A well written article that addresses the impact of duty hour restrictions in residency. Hoping to have a review of the new article that is cited shortly.

Health & Family

Giving residents less time on duty and more time to sleep was supposed to lead to fewer medical errors. But the latest research shows that’s not the case. What’s going on?

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Family presence during resuscitations…the debate continues

For those of us involved in acute care medicine, you’ve likely faced the question

“should we invite the family to be present during the resuscitation?”

More than likely you also have an opinion on the matter. In fact, as I’ve started to look at the literature, people have very strong opinions about this subject! For those with short attention spans…check out a recent New England Journal of Medicine article for further evdience! 

I’ll be candid – I support the practice of having families present for the resuscitation, or at least inviting them to be present. I understand some families will decline which is entirely their choice but importantly other families will find this important to be present.

The last time I invited a family to observe was in an ICU setting where we were in the process of resuscitating a young person who had suffered cardiac arrest. The patient was extremely unstable with episodes of CPR and increasing pressor requirements.  I knew the family was waiting in the family room so I handed over the role of team leader to another colleague and visited with the family. Before leaving, however, the entire team was made aware of the plan to have the family present. Everyone was in agreement with the plan. I invited all family members to be present though only 3 of 5 requested to observe. Before entering, I outlined that they would see their loved one with a “breathing tube” and that “CPR” may be in process. We had our most senior ICU nurse with the family throughout the resuscitation to explain exactly what was happening. Never once were they left alone, however, we did encourage if they wished to hold their loved ones hand. We had planned our equipment prior to allow for this. Unfortunately the patient died but the family expressed their gratitude to the entire team for their efforts. Furthermore, they thanked us for allowing them to be with the patient during the final moments of her life. I can’t speak to why the family chose to be present, but they expressed nothing but gratitude for the invitation.

Detractors will say that family presence may have hindered the teams performance and perhaps led to psychological harm to the patient’s family. I also can’t speculate on the long term consequences for observing this potentially traumatic event. However, our team unanimously decided it would be appropriate and we proceeded accordingly.

Importantly, our team had a short de-brief afterwards where any concerns, comments and opinions were heard. There was no disagreement among team members that what was done was appropriate.

I recalled this story after reading this week’s NEJM which published a pre-hospital trial which randomized family members to observation of CPR compared to standard practice. The primary outcome was the proportion of relatives with PTSD related symptoms. Impressively, those family members who observed the resuscitation had significantly lower frequency of PTSD related symptoms than those who did not witness the resuscitation. There was no affect on resuscitation characteristics, patient survival and none resulted in medicolegal claims.

In conclusion, the authors stated that:

“family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team or medicolegal conflicts”

Some will argue that this study applies only to the pre-hospital setting since in-hospital situations are very different. In this study setting, many may have witnessed the actual collapse which differs from the hospital. So in the pre-hospital setting, maybe this is sufficient evidence to proceed with offering family presence? I can’t imagine there’s going to be another randomized trial any time soon. This is likely the best evidence we’ll get…at least out of hospital.

There is a vast array of highly opinionated individuals who have posted replies to this topic and I believe these warrant reading. Its amazing how strong the opinions are despite the lack of evidence. There have been several studies that have evaluated ED personnel opinion – these show equipoise…in one study it was 50.9% who supported family presence.

As many who are against the practice have pointed out, lack of support and communication during the resuscitation are detrimental and counterproductive. There must  be a designated individual who can provide perspective and explanation to the family. Furthermore that individual must recurrently reassess the emotional state of the family. While some feel this is a pandora box that should NEVER be opened, I would disagree. One of the editorialists for the NEJM article summaries the situation quite well:

“Part of our job as physicians is to help patients and families establish goals of care, process life-threatening events, and, at times, orchestrate the best death possible.”

 

What is most important as acute care clinicians is that we continue the discourse and encourage future study. There is clearly no definitive answer and to argue in one direction or the other without acknowledging the lack of evidence is ignorant. We have multiple surveys that report equipoise among clinicians followed by anecdotal reports of success with family observation.  Interestingly, several large guidelines have endorsed family presence including those from the AHA.

Based on this emerging evidence, it certainly doesn’t discourage me from further pursuing family presence. I will continue to invite families into the resuscitation room, however, before this occurs I will ensure the following:

  1. Discuss with the team so that everyone is aware that the family will be entering 
  2. Offer to the family the opportunity to be present
  3. Prepare the family for what they may see and that the resuscitation may be stopped during their present
  4. Ensure there is a well experience clinician (either RN or MD) with the family throughout the resuscitation
  5. Debrief the resuscitation team afterwards

 

What should be encouraged is similar situations be incorporated within simulation training. Before we fully integrate family presence, just like any other high-risk procedure, we should practice it and be competent. The entire team should be aware and understand the implications.

For those wishing to read more, I highly recommend a critical review of the literature published in 2005. While it’s a bit older, it is quite helpful! At that time there was little evidence to support many of the concerns expressed by those do not support family presence…

 

Some pretty wild footage (at the 40min mark) of a surgical airway in-flight on a BlackHawk helicopter. Check it out on AucklandHEMS blog.

Auckland HEMS

Fast-forward to 40 minutes – soldier with severe maxillofacial trauma has scalpel-finger-tube cricothyroidotomy performed under IM ketamine in the back of a Blackhawk

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Google Glass = craziness!

Check out this video – the new Google Glass promo video.

I just watched this video at a conference combining social media & critical care (SMACC 2013 and I thought it deserved a mention). I have no affiliation with Google, but gotta love how they push the limits of awesome!

Imagine how this could work within medicine – what if, as the Resuscitation Team Leader, you were wearing Google Glass…all the drug doses, adverse reactions, algorithms would be available immediately. Or more interestingly, an educator could review the perspective of a trainee who is running a resuscitation. Or perhaps the trainee is provided with this technology to help enhance their learning experience. Or what about improving tele-medicine, where experts in a different city can provide expertise by viewing what’s happening in the trauma room. While this happens now, imagine if it came right from the team leader’s perspective. The possibilities…pretty well endless!

Auckland HEMS

In Helicopter Emergency Services (HEMS) around the world, winching to critically ill patients is an important aspect for those in patients otherwise inaccessible by road transport.

Most HEMS services have paramedics as the primary medical responders who are winched to patients, however, in some services physicians who are on-board are also winched resulting in a two clinician operation. For a North American (like myself, Andrew Petrosoniak) this idea of physicians on board the helicopter, nevermind winching to patients is completely foreign! But in HEMS operations around the world, this is a reality.

At ARHT we routinely winch highly trained paramedics to patients but less commonly are physicians required to be winched during a job. However, all our physicians are trained and ready depending on our task assignment. I wrote this post after conducting a recent simulation involving a two-clinician stretcher winch. The simulation was designed after discussion with our paramedics…

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A reflection on SMACC (Social Media and Critical Care Conference) in Sydney!

The past 3 days has been a whirlwind experience in Sydney, Australia where I attended the Social Media and Critical Care Conference (@smacc2013).

smacc-big

I joined a group of several of my colleagues at Auckland HEMS to participate in the inaugural conference. It combined two seemingly unrelated things – social media & critical care. Making it probably the among the first (if not the first) medical conference to have social media as a key theme. Over the past few years, physicians in critical care, emergency medicine and prehospital medicine have become leaders in social media and using the internet as a learning tool. The creators of the conference started the innovative website Lifeinthefastlane which is a blog read by thousands of acute care physicians around the world. They decided to extend their scope and create a conference which in my opinion was a huge success! This conference was a natural extension of the relatively new concept that highlights “medical education for anyone anytime, anywhere” – this concept is known as FOAM or “free access open meducation” (#FOAMed on twitter). I won’t describe it fully here as others have already done so. But it’s the way in which we use social media and the internet to share, disseminate and collaborate within medical education.

As a reflection on the conference I’d like to share a couple highlights and concepts that emerged. What was unique about the conference was the use of Twitter. There was heavy emphasis on live tweeting during each session with a designated twitter coordinator who would pose questions to the speakers directly from those asked on Twitter. There was constant discussion on Twitter with both conference attendees and even those clinicians half-way around the world. Let me provide a brilliant demonstration of this in action. In one session about coagulation in trauma, the session facilitator (Dr. Minh Le Cong from the blog PHARM) tweeted asking for comments from those in the twittersphere. Within minutes there were comments coming in from Dr. Karim Brohi, a trauma surgeon in London, England who is a world expert in coagulation in trauma. A discussion among the speaker and the audience resulted based on his comments. Never before had I seen such interaction at a global level occur during a conference. The power in capturing ideas and facilitiating live discussion among both those attending the conference and leading experts sitting in a room across the world is amazing!

When I would look around the room in each session, there was a barrage of tweeting with many sending out comments made by conference speakers as they happened. This is incredibly powerful. It allowed for an immediate online commentary for those not attending the conference. But it also allowed those of us in other sessions to hear some highlights and really get an idea of what was happening especially if there were controversial topics being discussed.

Every talk was videorecorded and posted online for free viewing by anyone in the world. This represents a huge step in promoting free open access medial education (FOAM). Why we restrict education to those who can afford or arrange travel to these conferences is mindboggling. Our business is to improve patient care and if we can collaborate and share ideas that emerge from great meetings like this then our patients will definitely benefit.

Imagine a speaker says something quite controversial. Previously it might never really be discussed again. Or perhaps it might be misrepresented several weeks or months later in a report. At this conference, speaker comments could be disseminated rapidly with the opportunity for rapid responses and discussion.

Unlike many academic conferences, speakers were introduced based on their blog (and not their publication count or number of academic achievements). While the merits of publications should not be diminished, it highlighted that an online presence where your ideas are shared, exposed and subject to review from people around the world is a new way to gain status within the medical world.

Finally, the conference started to address how FOAM, social media and asynchronous learning can be incorporated within medicine. There were enthusiastic talks that demonstrated the power of online education but also some excellent perspectives that online learning is not a learning panacea. These sessions were humbling since we must remember that despite all this technology, we still treat people. Our job requires human interaction and without reflection we can begin to forget this. Those on blogs and twitter drive the curriculum because topics are interesting, but sometimes the less sexy topics deserve discussion. There’s no curriculum to guide us online and this may not always benefit learners.

As long as we can appreciate these limitations we can maximize the potential of a asynchronous learning using an online platform. Never before can we collaborate, share, discuss and even criticize. It’s an exciting time for medical education and SMACC did a great job making it a reality!

Should the simulated patient die? Pros and cons to acting as the grim reaper

This post discusses a great article about death in simulation and the impact on learning. I’ve learned about the importance of this topic from @jameslhuffman, an ED physician with an interest in simulation. For those interested/involved in simulation, its importance is understated but probably moving forward we’ll hear more about.  I highly recommend that anyone who is regularly running simulations or involved in medical simulation check out this paper. I’ll review some of the highlights below.  This article follows the same topic that I wrote about a few weeks ago regarding the ethics (or impact of being unethical) of medical simulation.

Important to decide how much of a grim reaper you should be as a simulation facilitator

Important to decide how much of a grim reaper you should be as a simulation facilitator

The authors reviewed the literature for evidence about the impact of death during simulation and how it affects learners. I won’t discuss their methods as I really don’t think that’s the important message of the paper – it should be noted it’s simply a literature review rather than anything more detailed or comprehensive (e.g. systematic review or meta-analysis).

Who cares whether the simulated patient dies? Why does this even matter? These are two very reasonable questions and hopefully this review will help to shed some light on why some consideration should be made about the impact of the simulated patient’s life expectancy during the scenario!

The authors outline a few concerns that have been described regarding simulated death:

  • Stressful situations including death may negatively affect learning and memory, as a result the scenario may not achieve its predefined learning objectives
  • Death during simulation may instill negative feelings among learners about simulation (e.g. “every time I do a simulation, the patient dies…I don’t ever want to participate in that again!”)
  • Death of a simulated patient may overtake the other objectives of the scenario and may occupy most of the debriefing 
  • Inability to maintain an environment of psychological safety – learners lose trust in the instructors if too many unexpected and difficult situations occur thus detracting from learning

I think all of these are very reasonable concerns and should be considered when designing a simulation scenario however, I don’t believe (nor do the authors of this review) that death in simulation should be abandoned. It clearly has a role as death in real life is inevitable and we should train and practice how to manage it. In addition, trainees must be exposed to scenarios where regardless of the therapies implemented the patient will inevitably die. This happens almost every day for clinicians involved in acute care medicine.

What I liked about this review is that the authors included some recommendations for educators to consider when designing a scenario.

First, they defined 3 types of simulated death:

  1. Death expected by both the facilitator & the learner – include discussion about end-of-life
  2. Death expected by the facilitator & unexpected learner – may include a planned respiratory arrest that the learner must attempt to manage
  3. Death unexpected by facilitator & the learner – this involves the learner administering a fatal drug or failing to recognize a fatal condition

Depending on what type of death occurs may dictate the implications for debriefing. The following are recommendations that the authors make based on a combination of evidence and experience but in general, they’re quite reasonable. In planning for a death during simulation here are some considerations:

  • Ensure the instructor is prepared for the discussion
  • Ensure the participants have a pre-briefing session that includes mention of the possibility that the simulated patient may die 
  • Simulated death should probably not be used with novice learners
  • Scenarios for advanced learners should include simulated death if clinically appropriate
  • Simulated death shouldn’t be used for punishment (e.g. death shouldn’t occur if a participant administers a noncritical drug) – death should only occur when the learner’s actions lead to a life-threatening consequence in real-life
  • A de-briefing after a simulated death is essential – it must safely address the factors  that led to the patient death with discussion about team dynamics & medical management
  • Acknowledge participant emotions associated with death 

In my opinion, most important however is simply to acknowledge that death during simulation isn’t without consequences. The impact on learners is relatively unknown given the lack of evidence. But we should consider how much stress we place on the learners as it may positively or negatively impact their learning.

Hopefully these considerations will be helpful in evaluating the sim patient’s life expectancy! I found it extremely useful and I acknowledge that the paper is better than any summary I can provide. Here’s the reference below for the article

Simul Healthc. 2013 Feb;8(1):8-12. doi: 10.1097/SIH.0b013e3182689aff. To die or not to die? A review of simulated death. Corvetto MA, Taekman JM. 

A little bit more about the benefits of In-situ simulation. It’s time we practice where we work

In-situ simulation has become increasingly popular and just recently there’s some evidence that it’s achieving the holy grail of simulation…simulation resulting in improved patient-centered outcomes. Intuitively it makes sense that more practice will make us better and probably practice within the exact place that we work, will be good too! Look at an Olympic downhill skier…they train several days in advance of their race on the exact same course as the race. Why? So that they can gain a better understanding about where every difficult turn is located or how they should navigate through a particularly challenging section. I mean, for such a high risk setting, why wouldn’t you practice where you work? Well I think the same can extend to resuscitation medicine. We should practice where we work! And at the very least, it won’t hurt us…and it will probably help. And maybe, just maybe it will benefit our patients too. 

This study was just published in Resuscitation. It’s a prospective study that implemented in-situ simulation in a pediatric setting with their emergency response team and they studied several clinical outcomes in a pre-post study design.

Their results included that after in-situ simulation, deteriorating patients were recognised more promptly and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). Furthermore there were additional trends (though not significant) towards decreased morbidity & mortality – which warrants further investigation.

The authors also note some key features of their team training & human factors considerations that may have contributed to the success of this intervention. Each of these 5 factors are EXTREMELY important for successful in-situ simulation:

(1) Regular training for all team members (4–10 times/year depending on rotation).

(2) Training in real clinical roles in real clinical environment.

(3) Key decision makers (paediatric registrars and charge/deputy charge nurses) from all wards participate in team and team training, building capacity to deal with evolving critical illness on the wards, even if the team as such is not called.

(4) Senior medical and nursing staff from many departments are team trainers – enabling trainers to address issues identified in clinical practice during team training and to facilitate acceptance of team and team training across traditional departmental boundaries

(5) Senior clinical and managerial staff support team and team training (willingness to respond early to calls from team; protected training time).

Finally, I’ve included the study abstract if you’re interested.

Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. U. Theilen et al.  vol 84 (2):218-222

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.

There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.