Comparing Sensitivity and Specificity of Ultrasonography With Chest Radiography in Detecting Pneumothorax and Hemothorax in Chest Trauma Patients: A Cross-Sectional Diagnostic Study.

Background Thoracic trauma accounts for 20-25% of all traumas and is the third most frequent cause of death, after abdominal injury and head trauma. In the Emergency Department (ED), shifting an unstable patient to the X-ray room for detecting pneumothorax and hemothorax is always risky and bedside X-ray causes radiation exposure not only to the particular patient but also to the surrounding patients in a congested and busy ED. This can be avoided by using bedside ultrasonography (USG) as the initial imaging modality in chest trauma patients. Objective To compare the sensitivity and specificity of ultrasonography and chest radiography in detecting pneumothorax and hemothorax in chest trauma patients. Methods This cross-sectional diagnostic study was conducted for a period of one year at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, a tertiary care centre. All consecutive patients (n=255) with a suspected history of chest trauma were included in the study. The patients were evaluated bedside using USG by point of care ultrasonography trained emergency medicine physician and subsequently underwent chest radiography for documentation of pneumothorax and hemothorax. Sensitivity and specificity were calculated for ultrasonography and chest X-ray (CXR) compared with the composite gold standard (chest radiography and computed tomography thorax). Results Of the 255 patients, 89% were males. The mean age of the patients was 43.46 (standard deviation 16.3). Road traffic accident (RTA) was the most common mode of injury (81%). The median (interquartile range) time interval between injury and arrival at the hospital was four hours (2.5-7). About 16.1% of the patients had subcutaneous emphysema. About 88.2% of the patients were hemodynamically stable and 78% of the patients had associated other system injuries. The sensitivity and specificity of USG in detecting pneumothorax were 85.7% and 95.3% respectively and that of CXR were 71.4% and 100% respectively. Our study found that the sensitivity and specificity of USG in detecting hemothorax were 79% and 97.9% respectively and that of CXR were 62.9% and 100% respectively. Even in the subset of patients in whom a computed tomography scan was done, the sensitivity of USG was higher than that of CXR in detecting pneumothorax and hemothorax. The specificity of USG in detecting pneumothorax was the same as that of CXR and the specificity of USG in detecting hemothorax was higher than that of CXR in that subset of patients. Conclusion The sensitivities of USG in detecting pneumothorax and hemothorax were higher than that of CXR. The specificities of USG in detecting pneumothorax and hemothorax were comparable to that of CXR. Hence bedside USG performed by emergency physician during resuscitation helps in rapid diagnosis and early management of chest trauma patients.

The Effect of Simulated Patient Death on Learner's Stress and Knowledge Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Making the simulated patient die is one of the controversial decisions in healthcare simulation. Some experts believe that we should never make the manikin die as they believe the facilitator is deceiving the learners, whereas other groups of experts believe that there are advantages in making the simulated patient die as it provides a valuable learning experience to the learners, and it is as close to reality as possible. Hence, we undertook this review to know whether simulated patient mortality benefits the learners. A systematic literature search was performed in Embase, Scopus, PubMed Central, CENTRAL, MEDLINE, and Google Scholar. Randomized controlled trials assessing the learner's stress and knowledge retention when the simulated patient dies were eligible for inclusion. Comparative intervention effect estimates obtained from meta-analyses were represented as pooled standardized mean difference (SMD) with a 95% CI. Six studies with 384 participants (learners) were eligible for the analysis. All the studies had some concerns when the risk of bias was assessed. In the simulated patient mortality group, the learners experienced higher stress as assessed compared to the group where the simulated patient survives. The two groups' pooled mean difference for anxiety and stress levels was 0.63 (0.17-1.09). Three out of five studies showed improved knowledge retention in the simulated mortality group, one showed no difference, and one showed decreased knowledge retention in the simulated mortality group. The stress response of learners when exposed to simulated mortality during a simulation session is higher than the simulated survival group. However, this increased stress response is processed by the students differently. Some students will thrive when increased stress is presented to them, while some students perceive it negatively. Thus, this increased stress response can lead to knowledge retention if the timing of the stress response happens mainly during debriefing for select students. The role of the facilitator is also important as skilled debriefers will be able to use this increased stress to their advantage to increase knowledge retention. Thus, simulated mortality can be used as an effective stressor for increasing knowledge retention during the debriefing phase for select students by a skilled debriefer. This study would aid the simulation policymakers, simulation faculties, and simulation researchers in the impact of simulated patient death and learners' stress response. If the simulation scenario is designed well with robust pre-briefing, this increased stress response can enhance learning and knowledge retention during debriefing.

The ABCDE (Avoid Shaming/Personal Opinions, Build a Rapport, Choose a Communication Approach, Develop a Debriefing Content, Ensure the Ergonomics of Debriefing) Approach: A Simplified Model for Debriefing During Simulation in Emergency Medicine.

Several debriefing models have been described in the literature. However, all these debriefing models are designed in the general medical education format. Hence, for people involved in patient care and clinical teaching, sometimes it may become tedious and difficult to incorporate these models. In the following article, we describe a simplified model for debriefing using the well-known mnemonic ABCDE. The ABCDE approach is expanded as follows: A - Avoid Shaming/Personal Opinions, B - Build a Rapport, C - Choose a Communication Approach, D - Develop a Debriefing Content, and E - Ensure the Ergonomics of Debriefing. The unique thing about this model is that it provides a debriefing approach as a whole rather than only the delivery. It deals with human factors, educational factors, and ergonomics of debriefing, unlike other debriefing models. This approach can be used for debriefing by simulation educators in the field of emergency medicine and also by educators in other specialties.

Prevotella oris: A lesser known etiological agent of pleural effusion.

Prevotella are gram negative, obligate anaerobes and includes pigmented and non-pigmented species. They are typically regarded as commensals, especially of the gastrointestinal tract and oral cavity, although opportunistic endogenous infections are known to be caused by a small number of strains. We report a case of a 51-year-old man with right-sided chest pain. Chest X-ray showed mild haziness in the right lung and he was diagnosed with right sided pleural effusion. Prevotella oris was isolated after pleural pus culture.

A Rare Case of Limb-Threatening Injury Secondary to Extrinsic Vascular Compression Following Crocodile Bite.

Crocodile bites lead to fatal and nonfatal outcomes in humans. Mugger crocodiles (Crocodylus palustris) and saltwater crocodiles (Crocodylus porosus) are common in India. Most crocodile bites can cause severe injuries, especially to the extremities, due to the substantial bite force of the crocodile, which typically leads to extensive tissue damage, fractures, amputations, and vascular injuries. We report the case of a crocodile bite victim who presented with features of acute limb ischemia, was found to have vascular thrombosis of the common femoral artery, and was experiencing complete compression of the femoral vein due to external vascular compression by a hematoma. We discuss various injury mechanisms sustained in crocodile bites and the roles of point-of-care ultrasound and continuous tomography angiography, which could help identify these injuries. After thrombectomy and hematoma evacuation the patient recovered and was discharged without any physical dysfunction.

Pregnancy With Cardiac Arrest in the Emergency Department: Case Report With Review of Literature.

Cardiac arrest in pregnancy is an uncommon encounter, with the incidence being one in every 12,000 hospital admissions for delivery. Here we present, one such patient and our experience in managing the patient. A 23-year-old, third-trimester pregnant female presented with a history of polytrauma following a road traffic accident. On initial assessment, she was in cardiac arrest. We initiated high-quality cardio-pulmonary resuscitation (CPR) as per advanced cardiac life support (ACLS) protocol. We also performed a perimortem cesarean section within four minutes of cardiac arrest. A male baby was delivered who did not have any signs of life. Neonatal resuscitation was initiated. However, both the mother and the child could not be revived. Cardiac arrest in pregnancy is a unique scenario in resuscitation, and all emergency physicians should know the key highlights in managing such patients. We review some existing literature and pose some queries that are yet to be answered.