In this case, we report difficulty in the conduct of carotid surgery during an earthquake. With the epicenter >200 miles away, intraoperative movement was subtle and initially attributed to recovery from neuromuscular blockade. More significant seismic motion in a hospital is accompanied by additional challenges that are discussed.
Abstract Crisis resource management (CRM) has come to define the cognitive and teamwork skills that facilitate management of medical events bearing a high risk to patient well being. There are various definitions for crisis, but for purposes of this discussion, the definition below will be used.
BACKGROUND: An essential assumption to the use of model-driven simulators is that the devices generate consistent and reproducible results. While research has looked at improving the fidelity, validity, and clinical application of human patient simulators, few independent studies have rigorously tested the reliability of the embedded models. The METI-HPS was selected for its widespread use and as a standard model-driven simulator. We hypothesized that when the models were run on the workstation alone (disconnected from the tower and mannequin), the simulator should generate identical data each time the same initial state and exact sequence and timing of an action was followed. An “instantaneous” blood loss was selected as a perturbation with easily recognized effects on hemodynamics. METHODS: The METI HPS (Version 6.3,MAC OS 10.2.8) was used in the “disconnected state.” A “test” consisted of five procedurally identical runs: Tests 1,2: Both Standard Man (SM) and Orthostatic Granny (OG) were selected from the patient menu for simulator runs of two minutes. Tests 2–6: SM was subjected to blood loss of 300, 900, 1500, 2400, or 3000 ml at 15 or 16 seconds (consistent within a test) and run for two minutes. Tests 7–11: OG was subjected to blood loss of 150, 750, 1500, 2250, 3000 ml and run for two minutes. The logs of key vital signs for each run were analyzed using EXCEL. RESULTS: Overall, several types of variations were found: a lack of reproducibility of starting baseline values including CVP, partO2 with some markedly atypical curves. high-amplitude “cycling” (e.g. for CVP) – before blood loss the curves of different runs in a test were completely superimposed; after blood loss the curves diverged despite identical amount of blood loss. emergence of chaotic divergent values after an apparent steady state (e.g. heart rate see Figure 1).Figure 1: CVP and heart rate from the OG/750 ml blood loss test.CONCLUSIONS: The lack of reproducibility of baseline values and hemodynamic responses of the simulator can create further challenges in validating technical and behavioral scores of participants in training and exam situations.
Develop a scoring system that can assess the management of septic shock by individuals and teams.Retrospective review of videotapes of critical care house staff managing a standardized simulation of septic shock.Academic medical center; videotapes were made in a recreated intensive care unit environment using a high-fidelity patient simulator.Residents in medicine, surgery, and anesthesiology who had participated in the intensive care unit rotation.The septic patient was managed by the intensive care unit team in a graded manner with interns present for the first 10 mins and more senior-level help arriving after 10 mins. The intern was graded separately for the first 10 mins, and the team was graded for the entire 35-min performance.Both technical and nontechnical scoring systems were developed to rate the management of septic shock. Technical scores are based on guidelines and principles of managing septic shock. Team leadership, communication, contingency planning, and resource utilization were addressed by the nontechnical rating. Technical scores were calculated for both interns and teams; nontechnical scores applied only to the team. Of 16 technical checklist items, interns completed a mean of 7 with a range of 1.5-11. Team technical ratings had a mean of 9.3 with a range of 3.3-13. Nontechnical scores showed similar intergroup variability with a mean of 26 and a range of 10-35. Technical and nontechnical scores showed a modest correlation (r = .40, p = .05). Interrater reliabilities for intern and team technical scores were both r = .96 and for nontechnical scores r = .88.Objective measures of both knowledge-based and behavioral skills pertinent to the management of septic shock were made. Scores identified both adequate and poor levels of performance. Such assessments can be used to benchmark clinical skills of individuals and groups over time and may allow the identification of interventions that improve clinical effectiveness in sepsis management.
OBJECTIVES: Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated. DESIGN: We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania. SETTING: Quaternary academic medical center. PATIENTS: Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, “An acute worsening of a patient’s clinical status that poses a substantial increase to an individual’s short-term risk of death or serious harm.” Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5–6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2–30.0]). CONCLUSIONS: Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria.
Section 1 Introduction *Emergency Critical Care - Robert Rodriguez Section 2 Hemodynamic Monitoring *Tissue Oxygenation and Cardiac Output - Catherine S. Reid, Geoffrey K. Lighthall*Non-Invasive Hemodynamic Monitoring - Chad Myers*Arterial Blood Pressure Monitoring - Vidya Rao, John E. Arbo*The Central Venous and Pulmonary Artery Catheter - Carlos Brun, Geoffrey K. Lighthall Section 3 Critical Care Ultrasonography *Principles of Critical Care Ultrasonography - Philips Perera, Laleh Gharahbaghian, Thomas Mailhot, Sarah Williams, Diku P. Mandavia *Pulmonary Ultrasonography - Feras Khan, Anne-Sophie Beraud Section 4 Pulmonary Critical Care *Respiratory Failure and Mechanical Ventilation - John-Emile Kenny, Stephan J. Ruoss*Ventilation Strategies in COPD, Asthma, and Pulmonary Arterial Hypertension - Jey Chung, Paul Mohabir, Stephen J. Ruoss*Acute Pulmonary Edema - Nina Patel, Margaret Neff*High Risk Pulmonary Embolism - Tsuyoshi Mitari *Acute Respiratory Distress Syndrome - Darryl Abrams, Daniel Brodie*Extracorporeal Cardiopulmonary Membrane Oxygenation - Vidya Rao, Darryl Abrams, Cara Agerstrand, Daniel Brodie Section 5 Cardiac Critical Care * Heart Failure and Cardiogenic Shock - Daniel Sedehi, Venu Menon* Right Ventricular Failure - Joshua Sternbach, Francois Haddad, John E. Arbo, Anne-Sophie Beraud*Hypertensive Crises - Anand Swaminathan, Michael P. Jones*Controversies in Arrhythmia Management - Sam Senturia*Left Ventricular Assist Devices - Joseph Hsu, Rachel Dotson*Management of the Post-Cardiac Arrest Patient - Cappi Lay Section 6 Neurological Critical Care *Acute Ischemic Stroke - Mohamed Teleb, Paul Sing*Subarachnoid and Intracerebral Hemorrhage - Airton Leonardo de Oliveira Manoel, David Turkel-Parrella, Cappi Lay, Albert Goffi, Joshua Stillman*Seizure and Status Epilepticus - Brandon Foreman, Anil Mendiratta*Myasthenic Crisis and Peripheral Neuromuscular Disorders - Christina Ulane Section 7 Gastrointestinal and Hematological Critical Care *Gastrointestinal Hemorrhage - Parvathi Myer, Shai Freidland*Acute Liver Failure and Hepatic Encephalopathy - Robert Wong, Glen Lutchman*Pancreatitis - Susan Quan, Walter Park*Leukemia - Martina Trinkaus,*Sickle Cell Disease - Richard Ward*Platelet Disorders and Hemostatic Emergencies - Shawn Kaku, Catherine T. Jamin*Transfusion Therapy - Michael P. Jones, John E. Arbo Section 8 Sepsis and Septic Shock *Sepsis - Michael Scott, Michael Winters*Vasopressors and Inotropes - Matthew Strehlow*Principles of Antimicrobial Therapy - Chanu Rhee, Michael Klompas*Infections in the Immunocompromised Host - Maria Cristina Vazquez-Guillamet, Joshua Mooney, Joseph Hsu*Burns and Soft Tissue Infections - Carla M. Carvalho, Paul Maggio*Biomarkers in Sepsis - David M. Maslove Section 9 Disorders of Acid-Base, Electrolytes, and Fluid Balance *Acid-Base Disorders - Tara Scherer, Corey Slovis*Electrolytes Disorders - Katy Deljoui, Michael McCurdy*Rhabdomyolysis - Audrey Wagner, Deborah M. Stein*Acute Kidney Injury and Renal Replacement Therapy - Emilee Ruth Willhem-Leen, Glen Chertow Section 10 Endocrine Critical Care *Glycemic Control in the Critically Ill - Daniel Runde, Jarone Lee*Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State - Catherine T. Jamin, Jeffrey Manko*Adrenal Insufficiency - Thomas B. Perera*Thyroid Storm and Myxedema Coma - James Lantry III, John E. Arbo Geoffrey K. Lighthall Section 11 Toxicological Critical Care *Cardiotoxins - Nicholas Connor, Silas W. Smith*Pulmonary Toxins - Hong Kim, Rama B. Rao*Toxicologic Hyperthermic Syndromes - Mai Takematsu, Rama B. Rao*Metabolic Inhibitors - Lauren Shawn, Lewis S. Nelson*Caustics - Payal Sud, Mark Su*Anticoagulants - Betty Chen, Lewis S. Nelson*Drugs of Abuse - Rana Biary, Jane Marie Prosser*Alcohol Withdrawal - Nicole Bouchard Section 12 Environmental Critical Care *Hypothermia - Morgan Eutermoser, Jay Lemery*Altitude Emergencies - Zina Semenovskaya, Christopher Davis, Jay Lemery*Drowning and Dive-Related Emergencies - Samuel Gerson, Jose Evangelista III Section 13 Sedation and Delirium *Delirium - Jin H. Han, Eduard E. Vasilevsis, E. Wesley Ely*Sedation of the Agitated Patient - Randall Wood, Jin H. Han*Induction of Intubation and Sedation of the Mechanically Ventilated Patient - Jin H. Han, Pratik Pandharipande Section 14 Geriatrics and Palliative Care *The Geriatric Patient - Mary Mulcare, Alexis Halpern, Michael Stern*Palliative Care in the Emergency Department - Lawrence Ho, J. Randall Curtis Section 15 The ED-ICU Transfer of Care *Emergency Department Evaluation of the Critical Ill Patient - Geoffrey K. Lighthall, John E. Arbo*Severity of Illness Scores and Prognostication - David Maslove*Indications for Contact and Respiratory Isolation - Chanu Rhee, Michael Klompas Epilogue - Scott Weingart
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