Protect That Neck! Management of Blunt and Penetrating Neck Trauma.

Blunt and penetrating vascular injuries to the neck represent a significant burden of mortality and disability among trauma patients. Blunt cerebrovascular injury can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiogram and managed by antiplatelet agents or unfractionated heparin. In contrast, for patients presenting with penetrating neck injuries, assessment for hard signs of vascular and aerodigestive injury should be done and prompt emergent surgical consultation if present. Overall management priorities for penetrating neck injuries focus on airway management, hemorrhage control, and damage control resuscitation before definitive surgical repair.

The Future of Emergency Medicine (EM) Sim Cases: A Modified Massive Online Needs Assessment.

Objective Emergency Medicine (EM) Sim Cases was initially developed in 2015 as a free open-access simulation resource. To ensure the future of EM Sim Cases remains relevant and up to date, we performed a needs assessment to better define our audience and facilitate long-term goals. Methods We delivered a survey using a modified massive-online-needs-assessment methodology through an iterative process with simulation experts from the EM Simulation Educators Research Collaborative. We distributed the survey via email and Twitter and analyzed the data using descriptive statistics and thematic analysis. Results We obtained 106 responses. EM Sim Cases is commonly used by physicians primarily as an educational resource for postgraduate level trainees. Perceived needs included resuscitation, pediatrics, trauma, and toxicology content. Prompted needs included non-simulation-case educational resources, increased case database, and improved website organization. Conclusions Data collected from our needs assessment has defined our audience allowing us to design our long-term goals and strategies.

The revised Approved Instructional Resources score: An improved quality evaluation tool for online educational resources.

BACKGROUND: Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. OBJECTIVES: We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. METHODS: As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. RESULTS: Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). CONCLUSIONS: We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

Cognitive load theory as a framework for simulation-based, ultrasound-guided internal jugular catheterization training: Once is not enough.

OBJECTIVE: The main objective of this study was to use the principles of cognitive load theory to design a curriculum that incorporates a progressive part practice approach to teaching ultrasound-guided (USG) internal jugular catheterization (IJC) to novices. A secondary objective was to compare the technical proficiency of residents trained using this curriculum with the technical proficiency of residents trained with the current local standard of a single simulation session. METHODS: The experimental group included 16 residents who attended three 2-hour sessions of progressive part practice in a simulation lab. The control group included 46 residents who attended the current local standard of a single 2-hour simulation session just prior to their intensive care unit rotation. Technical proficiency was assessed using hand motion analysis and time to procedure completion. RESULTS: After three sessions, median scores for right hand motion (RHM) (34.5; [27.0-49.0]), left hand motion (LHM) (35.5; [20.0-45.0]), and total time (TT) (117.0 s; [82.7-140.0]) in the experimental group were significantly better than the control group (p<0.001). Results for eight experimental group residents who were assessed for retention at a later date revealed median scores for RHM (45.0; [32.0-58.0]), LHM (33.5; [20.0-63.0]), and TT (150.0 s; [103.0-399.6]), which were significantly better than those of the control group (p=0.01, p<0.01, and p=0.02, respectively). CONCLUSION: These results support multiple sessions of progressive part practice in a simulation lab as an effective competency-based approach to teaching USG IJC in preparation for the clinical setting.

Management of Major Vascular Injuries: Neck, Extremities, and Other Things that Bleed.

Vascular injuries represent a significant burden of mortality and disability. Blunt injuries to the neck vessels can present with signs of stroke either immediately or in a delayed fashion. Most injuries are detected with computed tomography angiography and managed with either antiplatelet medications or anticoagulation. In contrast, patients with penetrating injuries to the neck vessels require airway management, hemorrhage control, and damage control resuscitation before surgical repair. The keys to diagnosis and management of peripheral vascular injury include early recognition of the injury; hemorrhage control with direct pressure, packing, or tourniquets; and urgent surgical consultation.

Development and Evaluation of a Simulation-based Curriculum for Ultrasound-guided Central Venous Catheterization.

OBJECTIVE: To develop a simulation-based curriculum for residents to learn ultrasound-guided (USG) central venous catheter (CVC) insertion, and to study the volume and type of practice that leads to technical proficiency. METHODS: Ten post-graduate year two residents from the Departments of Emergency Medicine and Anesthesiology completed four training sessions of two hours each, at two week intervals, where they engaged in a structured program of deliberate practice of the fundamental skills of USG CVC insertion on a simulator. Progress during training was monitored using regular hand motion analysis (HMA) and performance benchmarks were determined by HMA of local experts. Blinded assessment of video recordings was done at the end of training to assess technical competence using a global rating scale. RESULTS: None of the residents met any of the expert benchmarks at baseline. Over the course of training, the HMA metrics of the residents revealed steady and significant improvement in technical proficiency. By the end of the fourth session six of 10 residents had faster procedure times than the mean expert benchmark, and nine of 10 residents had more efficient left and right hand motions than the mean expert benchmarks. Nine residents achieved mean GRS scores rating them competent to perform independently. CONCLUSION: We successfully developed a simulation-based curriculum for residents learning the skills of USG CVC insertion. Our results suggest that engaging residents in three to four distributed sessions of deliberate practice of the fundamental skills of USG CVC insertion leads to steady and marked improvement in technical proficiency with individuals approaching or exceeding expert level benchmarks.