Abstract: BACKGROUND: The implementation of ATLS® in the daily routine of trauma management in the emergency department is a challenge. This goal cannot be reached by educating ATLS® to a few team members only. In order to enforce the implementation of ATLS® in a level I trauma centre, a generic in-house training was introduced in 2009 with inter-professional integration of all specialists of the trauma team. MATERIALS AND METHODS: The TEAM® course (trauma evaluation and management concept of the American College of Surgeons) was the theoretical basis of the training. This educational program was developed for medical students and multidisciplinary team members. Prior training, a questionnaire for self-assessment was completed by n=84 team members to assess their knowledge about ATLS® principles. The hands-on training time was 90 min. N=10 members of the trauma team worked out three scenarios of multiple injured patients. These were provided as near-reality manikin simulations by a specialist trainer. After the training participants re-evaluated and analysed improvement by the training. Duration of trauma management and the number of missed injuries were analysed one year prior and one year after the training and served as a marker of the process and outcome quality of trauma care. RESULTS: Prior the training, 57% of trainees specified their knowledge related to the ATLS® can be improved. Their expectations were generally satisfied by the training. The mean time of trauma management in the ED could not be reduced one year after the training (36±16 min) compared to one year prior the training (39±18 min), however, the detection of missed injuries (5.6% vs. 3.2%, p<0.05) was significantly diminished after the training. CONCLUSION: Apart form education of ATLS® providers the inauguration of an interdisciplinary and interprofessionel team training may enhance implementation of ATLS- algorithms into daily routine.
Abstract: BACKGROUND:: Human patient simulators and airway training manikins are widely used to train airway management skills to medical professionals. Furthermore, these patient simulators are employed as standardized "patients" to evaluate airway devices. However, little is known about how realistic these patient simulators and airway-training manikins really are. This trial aimed to evaluate the upper airway anatomy of four high-fidelity patient simulators and two airway trainers in comparison with actual patients by means of radiographic measurements. The volume of the pharyngeal airspace was the primary outcome parameter. METHODS:: Computed tomography scans of 20 adult trauma patients without head or neck injuries were compared with computed tomography scans of four high-fidelity patient simulators and two airway trainers. By using 14 predefined distances, two cross-sectional areas and three volume parameters of the upper airway, the manikins' similarity to a human patient was assessed. RESULTS:: The pharyngeal airspace of all manikins differed significantly from the patients' pharyngeal airspace. The HPS Human Patient Simulator (METI®, Sarasota, FL) was the most realistic high-fidelity patient simulator (6/19 [32%] of all parameters were within the 95% CI of human airway measurements). CONCLUSION:: The airway anatomy of four high-fidelity patient simulators and two airway trainers does not reflect the upper airway anatomy of actual patients. This finding may impact airway training and confound comparative airway device studies.
Abstract: Objectives To establish a training course for Prehospital Focused Abdominal Sonography for Trauma (P-FAST) and to evaluate the accuracy of the participants after the course and at the trauma scene. Methods A training programme was developed to provide medical staff with the skills needed to perform PFAST. In order to evaluate the accuracy of P-FAST performed by the students, nine participants (five emergency doctors and four paramedics) were followed during their course and in practice after the course. An assessment was made of 200 ultrasound procedures performed during the course in healthy volunteers and in patients with peritoneal dialysis or ascites. Regular PFAST performed on-scene by the participants commenced immediately following the course. The results for the nine participants (C-group, course group) were compared with those members of medical staff with more than 3 years of experience in FAST (P-group, professional group). A group of physicians untrained in P-FAST served as a control (I-group, indifferent group). P-FAST findings were further verified by subsequent FAST and CT scans in the emergency department. Results After the training programme the C-group performed 39 P-FAST procedures without any false negative or false positive findings (100% accuracy). In the P-group, 112 procedures were performed with one false positive case. In the I-group there were 2 false negative cases among the 46 procedures performed. Conclusion following completion of a 1-day P-FAST course, participants were able to perform ultrasound procedures at the scene of an accident with a high level of accuracy.
Abstract: OBJECTIVE: In the case of an emergency, fast and structured patient management is crucial for a patient's outcome. Every physician and graduate medical student should possess basic knowledge of emergency care and the skills to manage common emergencies. This study determines the effect of a simulation-based curriculum in emergency medicine on students' abilities to manage emergency situations. METHODS: A controlled, blinded educational trial of 44 final-year medical students was carried out at Frankfurt Medical School; 22 students completed the former curriculum as the control group and 22 the new curriculum as the intervention group. The intervention consists of simulation-based training with theoretical and simulation-based training sessions in realistic encounters based on the Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS) and adapted Advanced Trauma Life Support (ATLS) training. Further common emergencies were integrated corresponding to the course objectives. All students faced a performance-based assessment in a 10 station Objective Structured Clinical Examination (OSCE) using checklist rating within a maximum of 4 months after completion of the intervention. RESULTS: The intervention group performed significantly better at all of the 10 OSCE stations in the checklist rating (p<0.0001 to p=0.016). CONCLUSIONS: The simulation-based intervention offers a positively evaluated possibility to enhance students' skills in recognising and handling emergencies. Additional studies are required to measure the long-term retention of the acquired skills, as well as the effect of training in healthcare professionals.
Abstract: In case of an emergency, a fast and structured patient management is crucial for patient's outcome. The competencies needed should be acquired and assessed during medical education. The objective structured clinical examination (OSCE) is a valid and reliable assessment format to evaluate practical skills. However, traditional OSCE stations examine isolated skills or components of a clinical algorithm and thereby lack a valid representation of clinical reality. We developed emergency case OSCE stations (ECOS), where students have to manage complete emergency situations from initial assessment to medical treatment and consideration of further procedures. Our aim was to increase the authenticity and validity in the assessment of students' capability to cope with emergency patients. 45 students participated in a 10-station OSCE with 6 ECOS and 4 traditional OSCE stations. They were assessed using a case-specific checklist. An inter-station and post-OSCE-questionnaire was completed by each student to evaluate both ECOS and traditional OSCE. In this study, we were able to demonstrate that ECOS are feasible as time-limited OSCE stations. There was a high acceptance on both students and examiners side. They rated ECOS to be more realistic in comparison to the traditional OSCE scenarios. The reliability estimated via Crohnbach's alpha for the 6 ECOS is high (0.793). ECOS offer a feasible alternative to the traditional OSCE stations with adequate reliability to assess students' capabilities to cope with an acute emergency in a realistic encounter.
Abstract: In the last decade prehospital focused abdominal sonography for trauma (P-FAST) could be established as a valid on-site diagnostic tool for both air and ground rescue medical services in Germany. An appropriate use of P-FAST demands a standardized training concept. Therefore a 1-day training program was developed by the working group "emergency ultrasound" in Frankfurt/Main and was introduced in 2003. The training consists of lectures on general and specific aspects of emergency ultrasound techniques with demonstrations of numerous pathological findings, intensive hands-on training with patients and volunteers, as well as simulated on-site training. After completing the P-FAST course the participants gained competency to perform prehospital emergency ultrasound with high accuracy. Strict application of the exact technique as well as appropriate integration of the adjunct into the algorithm of prehospital care are the most important prerequisites for successful use of P-FAST. From February 2003 to March 2008 540 participants were trained in P-FAST in the 1-day course.
Abstract: ABSTRACT: BACKGROUND: Since June 2002, revised regulations in Germany have required "Emergency Medical Care" as an interdisciplinary subject, and state that emergency treatment should be of increasing importance within the curriculum. A survey of the current status of undergraduate medical education in emergency medical care establishes the basis for further committee work. METHODS: Using a standardized questionnaire, all medical faculties in Germany were asked to answer questions concerning the structure of their curriculum, representation of disciplines, instructors' qualifications, teaching and assessment methods, as well as evaluation procedures. RESULTS: Data from 35 of the 38 medical schools in Germany were analysed. In 32 of 35 medical faculties, the local Department of Anaesthesiology is responsible for the teaching of emergency medical care; in two faculties, emergency medicine is taught mainly by the Department of Surgery and in another by Internal Medicine. Lectures, seminars and practical training units are scheduled in varying composition at 97% of the locations. Simulation technology is integrated at 60% (n=21); problem-based learning at 29% (n=10), e-learning at 3% (n=1), and internship in ambulance service is mandatory at 11% (n=4). In terms of assessment methods, multiple-choice exams (15 to 70 questions) are favoured (89%, n=31), partially supplemented by open questions (31%, n=11). Some faculties also perform single practical tests (43%, n=15), objective structured clinical examination (OSCE; 29%, n=10) or oral examinations (17%, n=6). CONCLUSION: Emergency Medical Care in undergraduate medical education in Germany has a practical orientation, but is very inconsistently structured. The innovative options of simulation technology or state-of-the-art assessment methods are not consistently utilized. Therefore, an exchange of experiences and concepts between faculties and disciplines should be promoted to guarantee a standard level of education in emergency medical care.
Abstract: BACKGROUND: Simulator training is well established to improve technical and non-technical skills in critical situations. Few data exist about stress experienced during simulator training. This study aims to evaluate performance and stress in intensivists before and after two different simulator-based training approaches. METHODS: Thirty-two intensivists took part in one of six 1-day simulator courses. The courses were randomised to either crew resource management (CRM) training, which contains psychological teaching and simulator scenarios, or classic simulator training (MED). Before and after the course each participant took part in a 10-min test scenario. Before (T1) and after (T2) the scenario, and then again 15 min later (T3), saliva samples were taken, and amylase and cortisol were measured. Non-technical skills were evaluated using the Anaesthetist's Non-Technical Skills (ANTS) assessment tool. Clinical performance of the participants in the test scenarios was rated using a checklist. RESULTS: Twenty-nine participants completed the course (17-CRM, 12-MED). ANTS scores as well as clinical performances were significantly better in the post-intervention scenario, with no differences between the groups. Both cortisol concentration and amylase activity showed a significant increase during the test scenarios. In the post-intervention scenario, the increase in amylase but not cortisol was significantly smaller. There were no differences between the CRM and MED group. CONCLUSIONS: High fidelity patient simulation produces significant stress. After a 1-day simulator training, stress response measured by salivary alpha-amylase was reduced. Clinical performance and non-technical skills improved after 1 day of simulator training. Neither stress nor performance differed between the groups.
Abstract: Background: Classic rapid-sequence induction of anaesthesia (RSI-classic) in infants and small children presents a time-critical procedure, regularly associated with hypoxia. This results in high stress levels for the provider and may trigger unsafe actions. Hence, a controlled induction technique (RSI-controlled) that involves gentle mask ventilation until full non-depolarizing muscular blockade has become increasingly popular. Clinical observation suggests that RSI-controlled may reduce the adverse effects noted above. We aimed to evaluate both techniques with respect to unsafe actions and stress. Methods: In this controlled, randomized simulator-based study, 30 male trainees and specialists in anaesthesiology performed a simulated anaesthesia induction in a 4-week-old infant with pyloric stenosis. Two different RSI techniques, classic and controlled, were applied to 15 candidates each. We recorded the incidence of hypoxaemia, forced mask ventilation, and intubation difficulties. In addition, we measured individual stress levels by ergospirometry, salivary cortisol, and alpha-amylase, as well as a post-trial questionnaire. Results: Hypoxaemia always occurred in RSI-classic but not in RSI-controlled, repeatedly resulting in unsafe actions. Subjective stress perception and some objective stress levels were lower in the volunteers performing RSI-controlled. Conclusions: Our data suggest that RSI-controlled, as compared with RSI-classic, leads to fewer unsafe actions and may reduce individual stress levels.
Abstract: BACKGROUND: Only a few data exist about the occurrence of emergencies in dental practice and the training experience of dental practice teams in life support. This study evaluates the incidence of emergencies in dental practices, the attitude of dentists towards emergency management and their training experience. METHODS: Anonymous questionnaires were sent to all 2998 dentists listed in the Saxony State Dental Council Register in January 2005. RESULTS: 620 questionnaires were returned. 77% of the responders expressed an interest in emergency management and 84% stated that they owned an emergency bag. In the 12-month study period, 57% of the dentists reported up to 3 emergencies and 36% of the dentists reported up to 10 emergencies. Vasovagal syncope was the most frequent emergency (1238 cases). As two cardiac arrests occurred, it is estimated that one sudden cardiac arrest occurs per 638,960 patients in dental practice. 42 severe life-threatening events were reported in all 1,277,920 treated patients. 567 dentists (92%) took part in emergency training following graduation (23% participated once and 68% more than once). CONCLUSION: Medical emergencies are not rare in dental practice, although most of them are not life-threatening. Improvement of competence in emergency management should include repeated participation in life support courses, standardisation of courses and offering courses designed to meet the needs of dentists.
Abstract: Fractures of the cervical spine in ankylosing spondylitis are rare. The rate of neurological complications is increased compared to fractures of the normal spine. Concerning its mechanical characteristics the ankylosing spine is similar to a long bone. Because of the deformity and the stiffness of the spine conventional orthoses do not provide enough stability and individualized techniques are necessary to perform safe rescue and transport. Because of severe instability an operation is indicated in most cases. The most stable fixation is the combined ventral and dorsal fusion. The dorsal approach is associated with an increased rate of complications, so we favour primary ventral fusion with long interlocking plates. This can be done even in difficult anatomic situations. If the screws can be tightened well, additional dorsal fusion is not necessary.
Abstract: The incidence of human errors in the field of medicine is high. Two strategies to increase patient safety are simulator training and crew resource management (CRM) seminars, psychological courses on human performance and error management. AIM: To establish a CRM course combining psychological training on human error with simulator training. METHODS: Evaluation of a new 1-day training approach targeting physicians, nurses, and paramedics. The course was divided into four modules focusing on situation awareness, task management, teamwork, and decision-making. Each of the modules was set up according to a new six-step approach. The course started with an introduction into good CRM behaviour and an instructor demonstration of a simulator scenario. The participants had to debrief the instructors regarding their human performance. Step 2 was a lecture about the psychological background, and the third step consisted of psychological exercises related to the topic of the module. A psychological exercise in a medical context (MiniSim) made up step 4, which involved a patient simulator. The last two steps were a simulator scenario and a debriefing, as in other simulator courses. A psychologist and a physician were the facilitators in all steps. Two pilot courses were evaluated. RESULTS: Seventeen evaluation questionnaires were received. All participants rated the course as good (10) and very good (7). The psychological exercises were highly valued (good, 5; very good, 11 participants). Thirteen participants agreed that the course content was related to their work. CONCLUSION: We established the first course curriculum combining psychological teaching with simulator training for healthcare professionals in emergency medicine. Similar concepts using the six-step approach can be applied to other medical specialties.
Abstract: BACKGROUND: As of October 1, 2003, a new government-initiated legislative basis for undergraduate medical education was initiated in Germany which resulted in substantial changes to the structure of the medical curriculum and in a heightened teaching load. METHODS: The Medical Faculty of the University of Dresden established an interdisciplinary reform curriculum in 1998. Since then a hybrid model of traditional lectures, seminars, practical and problem-based learning courses has been implemented for all courses in undergraduate medical training (Dresdener Integrated Problem-based Learning: DIPOL). RESULTS: Examplarly for all other DIPOL courses, the 2003 evaluation results of the "Emergency medicine-Injuries-Intensive care medicine" are presented and show that the course was very well received by students and tutors, and that 95% of the students passed the exams. CONCLUSIONS: The DIPOL anesthesiology course conforms with the new German federal law. A continuous further evaluation is an essential part of quality control and is necessary for the further development of a new curriculum.
Abstract: Dynamic decision making is one of the key skills in crew resource management training in aviation. In emergency medicine it is important to practice this skill as a prerequisite for effective treatment of patients. We report a case of paraplegia after a road traffic accident and cervical spine injury. During the prehospital treatment the patient's state was re-evaluated at different times. Although the patient was initially unconscious the physician at the scene decided not to intubate the trachea as the level of consciousness improved during resuscitation. In the emergency room a C5 fracture and a prolapsed intervertebral disc were diagnosed and immediate decompression and stabilisation of the cervical spine were performed. Dynamic decision-making has been in practise for a long time in aviation, similarities to decisions in medicine and the psychological background are described on the basis of the case report.
Abstract: BACKGROUND: Third-year students in the Dresden Medical School Programme undergo a 6 week course 'Basics of Drug Therapy' in a problem-based learning curriculum. As part of this course a practical seminar about antiarrhythmic drugs and ECG was set up. This study was conducted to evaluate the use of a simulator in this course. METHODS: A total of 234 students were randomly allocated to receive instructions with (Group S) or without (Group C [control]) the use of a simulator. After a lecture on antiarrhythmic drugs, arrhythmias were presented to Group S using an advanced life support (ALS) manikin. The students were asked to administer a drug or to defibrillate, and the outcome was shown on the monitor. The students in Group C were presented with ECG charts without a simulator. The course was evaluated by a questionnaire and multiple-choice questions (MCQ) about arrhythmias. RESULTS: We received 222 questionnaires. The content-time ratio was rated almost perfect in both groups, but the students in Group S rated the course better suited to link theory and practice. Students in Group S considered the simulator helpful and a good tool for teaching, and the extra effort to be worthwhile. A significantly higher number of students in Group S preferred electric cardioversion as therapy for ventricular tachycardia. CONCLUSIONS: An ALS manikin can be an effective tool in teaching clinical pharmacology.
Abstract: In the past years an ongoing controversial debate exists in Germany, regarding quality of the coroner's inquest and declaration of death by physicians. We report the case of a 90-year old female, who was found after an unknown time following a suicide attempt with benzodiazepine. The examination of the patient showed livores (mortis?) on the left forearm and left lower leg. Moreover, rigor (mortis?) of the left arm was apparent which prevented arm flexion and extension. The hypothermic patient with insufficient respiration was intubated and mechanically ventilated. Chest compressions were not performed, because central pulses were (hardly) palpable and a sinus bradycardia 45/min (AV-block 2 degrees and sole premature ventricular complexes) was present. After placement of an intravenous line (17 G, external jugular vein) the hemodynamic situation was stabilized with intermittent boli of epinephrine and with sodium bicarbonate. With improved circulation livores and rigor disappeared. In the present case a minimal central circulation was noted, which could be stabilized, despite the presence of certain signs of death ( livores and rigor mortis). Considering the finding of an abrogated peripheral perfusion (livores), we postulate a centripetal collapse of glycogen and ATP supply in the patients left arm (rigor), which was restored after resuscitation and reperfusion. Thus, it appears that livores and rigor are not sensitive enough to exclude a vita minima, in particular in hypothermic patients with intoxications. Consequently a careful ABC-check should be performed even in the presence of apparently certain signs of death, to avoid underdiagnosing a vita minima. Additional ECG- monitoring is required to reduce the rate of false positive declarations of death. To what extent basic life support by paramedics should commence when rigor and livores are present until physician DNR order, deserves further discussion.
Abstract: We report a patient to whom ropivacaine 1.1 mg kg(-1) was administered for brachial plexus blockade and who developed grand mal convulsions because of inadvertent i.v. injection. No symptoms of cardiovascular toxicity occurred. Venous blood samples were taken 15, 45, 75 and 155 min after the injection. The measured total plasma concentrations of ropivacaine were 3.3, 1.6, 1.2 and 1.0 mg litre(-1) respectively. Initial plasma concentration after the end of the injection period was estimated at 5.75 mg litre(-1) using a two-compartment pharmacokinetic model.
Abstract: Fluid resuscitation with hypertonic hydroxyethyl starch solutions (HES) is effective in haemorrhagic shock due to the rapid mobilisation of fluids into the intravascular compartment. Declamping of the abdominal aorta with acute redistribution of blood into the vessels of the lower body half causes declamping-induced hypotension. Usually large amount of fluids or vasopressors are necessary to restore hemodynamic stability. Therefore, infusion of a hypertonic colloid solution may be an attractive option to achieve hemodynamic stability. This study was conducted to determine the amount of fluid of either hypertonic HES (HES 6%;7.2% NaCl) or isotonic HES (HES 6%;0.9% NaCl) needed to attain best wedge pressure (PCWP) cardiac index (CI) relation after declamping. Thirty-two high-risk patients undergoing elective abdominal aneurysm resection were enrolled in a prospective, randomised, double blinded study. The individual optimised PCWP/CI relation was determined after induction of anaesthesia. After declamping, both solutions were titrated in small boluses of 100 mL until the previously determined best wedge was reached. The amount of fluid after declamping was significantly reduced in the hypertonic HES- group 162 mL vs. 265 mL in the control group (P < 0.05). Resuscitation time was shortened, and cardiac index was slightly higher in the treatment group. The use of hypertonic HES-solution after aortic declamping led to a significant reduction of fluids necessary to attain optimised PCWP/CI relation. In this clinical trial with moderate blood loss in high-risk patients, hypertonic HES applied in a titrated fashion restored hemodynamic stability faster and without volume overload.
Abstract: The underlying mechanisms of hemoglobin (Hb)-induced vasoconstriction are not yet well understood. The aim of this study was to elucidate the influence of nitric oxide (NO) and endothelin (ET) on Hb-induced pulmonary vasoconstriction. Therefore, an autologous Hb preparation was administered into isolated rabbit lungs, in which pulmonary artery pressure (PAP) and weight gain was monitored. Either glyceroltrinitrate (GTN; 10(-5) M; n=6), L-arginine (10(-2) M; n=6), L-NAME (10(-4)M; n=6), ET(A)- or ET(B)-receptor antagonists (BQ,23, 10 6M, n=6) or (BQ788, 10(-6) M, n=6) were added to the perfusion fluid and NOx and thromboxane A2 levels were measured. RESULTS: In the control group the Hb-stimulation resulted in a pressure response up to 25.1+/-2.1 mmHg (p < .05), which was 136+/-6% of the reference value. The PAP increase was significantly (p < .05) blunted after GTN (71+/-5%), L-arginine (93+/-6%) and BQ788 (88+/-7%). Pretreatment with L-NAME (139+/-13%) or BQ123 (115+/-9%) did not show significant changes in PAP. CONCLUSION: The reduction of the Hb-induced pulmonary hypertension by NO-donors points toward the inactivation of NO by free hemoglobin. Likewise, ET(B)-receptor mediated vasoconstrictive effects without changes in NOx concentrations seem to play a pathogenetic role in the Hb-induced pulmonary vasoconstriction.
