The Australian response to gun violence…less is more

This week, Annals of Internal Medicine published a well written editorial about how Australia has managed to significantly reduce gun violence with a nod to the measures it took back in 1996. It’s unfortunate the physician base within the US hasn’t been more vocal to advocate on behalf of patient safety or even prevention. The attempt to combat gun violence with more guns (and arming more people) doesn’t seem to be working. It would be awesome to see stronger advocacy from a well organized group of physicians who have the ability to exert considerable influence. Until US physicians advocate more vocally, it appears to be an opportunity lost.

 

An intriguing video…not about medicine…not about sim…but just about life

I came across this video via a feed on Facebook. It’s got nothing to do with sim, with helicopters, medicine or even education (well except maybe it contributes to general education of life).

http://www.upworthy.com/the-earth-shatteringly-amazing-speech-that-ll-change-the-way-you-think-about-adulthood-4?g=2

I thought it deserved to be shared. It struck a chord because I’ve been that guy stuck in line at the grocery store and just about ready to lose it…then having to get back in my car and drive home in Toronto’s ridiculous traffic. This video reminds us about others, that the people around us may not be in nearly the fortunate situations that we’re in or maybe they’ve just had an even worse day at work than me. Regardless, I hope I can remember this video next time I’m pissed off at how long the line in the grocery store is or when I’m stuck 3 hours of traffic, just trying to get home.

For those interested, the speech is an excerpt from a commencement speech delivered by David Foster Wallace in 2005 before his death in 2008.

 

 

Patient safety strategies ready for primetime

This week, Annals of Internal Medicine published a critical review for strategies designed to enhance patient safety. The best part, the authors summarized their findings into a 1/2 page table outlining 10 “strongly encouraged” and 12 “encouraged” strategies…this makes  for a quick read! Extremely important for those of us who’s attention spans are so short that we can’t even wait in a line at the grocery store without checking our email twice, posting a tweet and reading the daily news.

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

I really liked this list and I think it’s great to publish  for people to review. You can look at what you’re doing at your own institution and if there are things missing, it provides a basis for advocacy.

It’s interesting that many strategies relate to intensive care medicine. I’m not sure if that’s a function of the interest by intensivists/anesthesists in patient safety, a result of funding bias towards ICU-level patient safety studies or maybe that’s where much of the difference can be made (at least from a mortality perspective). What this list also demonstrates is that there are many areas within primary care, trauma care and emergency care that require attention. 

The authors mention that “pre-operative checklists and anesthesia checklists” are strongly encouraged. I agree! But what about checklists during acute resuscitations? We simply don’t know because the evidence hasn’t been developed yet. Certainly I think this can act as a call to those funding and researching patient safety in acute care medicine . Cliff Reid wrote about the “Resus Room Life Guard” several months ago…we don’t know if this is a good idea or improves patient oriented outcomes because it hasn’t been studied. Though intuitively, it seems like a great idea!

There was also no mention about the importance of adequate discharge follow-up from the ED…some hypothesis generating studies that patients who don’t have great follow-up are at risk. But clearly more studies are needed.

Finally, for those of us interested in simulation, it offers additional support that team training and simulation exercises with a focus on patient safety are worthwhile undertakings. A recent study from demonstrated improved communication and teamwork in a trauma centre following in-situ trauma simulation training. In addition, there appeared to be some patient oriented improvements including improved speed without compromise in critical task completion.

The list of strategies is worth a read…see how you compare and see how your institution compares. If you’re not doing the “strong encouraged” items…its probably worth considering why not? Do you really need to put the femoral line in during the resuscitation or will the 2 large bore IVs suffice until the patient can be properly draped and line insertion done under fully sterile conditions? Do you wash your hands before and after every patient encounter? I know at our hospital we have people in the ED (maybe posing  with acute Percocet insufficiency) or hiding in the shadows…yet…they’re really monitoring our handwashing complicance.   While I have been known to get in arguments with them…they’re actually just trying to implement important patient safety measures.

#patientsafety.

That’s it for now. Feel free to post any thoughts/comments.

Hybrid Simulation…using patient actors to enhance simulation

I’ve gotten a bit behind in my posts mostly as I’ve just moved back from New Zealand but I’m hoping to get a few more regular posts. For those who’ve read this blog, you’ll know that I like to highlight innovative approaches to simulation. This post is mostly for those interested in medical simulation…hopefully providing some new ideas.

One of my interests is procedural skill acquisition and how simulation can be used to enhance learning. So when I came across this paper I thought it deserved mention. The authors, from the University of Toronto describe using “hybrid” simulation for teaching knee arthrocentesis among internal medicine residents. Residents went through a procedural skills curriculum where they received teaching and practice performing arthrocentesis. They had to interact with a standardized patient and explain risks/benefits of the procedure. Then they were evaluated on both technical & non-technical skills in a separate scenario. They demonstrated the feasibility of this approach and they showed high ratings of realism among trainees & standardized patients and it functions as a hypothesis generating study for if these acquired skills are translated to the clinical setting.

Great use of hybrid simulation for obstetrical scenario - live patient actor "giving birth". source: http://www.samuelmerritt.edu/hssc/task-trainers

Great use of hybrid simulation for obstetrical scenario – live patient actor “giving birth”. source: http://www.samuelmerritt.edu/hssc/task-trainers

Hybrid simulation is actually a pretty cool concept. For those are new to this, hybrid simulation combines patient interaction (using a standardized patient) with a bench model (or task trainer) that allows for procedural skill practice. The benefit of this technique is the learner gets to interact with a patient as if they’ll be the recipient of the procedure while also getting to master the technical skills of the procedure.

Using procedural competency as a goal in procedural training, hybrid simulation is an excellent method for integration into a training curriculum. In one definition of competency:

“it refers to a resident’s ability to safely prepare for, perform and navigate the complications of a procedure” (Mourad et al. J Gen Med 2010).

Hybrid simulation will allow the learner to manage each of these aspects. They practice how to prepare for the procedure (both technically and preparing the patient). This will include consenting the standardized patient to the risk and benefits. I think we often forget this key aspect and instead focus on the technical skill. Furthermore, hybrid simulation scenarios can also integrate complications and evaluate the learner as they manage both the technical and interpersonal issues that must be addressed.

Another group at the University of Ottawa has started using OSCEs as a method for evaluating procedural skills which also is quite innovative! I came across an abstract they recently presented and a quick google search revealed a manuscript that further outlines the integration of an OSCE for procedural skills. Definitely worth checking out.

In simulation, we spend thousands of dollars on advanced equipment that is designed to replicate real patient interaction. However, hybrid simulation shows us that we can enhance fidelity even more by using some imagination and combining a task trainer with a live actor.

Another example while I was in Auckland, I ran full trauma simulations with a live patient. At the helicopter base, we had an actor who had suffered a considerable trauma from a motor vehicle accident. Its very impressive to watch a team interact with a “real” patient compared to a manikin. There’s much greater concern with pain and emphasis towards communication of each management step – these are definitely lost during interaction with a manikin.

I think medical educators and those involved in curriculum design need to take the next step as we seek to improve procedural skill teaching in medicine – let’s start integrating live patient actors into our simulations. We’re starting to see that it’s feasible and that some considerable benefit can be ascertained. As we seek procedural competence, we cannot forgot the trainee should be evaluated for their ability to explain and work with a live patient throughout the procedure. Its not infrequent that trainees learn to perform a procedure but they have no idea the complication rate or even what can go wrong! Then when something does actually go wrong they haven’t thought about it. Integration of these  hybrid simulations will only enhance trainee skills and lead to improvements in patient safety – something we’re all working so hard to improve.

Paper tigers – not quite ready to be tamed? by: Ken Locke

petro82:

Fascinating reflection on the utility (or lackthereof) of moving away from paper-based learning in medical education. This post summarizes a session at CCME 2013 (Canadian Conference for Medical Education). While I didn’t attend it, I read this post and thought it provided a thoughtful summary.

Originally posted on mededconference:

Saturday April 20, 2013

Blogger: Ken Locke, Director, Transition to Residency Program and UME Faculty Lead for Portfolios
Assistant Professor, Department of Medicine
Faculty of Medicine, University of Toronto

The ‘Faculty Perspective’ Post

I spent Saturday afternoon at a very engaging session at CCME 2013 entitled “Taming the Paper Tiger: Transitioning to a Mobile Curriculum”. This was a very well attended and fast-paced session focused on how medical schools may (or may not) be moving their learning materials out of the traditionally distributed bundles of printed pages, and into digital formats that students access from mobile devices, amongst other means.

Chaired by David Lampron from UBC, this was a symposium put on by 3 faculty members and one medical student, from 4 different institutions, each of which had a different perspective on this issue. The collected tweets from this presentation can be found under the hashtag #papertiger, or at Storify

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Information overload…staying up to date with new medical journal publications

As physicians, some of us love to read the latest journal publication while some of us don’t give a s@#!. Those in the latter category are more than happy to get the information at conferences or journal clubs in due time. There’s nothing wrong with these people…in fact, it could be argued this is a healthier approach than being addicted to your wireless device or computer waiting for the newest publication!

But for those of us who do get turned on by reading then talking about the newest publication the day it comes out “Epub ahead of print”, it can be a daunting task to stay up to date.

In our world where we’re exposed to up to the minute Twitter feeds, blog posts or push notifications, we can easily become overloaded and inundated with how to manage this information. The challenge is particularly difficult with journal publications. I admit, that I really enjoy reading the latest research data and while that doesn’t make me a bad person…it arguably makes me a less attentive husband (one woman’s opinion).

Are there any strategies for improving information intake and staying up to date with recent research? I don’t think this area is well taught in medical school or residency, partly due to the fact it’s a brand new method of information acquistion. Also, it’s rapidly changing with new sites and apps coming all the time.

I follow a few different journal topics including emergency medicine related, critical care, general medicine and medical education. Overall, this probably results in about 15-20 journals per month. I don’t read every article, nor do I read every abstract but I routinely read through table of contents or titles to make sure I’m staying up to date.

I’ve been thinking about this recently and while this post isn’t intended to be comprehensive, it does offer a few strategies that I’ve used to ensure I’m reading the newest evidence (any mention of a product/app below is only because I’ve found them helpful…I take no money from anyone). The following are in no particular order of preference. And if there’s an app or strategy I’m missing, please comment and I’ll add it to the post!

Here we go.

QxMD “Read”: I just started using this app and I really like it and I highly recommend it for any physician trying to keep up with the medical literature. And it’s FREE!  Anyways, it’s a Canadian company that “provides a single place to discover new research, read outstanding topic reviews and search PubMed“. It allows you to sign up through your library Proxy account and access PDFs for any medical journal that your library has available. If your university isn’t supported, email them, I believe they are really working hard to add new institutions. The key component for this app is the user can select which journals they want to receive regular updates from and easily access. Here’s a great review of the product.  For those using Android/non-Mac products I don’t think its available for any other platform than Apple (I only use Mac so I can’t confirm this).

Settings page for "Read"

Settings page for “Read”

Main interface used when reading articles

Main interface used when reading articles

Feedly: I also highly recommend this! and it syncs with GoogleReader which inexplicably is getting shut down. This program provides regular updates to any journal you wish to add to your list. The benefit to this approach is that it syncs well across platforms (both mobile and desktop) and it also houses all of your non-medical blogs and news sites. The difference between Feedly and QxMD is the latter offers a much easier route to read the PDF. Feedly simply provides you with the abstract then its up to you to figure out your own access method.

Screen Shot 2013-04-21 at 11.40.53 AM

Subscribe to a journal’s table of contents (TOC): Most journals allow you to provide your email so that every time a new volume is published, the TOC arrives in your inbox. This is how I started following journals though depending on the number of emails you receive (and the number of journals you follow), this process can easily overwhelm.

Example of "The Lancet" Table of Contents email

Example of “The Lancet” Table of Contents email

Subscribe to programs such as Journal Watch or InfoPOEMs (from Cdn Med Assoc): Essentially these organizations review the literature (typically 1-2 months behind) and send brief summaries of selected articles. This isn’t comprehensive and they’re not always free (e.g. Journal Watch) but it does help you find out about papers that maybe you wouldn’t have read. I use these methods then I download the article myself using my University library account. But it is a bit more labor intensive than Feedly or QxMD.

Follow an up to date medical blog. For those in emergency medicine/critical care, lifeinthefastlane.com is a must. The authors of this blog provide high quality, regular, up to date information about new publications that will interest EM physicians. Sign up to their LITFL review and they outline some of the newest journal articles out there. In addition, they link you up with all the most recent blog posts from around the EM world.

For those interested in medical education – I highly recommend a new blog “Medical Educator 2.0” that compiles medical education (and general education) related topics from sources around the world. Ali Jalali is a medical educator at the University of Ottawa (and happened to be a professor of mine in med school) and he puts together a very high quality site. If you subscribe then you’ll get regular emails when a new version/updates are posted.

Download each journal’s app: Great if you only read 1-2 journals but not sure how useful this is if you’re looking for regular updates from a broad range of journals. Here’s a list of journal apps for download.

Twitter: Either sign up and follow a journal’s twitter account (e.g. @EmergencyMedBMJ) or follow individuals that often retweet or post comments about new articles. This approach really maximizes the power of crowds and can make reviewing new articles much easier. On Twitter, you can also follow hasthtags like #meded and #FOAMed.

So those are a few strategies that I use. I welcome feedback and suggestions that I’ve missed. I’m happy to update this post with any ideas that you feel should be included.

A HEMS experience from a resident perspective (and a few pictures from my last flight)

This post is being written while on a plane back to Toronto…I’m just settling into some serious jetlag so I figured no better time than put down a few thoughts on my experience in Auckland. For the past 6 months I’ve worked in NZ with the Auckland Rescue Helicopter Trust as the HEMS education fellow and flight physician. Coming from Canada where putting physicians on-board helicopters to work in a pre-hospital environment is about as foreign as …. I came to Auckland with little knowledge about what to expect.

Posing for the photo op. Realized a modeling career isn't in my future.

Posing for the photo op. Realized a modeling career isn’t in my future.

To say the least, the entire experience was amazing and unforgettable! And much of this must be attributed to amazing group who work at ARHT. My supervisor and HEMS medical director, Chris Denny, got me organized and met with me weekly. We set out a plan, established learning outcomes and gradually implemented an advanced simulation plan at ARHT. Amazingly the ARHT facilitated this with the purchase of several brand new simulation manikins which only enhanced the learning possibilities. I worked alongside several talented physicians (Sam Bendall and Scott Orman) who mentored me in advanced simulation techniques, e-learning, integration of social media and blogging into education.

My time at ARHT was divided between educational endeavours and work as the HEMS duty doctor. Both allowed me to work and learn with the entire ARHT team who taught me more than they can imagine! While I can’t possibly thank everyone in this format, I developed great relationships with Barry Watkin (chief paramedic) and Herby Barnes (head crewman) who both worked to help me implement some of our educational objectives!

A view of Auckland at sunset

A view of Auckland at sunset

As the HEMS education fellow, I ran weekly simulations (often based on jobs we had recently done or questions that had come up), case-based learning sessions and finally task training sessions. We described our learning online both through the aucklandhems.com blog and via Twitter. We flew across the Tasman to practice our pre-hospital ultrasound skills at SMACC2013 (an impressive 2nd place…despite our less than optimal subject matter we had to teach)! (link). We implemented new standard operating procedures based on (and tested in) simulation. There was collaboration with teaching and simulation with the Auckland City ED as I worked there part-time as well.

On the west coast outside Auckland

On the west coast outside Auckland

Finally, I had the opportunity to practice pre-hospital & retrieval medicine. This opportunity to learn from some amazing doctors, paramedics, crewmen and pilots in a setting that previously was entirely unfamiliar, was awesome! I gained an entirely new appreciation for ergonomics as practicing medicine in the back of a helicopter is entirely different than even the craziest of emergency departments! I had opportunities to do winch rescues (both practice and operational), jumping from helicopters, rock swims with surf rescue, run resuscitations in remote areas and the list goes on.

What stood out however, was the theme of safety. In medicine, safety is sadly a relatively new topic…but for many of our pilots and crewmen, safety has been a part of their work since they started. In fact, those in aviation who don’t embrace safety…tend not to have very long work careers (for obvious & unfortunate reasons). Working in a helicopter is among the highest risk occupations around so it’s not surprising the ARHT team take safety so seriously. I spoke with the crewmen and pilots as much as a could to better appreciate their perspective…so that perhaps in medicine I can borrow and learn from their obsession. I suspect (as others have as well) that medicine lags in safety management because bad outcomes don’t harm clinicians directly…in a helicopter however, lack of concern for safety does affect everyone onboard. Thus the entire team has a vested interest in promoting and ensuring safe procedures. We run safety briefings, we have an online safety management system in place and just like the rest of aviation we incorporated checklists for both routine & high-risk procedures. As HEMS doctors, we tried to emulate the pilots/crewmen so we also use a checklist for our high-risk procedures like rapid sequence intubation…this is just starting to catch on in the ED but in my opinion there’s much room for improvement! I once asked one of our pilots about checklists and why they use them… I told him that in medicine, people fear checklists because they think it will take away their ability to think…he laughed and replied:

“we have checklists not so that we stop thinking…but so we can start thinking during a crisis and not worry about forgetting small details”.

And that brings me to the end of my last blog post at ARHT. A huge thanks to the entire team at HEMS & ARHT for inviting me to Auckland, helping me learn and trying new things! I will continue blogging but likely with a shift towards simulation and education. I’ll still be collaborating with the HEMS team at ARHT and hopefully posting some stuff on aucklandhems.com. So that’s it for now…back to my inflight movie, Argo.

ARHT Surgical Airway Skills Session

petro82:

Most recent Auckland Rescue helicopter training session on surgical airway.

Originally posted on Auckland HEMS:

One of the challenges of resuscitation and pre-hospital medicine is that there are multiple high-risk but rarely performed procedures that clinicians must be ready to perform. The difficulty is that we may go our entire careers and only perform them once or even more likely never. However, the difference from success and failure for these procedures can mean life or limb. Consequently we must remain competent despite the challenges with practice.  There is an excellent article that articulates these issues by Cliff Reid & M Clancy which I highly recommend reading (for anyone interested in the topic).

(a primer video I integrated into a recent cric teaching session to get our participants into the mood!)

These life-saving, rarely performed procedures happen to be an interest of mine. It’s a fascinating exercise in education and cognition to maintain competence in performing these procedures yet have virtually no real-life patient practice. The…

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