W. Bosseau Murray

Evaluation of anesthesia residents using mannequin-based simulation: a multiinstitutional study.

Background Anesthesia simulators can generate reproducible, standardized clinical scenarios for instruction and evaluation purposes. Valid and reliable simulated scenarios and grading systems must be developed to use simulation for evaluation of anesthesia residents. Methods After obtaining Human Subjects approval at each of the 10 participating institutions, 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulators. Using two different grading forms, two evaluators at each department independently reviewed the videotapes of the subjects from their institution to score the residents’ performance. A third evaluator, at an outside institution, reviewed the videotape again. Statistical analysis was performed for construct- and criterion-related validity, internal consistency, interrater reliability, and intersimulator reliability. A single evaluator reviewed all videotapes a fourth time to determine the frequency of certain management errors. Results Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. Subjects rated the simulator scenarios as realistic (3.47 out of possible 4), further supporting construct-related validity. Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37–0.41, P < 0.01), ABA written in-training scores (0.44–0.49, P < 0.01), and departmental mock oral board scores (0.44–0.47, P < 0.01). Reliability of the simulator assessment was demonstrated by very good internal consistency (&agr; = 0.71–0.76) and excellent interrater reliability (correlation = 0.94–0.96;P < 0.01; &kgr; = 0.81–0.90). There was no significant difference in METI versus MedSim scores for residents in the same year of training. Conclusions Numerous management errors were identified in this study of anesthesia residents from 10 institutions. Further attention to these problems may benefit residency training since advanced residents continued to make these errors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes.

Review of video laryngoscopy and rigid fiberoptic laryngoscopy.

Purpose of review Recent advances in fiberoptic systems and video technology have resulted in the development of new intubation devices and techniques. A defining characteristic of rigid fiberoptic and videolaryngoscopic techniques is that glottic opening is viewed indirectly in place of direct line-of-sight. Various issues common to all instruments in this group are highlighted, and a few recently released tools are described. The aim of this article is to review material published since January 2007. Recent findings Indirect laryngoscopic techniques seemed to be easy to learn by both novice and experienced intubators, and can be used to teach both direct laryngoscopy and fiberoptic intubation. An adequate glottic view is generally easily obtained, which is frequently superior to that obtained by direct laryngoscopy. However, endotracheal tube insertion may be problematic, and various techniques have been developed to facilitate this procedure. Indirect laryngoscopic techniques are proving useful in situations of both anticipated and unanticipated difficult intubations, and therefore challenge the preeminence of flexible fiberoptic intubation. Summary As indirect laryngoscopic tools become more available, and clinicians become more facile in their use, the management of (potentially) difficult intubations is likely to change. Further technological advances are likely to lead to the development of even more new instruments.

Impact of Resident Participation in Cataract Surgery on Operative Time and Cost

OBJECTIVE To investigate the impact of resident participation in cataract surgery on operative time and cost. DESIGN Retrospective chart review. PARTICIPANTS All patients who underwent phacoemulsification cataract surgery by an attending or resident surgeon of the Penn State Hershey Eye Center between July 1, 2004, and June 30, 2007. METHODS Operating room records of all phacoemulsification surgeries performed at a single academic center between July 1, 2004, and June 30, 2007, were reviewed. MAIN OUTCOME MEASURES Operative case length in minutes and cost of operating room time. RESULTS The primary surgeon was an attending physician in 474 cases and a senior resident physician in 473 cases. Phacoemulsification surgeries took an average of 12 minutes 41 seconds longer per eye when performed by a senior resident compared with an attending surgeon (95% confidence interval [CI], 1 minute 48 seconds to 23 minutes 35 seconds; P = 0.027). Resident cases averaged 63 minutes in July, and decreased to an average of 27 minutes in June. Every month from July through December of the academic year, the monthly mean operative case length for resident cases was significantly longer than the mean operative case length for attending cases (P<0.05), except November, when the difference was borderline significant (95% CI, -23 seconds to 23 minutes 9 seconds; P = 0.057). From January through June, there was no difference. Using the nonsupply cost of running the operating room at our institution (

Targeted Crisis Resource Management Training Improves Performance Among Randomized Nursing and Medical Students

8.30 per operating minute), resident participation added

Complications of regional anesthesia

105.40 to the average phacoemulsification case. This cost totaled

Central venous pressure measurements: peripherally inserted catheters versus centrally inserted catheters.

8293.23 per resident per year. CONCLUSIONS Resident participation is associated with significantly increased phacoemulsification operative times and costs during the first half, but not the second half, of the academic year. The time and cost per resident may be important to consider when allocating resources for preclinical training. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any of the materials discussed in this article.

Learning about new anesthetics using a model driven, full human simulator.

Introduction: In this study designed with adequate statistical power to detect relevant training effects, investigators evaluated Crisis Resource Management (CRM) training during a simulated patient crisis. This study is guided by the Team Effectiveness Conceptual Model by Kozlowski and Ilgen. Methods: An experimental pretest/posttest design was used. Four-member, interdisciplinary teams, each composed of nursing and medical students, were randomly assigned to experimental or control conditions: Basic Life Support plus CRM training or Basic Life Support only, respectively. Team process (task management, teamworking, situation awareness, and interprofessional attitude) and team effectiveness (team error rate and response times) were the outcomes of interest. Results: Experimental teams demonstrated significant improvement in team process measures compared with control teams. CRM training predicted 13% of the variance in task management (P = 0.05), 15% of the variance in teamworking (P = 0.04), and 18% of the variance in situation awareness (P = 0.03). CRM training and task management predicted 22% of the variance (P = 0.04) in team error rate; CRM training and teamworking predicted 35% of the variance (P = 0.01), while CRM training and situation awareness predicted 20% of the variance (P = 0.04) in response time to chest compressions. Both experimental and control teams demonstrated significant improvement in team effectiveness measures. Conclusions: CRM team training and team practice in an environment of high-fidelity simulation and facilitated debriefing have significant effects on team process and team effectiveness. The conceptual framework is potentially adaptable to additional settings and populations for team-related research and education.

“Helper:” A critical events prompter for unexpected emergencies

Purpose of review The use of regional anesthesia, either alone or as an adjunct to general anesthesia, is at an all-time high. Demonstrated benefits include reduced side effects, more efficient use of facilities and enhanced patient satisfaction with the improved postoperative pain relief. New advances in equipment, techniques and medications have been incorporated over the past 10 years, and especially over the last 2 years. As the number of practitioners and procedures increase, the number of complications may rise as well. Recent findings The specific issues of nerve damage, treatment of local anesthetic toxicity with lipid solutions and prevention of wrong-sided procedures are examined with special reference to recent publications. Summary Specific needle shapes, appropriate pharmacologic resuscitation from intravascular injection of local anesthetics and institutional procedures to positively identify patients and the correct block location are all part of a strategy to minimize the occurrence of adverse outcomes and to mitigate the consequences of those adverse events when they do occur. More importantly, these are changes that can be instituted immediately with minimal expense to the institution and great benefit to the patient.

Subcutaneous Paravertebral Block for Renal Colic

ObjectiveTo determine whether central venous pressure measurements taken from a peripherally inserted central catheter (PICC) correlate with those from a centrally inserted central catheter (CICC). DesignA pilot bench study followed by a prospective, nonblinded, clinical comparison. SettingA 16-bed medical coronary intensive care unit and a 30-bed surgical intensive care unit at a university hospital. PatientsSeven surgical intensive care unit patients and five medical coronary intensive care unit patients. InterventionsDuring the bench study, a simple manometer system was set up to test the catheters. During the clinical study, measurements of central venous pressure were recorded from patients who had an indwelling CICC and PICC concomitantly. Positions of the catheter tips in the chest were verified by radiography. Paired central venous pressure measurements were taken from 19-gauge dual-lumen PICCs and from 7-Fr, 16-gauge, 18-gauge, and pulmonary artery catheter CICCs, all with continuous pressure infusion devices. Measurements and Main ResultsBench work showed that PICCs, because of their longer length and narrower lumen, have a higher inherent resistance, which can be overcome with a continuous infusion device. During the clinical study, three to 12 paired, digital, central venous pressure measurements were recorded from each of 12 patients for a total of 77 data pairs. Measurements were recorded at end-expiration. Mean central venous pressure from the CICCs was 11 ± 7 mm Hg, and from the PICCs was 12 ± 7 mm Hg. PICC pressure versus CICC pressure correlated (r = 0.99) for all data pairs. Analysis by repeated measures showed PICC central venous pressure more than CICC central venous pressure by 1.0 ± 3.2 mm Hg (p = 0.02). ConclusionsPICCs can be used to measure central venous pressure and to follow trends in a clinical setting when used with a pressure infusion device to overcome the natural resistance of the PICC. Central venous pressure recorded via PICCs is slightly higher, but the difference is clinically insignificant.

A path to better healthcare simulation systems: leveraging the integrated systems design approach.

Objective.New pharmacological agents are introduced into medical practice at an ever-increasing pace. Teaching how to use new medications in the clinical setting presents educational challenges and puts patients at risk. Methods.Patients and clinical settings in which remifentanil might provide clinical advantages over existing anesthetics were identified. A simulator curriculum was developed to demonstrate the use of remifentanil in the sample cases. The simulation was designed to highlight the clinical advantages and potential side effects of remifentanil. A screen displaying the concentrations of remifentanil in plasma and in the hypothetical effector site was developed. A simulator was modified (addition of an infusion pump and a pharmacokinetic screen display) and transported to several cities in the U.S.A. An instructor guided small groups of anesthesiologists and anesthetists through a structured program that enabled participants to observe drug effects in simulated patients. Results.There were 836 participants in the remifentanil program, which was offered in 58 cities in the U.S.A. Surveys were completed by 574 anesthesiologists. There was a significant difference in comfort level for using remifentanil after the session compared to before (Chi-square, p< 0.001.) The statement: “Clinical simulation experience is a means to learn about new agents like remifentanil”was rated as “excellent” by 81% and as “good” by 19% of participants. No participant found the experience to be “not useful.” Conclusions.Patient simulation is a novel method of introducing new drugs to the medical community and is perceived by anesthesia providers as a valuable addition to available teaching methods.