Having recently returned to the real world after attending SMACCDUB in Dublin, we thought we should try to articulate some of the things we learnt. Rich: Having only lost my SMACC virginity last year, I had little by way of comparison other that what had been a monumental learning experience. SMACC Dublin felt and […]
Sitting at the airport in Dublin I would like to highlight some of our take home points and thoughts from the in situ sim workshop I attended with my friend Martin a couple days ago. If you want to read that in German, click here for some German foam. It has been one of the best workshops I have participated in so far. When I was thinking to myself what made this workshop better than many of the others, three reasons have come to my mind:
- Pre conference preparation
Although I didn’t enjoy it and I am pretty good at procrastination: it just makes sense. It gets you focused, you read something you would otherwise never read and highlights the learning objectives.
- Clear timetable, clear sessions with designated learning points
- Using more that just one media & interactivity
Even though it was a social media conference and high tech was everywhere (even WIFI ;)) the teachers also used flip charts, pen and paper, discussion rounds and some acting. And of course (good) powerpoint presentations.
I think it is the right mixture of everything mentioned above that kept the participants (inter)active and focused.You also have to consider that it was quite a large crowd to be in just one room.
I will definitely try to implement those things in my own workshops.
Negative to mention: as far as I know there has been no feedback possibility offered so far.
Now on to the actual workshop learning points:
- How to get started. It is important to have support. Senior support and nursing support. Get buy-in from the top and bring in motivated people, the other ones will follow with the recognition of its usefulness. Think about Kottter’s 8 ways to change.
- Preparation and design of a scenario. Thoughtful design is vital. Really think through your learning objectives (define them ahead). Create a checklist for each scenario so you won’t forget technical tools or any items needed for the sim. Also think about your cancellation criteria and potential hazards that might occur. Declare them and mention them ahead of the simulation. Make clear what equipment is used and do not mix it with equipment used for real patients. A separate box for simtraining would be an option for that. Also don’t forget to explain and show the tools and manikin ahead of a scenario.
- Interprofessionality. Who is that simulation for? Patient care is team effort and so should be the team training. It is not “team leader training”. In situ sim should be interprofessional: Create learning points for everyone: doctors AND nurses AND everybody else involved. Tasks for everybody should be realistic. Get representatives of every profession on board.
- Use a “confederate”. Which is a supporter. Integrate this person into your scenario in order to help the participants out and keep the scenario on track.
- How to bring realism into in situ sim
Ultrasound: declare what you want to learn:
- Interpretation of the image or
- Integration of ultrasound into the sim
This makes a difference: Both might be too much for one scenario. Split the learning objectives!
- For interpreting images: There are a couple of useful apps:
See KI doc’s review on simulation apps.This could also be an option. It is based on RFID technology. Once you find the correct position with the ultrasound probe an image will be sent to your tablet/computer. Also think about where to put the tablet: On the US machine? Somewhere else?
- For integration: Learning points could be: indications for ultrasound, finding the US machine, how do I get it to the patient the most efficient way,who should get it and where do I position it in in the resus/operating room.Further reading here.
- Suboptimal manikin.There are typically 3 types of manikins: adults, babies and every once in a while an about 10 year old kid. But what if you want something in between? A 4 year old? Or an obese patient?
- Show the participants a video.They will get some sense of age, pathology and appearance of the patient. reeldx.com is an option for that.
- Print out a foto of the patient.
- Or dress up like Chris Nickson does for obesity cases:
- Pause if needed. If you want to switch from a simulated patient to the manikin during the scenario: pause and discuss the case and then continue the scenario with the manikin.
- ANTS. For anesthetists this tool is an option to evaluate your non technical skills.
- Debriefings is everything. Learn how to debrief and train the debriefers first. FFAST was recommended by the teachers. The European Resuscitation Council used “the learning conversation” as a feedback tool. Be aware that it is not team -leader- training but team – training.
As you can imagine I was part of the “ultrasound” discussion group. But there were so many more good take home points from the other groups as well. If you can think of any, share them here with us and we can make a part 2 of this blogpost.
This edition contains 6 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors
This Edition’s R&R Hall of Famer
Arima H et al. Optimal achieved blood pressure in acute intracerebral hemorrhage: INTERACT2. Neurology 2014. PMID 25552575
- This paper is creating noise since the mid of the year as it is pretending to change the current recommendations for the management of blood pressure in acute intracerebral hemorrhage (ICH). The original INTERACT2 study (N Engl J Med 2013; 368:2355-2365) did not show differences in mortality but improved functionality in patients with ICH when the BP goal was <140mmHG instead of the current 180mmHg.This study is a reanalysis of the data, attempting to identify the threshold where the benefit in functionality is produced, using ranges of <160, 160–169, 170–179, 180–189, and ≥190 mm Hg. The outcome was Rankin Scale at 90 days. Although the ranges proposed by the authors only include a <160 as the lowest, the linear analysis of SBP and Rankin Score shows a direct correlation going as low as 130-139mmHg, therefore the authors conclude that 130-139mmHg for SBP is the optimal range for management of patients with ICH.
- The study is a post-hoc analysis of a previous large study (open and unblinded) making no claims about mortality but showing a consistent effect of better functional outcomes if the pressure is managed closer to SBP of 130-139mmHg.
- Recommended by Daniel Cabrera
The Best of the Rest
Green SM et al. Sick Kids Look Sick. Ann Emerg Med 2014. PMID 25536869
- Nice editorial on missing the sick child. – take home message: sick kids look sick and the authors reassures us that careful examination and trust in ones clinical judgment is still the best approach.
- Recommended by Soren Rudolph
Surgery, Critical Care, respiratory
Tyson AF et al. The Effect of Incentive Spirometry on Postoperative Pulmonary Function Following Laparotomy: A Randomized Clinical Trial. JAMA Surg 2015. PMID 25607594
- A single centre randomised clinical trial from Malawi with 150 patients randomised in total. As suspected incentive spirometry for unmonitored patient use does not result in statistically significant improvement in pulmonary dynamics following laparotomy. Interestingly most of the patients were male and most of the procedure were emergency laparotomies.
- Recommended by Nudrat Rashid
Alrajhi KN et al. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015. PMID 25440860
- It’s well known that patients on warfarin have a high rate of intracranial hemorrhage after minor head trauma. This study found that 4.8% of those with minimal head trauma (GCS 15, no loss of consciousness, amnesia or confusion) had ICH as well. The study has limitations but suggests that all head trauma patients on warfarin should have a NCHCT regardless of severity of injury
- Recommended by Anand Swaminathan
Gu WJ et al. Single-Dose Etomidate Does Not Increase Mortality in Patients With Sepsis: A Systematic Review and Meta-analysis of Randomized Controlled Trials and Observational Studies. Chest 2015. PMID 25255427
- This is another bullet in favor of etomidate for RSI. The authors of the paper did an extensive review and meta-analysis, pooling a total of 5552. Data shows that single use of etomidate for RRT does not increase mortality, despite increase in the incidence of adrenal insufficiency. Etomidate still appears to be a viable option for the RSI of critically ill patients.
- Recommended by Daniel Cabrera
Ultrasound and imaging
Russell FM et al. Diagnosing Acute Heart Failure in Patients With Undifferentiated Dyspnea: A Lung and Cardiac Ultrasound (LuCUS) Protocol. Acad Emerg Med 2015. PMID 25641227
- POC Ultrasound has receive a lot of attention for it’s ability to improve diagnostic accuracy in patients with undifferentiated dyspnea. The LuCUS protocol looks at a combined lung and cardiac ultrasound approach to aid in rapidly diagnosing patients. This study showed that the LuCUS protocol had a (+) LR of 4.8 and a (-) LR of 0.20 for this objective. However, the study results will be difficult to apply. All examinations were performed by highly skilled US physicians with no other clinical duties at the time. The protocol includes non-standard imaging (assessment for pleural effusion, measuring diastolic function) that most providers have never performed. Additionally, the study did not set out to, and thus does not, show improved patient outcomes as a result of the LuCUS protocol.
- Recommended by Anand Swaminathan
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|The list of contributors||The R&R ARCHIVE|
|R&R Hall of famer You simply MUST READ this!||R&R Hot stuff! Everyone’s going to be talking about this|
|R&R Landmark paper A paper that made a difference||R&R Game Changer? Might change your clinical practice|
|R&R Eureka! Revolutionary idea or concept||R&R Mona Lisa Brilliant writing or explanation|
|R&R Boffintastic High quality research||R&R Trash Must read, because it is so wrong!|
|R&R WTF! Weird, transcendent or funtabulous!|
That’s it for this week…
That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.
Trauma Team members typically wear a lead gown under their personal protective equipment so they don’t have to run out of the room when x-rays are taken. How often do you see people do this?
Is it really necessary? Tomorrow I’ll talk about how much radiation team members are really exposed to.