. Bacterial infection was determined by positive blood cultures, radiographic evidence of pneumonia, or a discharge diagnosis of bacterial infection. Receiver operating characteristic curve, analysis of variance, and Student t test were used to analyze results. RESULTS Over 3 influenza seasons there were 131 total patients analyzed (48 influenza infection, 42 other viral infection and 41 bacterial infection). CRP values were 25.65 mg/L (95% CI, 18.88-32.41) for influenza, 18.73 mg/L (95% CI, 12.97-24.49) for viral and 135.96 mg/L (95% CI, 99.38-172.54) for bacterial. There was a significant difference between the bacterial group, and both the influenza and other viral infection groups (P < .001). The receiver operating characteristic curve for CRP as a determinant of bacterial infection had an area under the curve of 0.978, whereby a CRP value of <20 had a sensitivity of 100% and >80 had a specificity of 100%. CONCLUSION C-reactive protein is both a sensitive and specific marker for bacterial infection in patients presenting with ILI during the influenza season.