Peer Role-Play Simulation: A Valuable Alternative to Bedside Teaching During the COVID-19 Pandemic.

Purpose: The COVID-19 pandemic dramatically affected every aspect of life worldwide. Contact restrictions and social distancing during the epidemic has led to the suspension of bedside teaching (BST) and shifting to online didactic teaching and other methods of active learning. We implemented peer role-play simulation (PRPS) during the pandemic to compensate for the suspended BST. This study aims to explore the effectiveness of PRPS in developing the students' verbal communication, empathy and clinical reasoning skills compared to BST. Methods: This is a cross-sectional observational study conducted in Jazan University faculty of medicine with the study sample including all medical students enrolled in 5th and 6th year during the academic year 2020-21. Data collection involved using a web-based validated questionnaire. Results: Most of the students (84.1%) rated bedside teaching (BST) as extremely beneficial or beneficial in developing verbal communication skills compared to 73.3% for peer role-play simulation (PRPS). A similar pattern was found in empathy skills development with 84.1% for bedside compared to 72.2% for PRPS. The pattern is reversed with the development of clinical reasoning skills with 77.7% rating BST as beneficial or extremely beneficial compared to 81.2% for PRPS. Conclusion: Overall, peer role-play is generally a valuable and trustworthy method in the absence of bedside teaching for enhancing clinical reasoning skills of medical students during the COVID-19 pandemic from students' perspective. It is less efficient than bedside teaching in enhancing communication skills. It cannot wholly replace bedside teaching, although it can be used reliably for that purpose in exceptional circumstances when bedside teaching cannot be implemented.

Is It Time to Call 'Code Blue' on Nursing Infrastructure? A Nurse's Perspective from the COVID-19 Front-line.

The COVID-19 pandemic has highlighted the significance of every role within the interdisciplinary team and has exacerbated the challenges posed to every member. From the nursing perspective, many of these challenges were present before the pandemic but have become significantly larger problems that continue to demand global attention. This has provided an opportunity to critically evaluate and learn from the challenges the pandemic has both highlighted and created. We conclude that the nursing infrastructure requires a revolution in order to support, grow and retain nurses, who are vital to the delivery of high-quality healthcare.

A safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19: A quality improvement study.

Importance: The number of infections and deaths caused by the global epidemic of severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) invasion is steadily increasing daily. In the early stages of outbreak, approximately 15%-20% of patients with coronavirus disease 2019 (COVID-19) inevitably developed severe and critically ill forms of the disease, especially elderly patients and those with several or serious comorbidities. These more severe forms of disease mainly manifest as dyspnea, reduced blood oxygen saturation, severe pneumonia, acute respiratory distress syndrome (ARDS), thus requiring prolonged advanced respiratory support, including high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), and invasive mechanical ventilation (IMV). Objective: This study aimed to propose a safer and more practical tracheotomy in invasive mechanical ventilated patients with COVID-19. Design: This is a single center quality improvement study. Participants: Tracheotomy is a necessary and important step in airway management for COVID-19 patients with prolonged endotracheal intubation, IMV, failed extubation, and ventilator dependence. Standardized third-level protection measures and bulky personal protective equipment (PPE) may hugely impede the implementation of tracheotomy, especially when determining the optimal pre-surgical positioning for COVID-19 patients with ambiguous surface position, obesity, short neck or limited neck extension, due to vision impairment, reduced tactile sensation and motility associated with PPE. Consequently, the aim of this study was to propose a safer and more practical tracheotomy, namely percutaneous dilated tracheotomy (PDT) with delayed endotracheal intubation withdrawal under the guidance of bedside ultrasonography without the conventional use of flexible fiberoptic bronchoscopy (FFB), which can accurately determine the optimal pre-surgical positioning, as well as avoid intraoperative damage of the posterior tracheal wall and prevent the occurrence of tracheoesophageal fistula (TEF).

Bedside Lung Ultrasound as an Independent Tool to Diagnose Pneumonia in Comparison to Chest X-ray: An Observational Prospective Study from Intensive Care Units.

Background: Diagnosing pneumonia is challenging because of multiple differential diagnosis. Bedside lung ultrasound (BLUS) is a safe, portable, rapid and inexpensive new modality to diagnose pneumonia. This study was aimed to evaluate the sensitivity of BLUS vs chest X-ray (CXR) to diagnose community-acquired pneumonia (CAP) using computed tomography (CT) scans as the gold standard. Patients and methods: An observational cross-sectional study was conducted in selected intensive care units (ICUs). Eligible 85 adult patients with symptoms suggestive of pneumonia as per 2007 Infectious Disease Society of America (IDSA), American Thoracic Society (ATS) criteria, and 2D echocardiography were enrolled consecutively by using convenient sampling technique. Real-time reverse transcription-polymerase chain reaction (RT-PCR) assay for SARS-associated coronavirus was sent with in 1 hour followed by BLUS and CXR within 24 hours of ICU admission. The final confirmation of CAP was done by a thoracic CT scan. Results: Bedside lung ultrasound vs CXR could detect 74 vs 58 cases out of 84 confirmed cases. Sensitivity and specificity of BLUS vs CXR was 88.1% vs 67.8% and 100% vs 0%, respectively. Moreover, LR+ and LR- for BLUS was found to be 0 and 0.12 in comparison to 0.68 and 0 for CXR. The area under receiver operator characteristics (ROC) curve for BLUS vs CXR was 0.94 (95% CI 0.0-1.0) with p = 0.13 and 0.66 (95% CI 0.12-1.0) with p = 0.58. There was a significant agreement between diagnostic accuracy of BLUS and CT scan [kappa value (κ) = 0.14, p = 0.009], whereas CXR could not establish its diagnostic efficiency (κ = -0.023, p = 0.493). Sonographic features of pneumonia were B-lines, shred, and hepatization signs. Conclusion: It is observed that BLUS showed higher sensitivity, specificity, and diagnostic accuracy as compared to CXR to diagnose pneumonia. How to cite this article: Dhawan J, Singh G. Bedside Lung Ultrasound as an Independent Tool to Diagnose Pneumonia in Comparison to Chest X-ray: An Observational Prospective Study from Intensive Care Units. Indian J Crit Care Med 2022;26(8):920-929.

Handheld ultrasound as an adjunct to physical examination in the diagnosis of cardiopulmonary disease.

Handheld 2D ultrasound devices (HUDs) have become available as an adjunct to physical examinations, visualizing the heart and lungs in real time and facilitating prompt patient diagnosis and treatment of cardiopulmonar.y disorders. These devices provide simple and rapid bedside alternatives to repetitive chest x-rays, standard ultrasound examinations and thoracic CT scans. Two currently available HUDs are described. This paper discusses the use of HUDs in the diagnosis of patients with pericardial effusion and tamponade, ventricular dilation, aortic and mitral regurgitation, cardiogenic pulmonary edema, viral and bacterial pneumonia, pleural effusion and pneumothorax. The use of a HUD by physicians increases clinical diagnostic accuracy, adds quantitative information about cardiopulmonary disease severity and guides the use of medications and interventions.

Teaching Evidence-Based Physical Diagnosis: A Workshop for Hospitalists.

Introduction: Teaching on physical examination, especially evidence-based physical diagnosis, is at times lacking on general medicine rounds. We created a hospitalist faculty workshop on teaching evidence-based physical diagnosis. Methods: The workshop included a systematic approach to teaching evidence-based physical diagnosis, multiple teaching resources, and observed peer teaching. A long-term follow-up session was offered several months after the workshop. Participants completed questionnaires before and after the workshop as well as after the long-term follow-up session. Results: Four workshops were conducted and attended by 28 unique participants. Five hospitalists attended long-term follow-up sessions. Due to the COVID-19 pandemic, repeat sessions and long-term follow-up were limited. In paired analyses compared to preworkshop, respondents after the workshop reported a higher rate of prioritizing ( p = .008), having a systematic approach to ( p < .001), and confidence in ( p = .001) teaching evidence-based physical diagnosis. Compared to before the workshop, participants after the workshop were able to name more resources to inform teaching of evidence-based physical diagnosis ( p < .001). Informal feedback was positive. Respondents noted that the workshop could be improved by allowing more practice of the actual physical exam maneuvers and more observed teaching. Discussion: We created and implemented a workshop to train hospitalists in teaching evidence-based physical diagnosis. This workshop led to improvements in faculty attitudes and teaching skills. Long-term outcomes were limited by low participation due in part to the COVID-19 pandemic.

Neonatal intensive care unit on-site surgery for congenital diaphragmatic hernia.

The present study presents the experience gained in the Newborn Intensive Care Unit (NICU) of 'Maria S. Curie' Emergency Clinical Hospital for Children in Bucharest (Romania) after performing a series of bedside surgery interventions on newborns with congenital diaphragmatic hernia (CDH). We conducted a retrospective analysis of the data for all patients operated on-site between 2011 and 2020, in terms of pre- and post-operative stability, procedures performed, complications and outcomes. An analysis of a control group was used to provide a reference to the survival rate for non-operated patients. The present study is based on data from 10 cases of newborns, surgically operated on, on average, on the fifth day of life. The main reasons for operating on-site included hemodynamical instability and the need to administer inhaled nitric oxide (iNO) and high-frequency oscillatory ventilation (HFOV). There were no unforeseen events during surgery, no immediate postoperative complications and no surgery-related mortality. One noticed drawback was the unfamiliarity of the surgery team with the new operating environment. Our experience indicates that bedside surgery improves the likelihood of survival for critically ill neonates suffering from CDH. No immediate complications were associated with this practice.

Assessing the SAfety and FEasibility of bedside portable low-field brain Magnetic Resonance Imaging in patients on ECMO (SAFE-MRI ECMO study): study protocol and first case series experience.

BACKGROUND: To assess the safety and feasibility of imaging of the brain with a point-of-care (POC) magnetic resonance imaging (MRI) system in patients on extracorporeal membrane oxygenation (ECMO). Early detection of acute brain injury (ABI) is critical in improving survival for patients with ECMO support. METHODS: Patients from a single tertiary academic ECMO center who underwent head CT (HCT), followed by POC brain MRI examinations within 24 h following HCT while on ECMO. Primary outcomes were safety and feasibility, defined as completion of MRI examination without serious adverse events (SAEs). Secondary outcome was the quality of MR images in assessing ABIs. RESULTS: We report 3 consecutive adult patients (median age 47 years; 67% male) with veno-arterial (n = 1) and veno-venous ECMO (n = 2) (VA- and VV-ECMO) support. All patients were imaged successfully without SAEs. Times to complete POC brain MRI examinations were 34, 40, and 43 min. Two patients had ECMO suction events, resolved with fluid and repositioning. Two patients were found to have an unsuspected acute stroke, well visualized with MRI. CONCLUSIONS: Adult patients with VA- or VV-ECMO support can be safely imaged with low-field POC brain MRI in the intensive care unit, allowing for the assessment of presence and timing of ABI.